Nicotine, Dan Patch, MTA discussed on Real Life Pharmacology - Pharmacology Education for Health Care Professionals
CQ Is the one that I've seen gene used most commonly with nicotine patches. I I think it is important to note that we do have three primary dosage strengths. So we've got a seven milligram patch of fourteen milligram patch in a twenty one milligram patch in really there is A lower end weight restriction. But for most adult patients. They're they're above that so if somebody super low weight You Might WanNa double check and look that up but by and large we look at the number of cigarettes smoked per day and judge our initial dosing off. Offer that in most cases so obviously there could be a situation clinically were maybe a patient has tried patches in the past and they didn't tolerate the high dose or something. You might start at a at a lower dose in that type of situation but Going off of the cigarettes smoked per day. If we've got a patient isn't that is smoking eleven or more. We're going to generally go with the twenty one milligram patch and start with that. That's the the highest dose. Does there if it's ten or less than we might start with. Fourteen milligrams as far as the the patch. Goes there and end so tens. Ten's a good number to Kinda remember in an easy number to remember Based upon the number of cigarettes smoked there so if we got above that twenty one milligrams below that Fourteen milligrams so with that dosing. How long do we do the dosage form so usually or what's approved is twenty one milligrams That dose for six weeks and then we would do fourteen milligram. Dan Patch for a couple of weeks. And then the seven Milligram Patch for a couple weeks so kind of a of a taper down with a longer period of time on the higher dose us now for starting at that lower dose or the medium dose fourteen. Milligrams that's fourteen milligrams for six weeks and then seven milligrams for two weeks weeks there so that that dose is is generally at least initially going to be based on The number of cigarettes smoked From a mechanism of action standpoint. Obviously we're replacing nicotine That's our objective. Our goal to to replace that nicotine so patients feel. They don't need it necessarily through smoking cigarettes so nicotine itself In the rain essentially vines nicotinic and cholinergic receptors which can produce a stimulating type of fact In it can also impact kind of the rewards center on the the LIMBIC system which that can really fuel That reward can fuel that addiction to cigarettes. Which is why so many patients struggle to Come off smoking Back Kinda relating the patch to clinical judgement. So we talked about the number of cigarettes. Smoked It's always important to us. Clinical judgment. I if you've got a patient that's experiencing adverse fact intolerability due to a higher ear dose. Obviously we're probably going to reduce that dose same thing if you've got a patient reporting Significant withdrawal symptoms news. You know that's a situation where we we might escalate the dose an go up you know if you started a fourteen milligram. Patch they're experiencing those withdrawal symptoms symptoms. We might bump them up to the twenty one milligram patch. And here's a shock to you patients. Maybe don't exactly report Exactly exactly how much. They're smoking as well. Just like drinking alcohol and other things we tend to. Maybe Underestimate how much of a negative. The thing that we're doing so Very important to to use that clinical judgment and recognize that that patients might not be exactly Accurately portraying how much they're doing something or they're smoking in this case if you other clinical pearls with regard it to the patch So only one at a time. I think that's kind of common sense. this specific patch. You cannot cut so something like a lighted arm patch for pain. You can cut that type of patch but nicoderm replacement patches nicotine replacement patches. You cannot cut them. Essentially what's going to happen is you're going to lose some of the the drug and obviously reduce effectiveness. There you want to a non in Harry area clean area on the body usually most patients I've seen on the kind of the back of the arm have seen some kind of upper chest area Korea that type of of location as well. They're now wearing the patch. This is something that has definitely come up before in clinical uncle practice. How long do I have to wear this? How long can I wear this patch? So they are intended to be once daily and really in most patients. We're GONNA use them sixteen to twenty four hours and probably the biggest. The two big things is that I remember with how long to determine To wear the patch is are they having adverse effects at night and specifically adverse effects like insomnia vivid dreams. If that's problematic at night that definitely could be because of nicotine concentrations so in that situation we might say hey taken off at night now that can be balanced with morning cravings so. So if you've got a patient that it's like Yup I get up the first thing I do during the day as my cigarette. That's how I get going. That's how I do my thing That's a situation in where you're probably GonNa want that nicotine in the body because remember these. These patches have a slower onset. They're intended to be longer longer acting nicotine replacement. It's not like a piece of Gum. It's not like an inhaler. You're not going to get that quick. Absorption from nicotine. Patch that that you would with some other dosage forms that are meant for acute relief. So that's kind of some of the downsides of the patch and the kind of the ying and the Yang the good and the bad so to speak. Is that slow onset so it's it's not going to be used for quick relief and and one other downside is throughout the day if patients have really strong cravings You can't adjust the dose of the patch. She can't somehow how did it up. And and increase the dose. That's being delivered from that patch. And even if you could that dose would take a while to get get ramped up because it takes time for that drug to pass through the skin so Those are definitely some important pearls To think about when we're talking talking about Nicotine Patch administration and use of it Let's wrap up the first section here talking about adverse effects facts so I mentioned a couple Insomnia the dreams patients are having those. That's probably candidate that we're likely going to take that patch off at night night Other adverse effects I have seen have heard of Gi upset which tends to be obviously a lot more common. If you're oh you know doing a nicotine gum or something because that nicotine is going right into the got their With the patch it is possible. Maybe a little less likely Headache and then of course with any topical administration there's potential for a skin reaction so You know keeping that that let's say clean obviously not placing the patch right on the same exact spot over and over and over again that may lead to some worsening of of the year ISSUE THERE SO I keep that in mind obviously if somebody's reporting really severe reaction Rashes Spreading. It's getting worse You No it's it's painful it's weeping. It's you know other Worrisome symptoms Yeah you've got to educate your patients to report Those issues to you if if they are having problems that maybe something else is going on infection or or whatever so I think that wraps up adverse effects We'll take a quick break. Then we'll finish finish up on drug interactions if you're looking for board certification study material be CPS GP ambulatory care BC the MTA or nap. LEX material We've got lots of cool stuff. GOING ON AT MED one one dot com slash store. You can find links to all the resources we have also uniquely Just released a drug interactions book that I will cover many of the interactions that. I'm I'm covering today. Today is with regards to nicotine and smoking. So you definitely go check that out. I've got.