NRT COMBO THERAPY
Place in Therapy
Place in therapy
Combination NRT most often refers to providing patients who both a long acting source of nicotine to suppress cravings and withdrawal symptoms, combined with a short-acting alternative to help manage ‘breakthrough cravings’ experienced by patients. This approach is termed the ‘basal-bolus’ approach and is a way to help patients overcome significant withdrawal symptoms not relieved by monotherapy.
Combination NRT has been shown to be more effective for smoking cessation than any one type of NRT used as monotherapy. The combination approach may be initiated up front, during the first few months of therapy when cravings and withdrawal symptoms are thought to be the most problematic. This approach has been shown to be effective in a randomized trial. When the combination approach was used in this manner, abstinence rates were better in the short term at six months but have been were similar as compared to monotherapy at one year. Thus, the durability of the effect of upfront combination NRT is still questionable. The combination approach has shown to relieve withdrawal symptoms better than monotherapy and has shown no real increased risk of adverse reactions when used in patients in whom NRT is not contraindicated.
Current guidelines state that combination NRT is more effective than monotherapy, and recommend combination therapy for those who are unable to achieve abstinence with single therapy. Some references recommend that combination therapy is more effective in patients who are heavy smokers (greater than 21 cigarettes a day), and therefore higher dose combination NRT would provide higher success rates in this population and may be recommended first line. Combination therapy should not be recommended in patients who smoke less than 10 cigarettes per day due to the potential side effects as well as the theoretical risk of inducing a more substantial addiction to nicotine than the patient is already experiencing.
Research is limited as to the point in time over the course of a patient’s attempt to quit smoking that the combination approach should be used. Recently, guidelines have suggested taking an individualized approach and working with the patient to titrate all forms of NRT to a dose that meets their needs, and this may include a ‘basal-bolus’ approach if necessary. Therefore, clinicians must use their judgement and a thorough patient history which evaluates the number of packs a day smoking and triggers to find a strategy that accommodates the patient.
Therefore, combination therapy is definitely not for all patients and it is unclear whether combination therapy should be used for those patients who cannot achieve abstinence on a single agent or for patients who are highly dependent on nicotine (i.e., 21-40 cigarettes per day), or either situation. Therefore, the place of combination therapy should be left to the discretion of the patient and clinician and be highly individualized. It is important to note that the only Health Canada approved combination therapy is the nicotine patch and gum.
References
1. Pipe A. Nicotine Replacement Therapy. Ontario Pharmacists’ Association. Last updated: n/a. Accessed on June 7, 2012.
2. Regier L, Jensen B, Chan W. Smoking cessation pharmacotherapy. RxFiles. Last updated: March 2012. Accessed on June 7, 2012.
3. Sweeney CT, Fant RV, Fagerstrom KO, McGovern JF, Henningfield JE. Combination nicotine replacement therapy for smoking cessation: rationale, efficacy and tolerability. CNS Drugs. 2001;15(6):453-67.
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Combination NRT most often refers to providing patients who both a long acting source of nicotine to suppress cravings and withdrawal symptoms, combined with a short-acting alternative to help manage ‘breakthrough cravings’ experienced by patients. This approach is termed the ‘basal-bolus’ approach and is a way to help patients overcome significant withdrawal symptoms not relieved by monotherapy.
Combination NRT has been shown to be more effective for smoking cessation than any one type of NRT used as monotherapy. The combination approach may be initiated up front, during the first few months of therapy when cravings and withdrawal symptoms are thought to be the most problematic. This approach has been shown to be effective in a randomized trial. When the combination approach was used in this manner, abstinence rates were better in the short term at six months but have been were similar as compared to monotherapy at one year. Thus, the durability of the effect of upfront combination NRT is still questionable. The combination approach has shown to relieve withdrawal symptoms better than monotherapy and has shown no real increased risk of adverse reactions when used in patients in whom NRT is not contraindicated.
Current guidelines state that combination NRT is more effective than monotherapy, and recommend combination therapy for those who are unable to achieve abstinence with single therapy. Some references recommend that combination therapy is more effective in patients who are heavy smokers (greater than 21 cigarettes a day), and therefore higher dose combination NRT would provide higher success rates in this population and may be recommended first line. Combination therapy should not be recommended in patients who smoke less than 10 cigarettes per day due to the potential side effects as well as the theoretical risk of inducing a more substantial addiction to nicotine than the patient is already experiencing.
Research is limited as to the point in time over the course of a patient’s attempt to quit smoking that the combination approach should be used. Recently, guidelines have suggested taking an individualized approach and working with the patient to titrate all forms of NRT to a dose that meets their needs, and this may include a ‘basal-bolus’ approach if necessary. Therefore, clinicians must use their judgement and a thorough patient history which evaluates the number of packs a day smoking and triggers to find a strategy that accommodates the patient.
Therefore, combination therapy is definitely not for all patients and it is unclear whether combination therapy should be used for those patients who cannot achieve abstinence on a single agent or for patients who are highly dependent on nicotine (i.e., 21-40 cigarettes per day), or either situation. Therefore, the place of combination therapy should be left to the discretion of the patient and clinician and be highly individualized. It is important to note that the only Health Canada approved combination therapy is the nicotine patch and gum.
References
1. Pipe A. Nicotine Replacement Therapy. Ontario Pharmacists’ Association. Last updated: n/a. Accessed on June 7, 2012.
2. Regier L, Jensen B, Chan W. Smoking cessation pharmacotherapy. RxFiles. Last updated: March 2012. Accessed on June 7, 2012.
3. Sweeney CT, Fant RV, Fagerstrom KO, McGovern JF, Henningfield JE. Combination nicotine replacement therapy for smoking cessation: rationale, efficacy and tolerability. CNS Drugs. 2001;15(6):453-67.
.
.