BNF for Children 2011-2012

BNFC 2011–2012 4.10.2 Nicotine dependence 239Nicotine replacement therapyNicotine replacement therapy can be used in place ofcigarettes after abrupt cessation of smoking, or alternativelyto reduce the amount of cigarettes used inadvance of making a quit attempt. Nicotine replacementtherapy can also be used to minimise passive smoking,and to treat cravings and reduce compensatory smokingafter enforced abstinence in smoke-free environments.Smokers who find it difficult to achieve abstinenceshould consult a healthcare professional for advice.Choice Nicotine patches are a prolonged-release formulationand are applied for 16 hours (with the patchremoved overnight) or for 24 hours. If the individualexperiences strong cravings for cigarettes on waking, a24-hour patch may be more suitable. Immediate-releasenicotine preparations (gum, lozenges, sublingual tablets,inhalator, nasal spray, and oral spray) are used wheneverthe urge to smoke occurs.The choice of nicotine replacement preparationdepends largely on patient preference, and should takeinto account what preparations, if any, have been triedbefore. Patients with a high level of nicotine dependence,or who have failed with nicotine replacementtherapy previously, may benefit from using a combinationof an immediate-release preparation and patches toachieve abstinence.All preparations are licensed for children over 12 years(with the exception of Nicotinell c lozenges which arelicensed for children under 18 years only whenrecommended by a doctor).Cautions Most warnings for nicotine replacementtherapy also apply to continued cigarette smoking, butthe risk of continued smoking outweighs any risks ofusing nicotine preparations. Nicotine replacement therapyshould be used with caution in haemodynamicallyunstable patients hospitalised with severe arrhythmias,myocardial infarction, or cerebrovascular accident, andin patients with phaeochromocytoma or uncontrolledhyperthyroidism. Care is also needed in individuals withdiabetes mellitus—blood-glucose concentration shouldbe monitored closely when initiating treatment.Specific cautions for individual preparations are usuallyrelated to the local effect of nicotine. Oral preparationsshould be used with caution in patients with oesophagitis,gastritis, or peptic ulcers because swallowednicotine can aggravate these conditions. The gum mayalso stick to and damage dentures. Acidic beverages,such as coffee or fruit juice, may decrease the absorptionof nicotine through the buccal mucosa and shouldbe avoided for 15 minutes before the use of oral nicotinereplacement therapy. Care should be taken with theinhalation cartridges in patients with obstructive lungdisease, chronic throat disease, or bronchospastic disease.The nasal spray can cause worsening of bronchialasthma. Patches should not be placed on broken skinand should be used with caution in patients with skindisorders.Hepatic impairment Nicotine replacement therapyshould be used with caution in moderate to severehepatic impairment.Renal impairment Nicotine replacement therapyshould be used with caution in severe renal impairment.Pregnancy The use of nicotine replacement therapy inpregnancy is preferable to the continuation of smoking,but should be used only if smoking cessation withoutnicotine replacement fails. Intermittent therapy is preferableto patches but avoid liquorice-flavoured nicotineproducts. Patches are useful however, if the youngwoman is experiencing pregnancy-related nausea andvomiting. If patches are used, they should be removedbefore bed.Breast-feeding Nicotine is present in milk; however,the amount to which the infant is exposed is small andless hazardous than second-hand smoke. Intermittenttherapy is preferred.Side-effects Some systemic effects occur on initiationof therapy, particularly if the individual is using highstrengthpreparations; however, the individual may confuseside-effects of the nicotine-replacement preparationwith nicotine withdrawal symptoms. Commonsymptoms of nicotine withdrawal include malaise, headache,dizziness, sleep disturbance, coughing, influenzalikesymptoms, depression, irritability, increased appetite,weight gain, restlessness, anxiety, drowsiness, aphthousulcers, decreased heart rate, and impaired concentration.Mild topical reactions at the beginning of treatment arecommon because of the irritant effect of nicotine. Oralpreparations and inhalation cartridges can cause irritationof the throat, gum, lozenges, and oral spray cancause increased salivation, and patches can cause minorskin irritation. The nasal spray commonly causescoughing, nasal irritation, epistaxis, sneezing, andwatery eyes; the oral spray can cause watery eyesand blurred vision.Gastro-intestinal disturbances are common and may becaused by swallowed nicotine. Nausea, vomiting, dyspepsia,and hiccup occur most frequently. Ulcerativestomatitis has also been reported. Dry mouth is acommon side-effect of lozenges, patches, oral spray,and sublingual tablets. Lozenges cause diarrhoea, constipation,dysphagia, oesophagitis, gastritis, mouthulcers, bloating, flatulence, and less commonly, tastedisturbance, thirst, gingival bleeding, and halitosis. Theoral spray may also cause abdominal pain, flatulence,and taste disturbance.Palpitations may occur with nicotine replacement therapyand rarely patches and oral spray can causearrhythmia. Patches, lozenges, and oral spray cancause chest pain.Paraesthesia is a common side-effect of oral spray.Abnormal dreams can occur with patches; removal ofthe patch before bed may help. Lozenges and oral spraymay cause rash and hot flushes. Sweating and myalgiacan occur with patches and oral spray; the patches canalso cause arthralgia.Nicotine medicated chewing gum Individuals whosmoke fewer than 20 cigarettes each day should use onepiece of 2-mg strength gum when the urge to smokeoccurs; individuals who smoke more than 20 cigaretteseach day or who require more than 15 pieces of 2-mgstrength gum each day should use the 4-mg strength.Individuals should not exceed 15 pieces of 4-mgstrength gum daily. If attempting smoking cessation,treatment should continue for 3 months before reducingthe dose.4 Central nervous system