Making Every Contact Count Darush Attar-Zadeh BPharm MRPharmS This - PowerPoint PPT Presentation

Making Every Contact Count Darush Attar-Zadeh BPharm MRPharmS This presentation is organised and funded by Pfizer Prescribing Information for Champix  (varenicline tartrate) is available at this meeting Adverse events should be reported. Reporting forms and information can be found at www.mhra.gov.uk/yellowcard. Adverse events should also be reported to Pfizer Ltd on 01304 616161. MTGGIP30133a September 2015

Making every contact count By Darush Attar-Zadeh BPharm MRPharmS darushattar@hotmail.com

Principles underlying treatment To keep the motivation not to smoke above the motivation to smoke at all times Resolve not to smoke Urge/need Maximise Minimise to smoke resolve: urge/need: ‘Not a puff rule’ Avoid cues Ex-smoker Reduce identity physiological need Social contract Distraction/coping Personal satisfaction 4

Skin, Hair, Nails & Gums – cosmetic benefits

Health Benefits

CO (ppm ppm) % COHB 20 and above 3.20+ Heavy vy Smoker 20 20 3.20 19 19 3.04 18 18 2.88 17 17 2.72 16 16 2.56 15 15 2.40 Smoker 14 14 2.24 13 13 2.08 12 12 1.92 11 11 1.76 10 10 1.60 9 1.44 Light Smoker 8 1.28 7 1.12 6 0.96 5 0.80 4 0.64 Non-Smoker 3 0.48 2 0.32 1 0.16

Why should we help people stop smoking?

SMOKING RELATED DEATHS IN ENGLAND (2011) Proportion of deaths estimated to be caused by smoking 1 Lung, trachea and bronchus cancer 1% 12% Other cancers 29% 11% COPD 6% Pneumonia 18% 23% Ischaemic Heart Disease Other circulatory Digestive 1. http://ash.org.uk/files/documents/ASH_107.pdf

COPD Causes: • Approximately 90 percent of COPD cases in the UK are caused by smoking tobacco • Links with passive smoking and air pollution

Asthma & COPD

It only takes 30 seconds

NMS, MUR Are you on any PMR OTC Inhalers medication? Antihypertensives Check PMR/Label Warfarin Does anybody in Diabetes your household Mental Health smoke? Team Approach

Am J Health-Syst Pharm — Vol 64 Sep 15, 2007

• Pharmacotherapy in combination with intensive behavioural support gives the optimum chance of success 1 1. NHS. Local stop smoking services. Service delivery and monitoring guidance, 2011/12. 3 West R, et al. Thorax 2000;55:987─999. 2. Hilton A. Prescriber 2003 ; February:14─20 . 3. Fowler G. Update 2000 ; May supplement:3 ─ 7. 4.

. Effectiveness Intervention Outcome NNT Statins Prevent one death over five 107 years Antihypertensive therapy Prevent one stroke, 700 myocardial infarction, death over one year Cervical cancer screening Prevent one death over 10 1140 years GP brief advice to stop Prevent one premature death 80 smoking (< five minutes) Add pharmacological support Prevent one premature death 38 - 56 Add behavioural support Prevent one premature death 16 - 40 Successful quit attempt Prevent one premature death 2 darushattar@hotmail.com 19 Note: For illustrative purposes only since NNTs across trials shouldn't theoretically be compared due to e.g. different study populations, trial lengths and outcomes.

Effectiveness of smoking cessation therapies – The Cochrane review • The Cochrane Collaboration is a well established, non-profit, independent organisation dedicated to making up-to-date and accurate information about the effects of healthcare interventions available 1 • A Cochrane review assessed the efficacy and tolerability of nicotine receptor partial agonists, including varenicline, for smoking cessation 2 NNT to achieve additional successful quitter compared with placebo 2 All types of NRT 23 (95% CI 20-27) Bupropion 20 (95% CI 16-26) Varenicline 10 (95% CI 8-12) 1. The Cochrane database. Available at: www.cochrane.org/about-us. Accessed May 2011. 2. Cahill K, Stead LF, Lancaster T. Nicotine receptor partial agonists for smoking cessation. The Cochrane Database of Systematic Reviews 2011;Issue 2. [DOI: 10.1002/14651858.CD006103. pub5]. .

The Importance of NHS Support & Medication Success rate at 4 weeks Best possible treatment with no support or outcome at 4 weeks medication (16%) (74%) Support & Medication [1] Cochrane Database of Systematic Reviews [2] Cochrane Database of Systematic Reviews

NICOTINE IS HIGHLY ADDICTIVE

Why is it hard for your patient to stop smoking? • Short half life of nicotine requires smokers to regularly smoke to maintain levels 2 • Reinforcing desired effects of nicotine with each cigarette soon becomes addictive 2 1. Russell MAH, et al. BMJ 1976; 1:1043-1046 2. Nicotine addiction in Britain: A report of the Tobacco Advisory Group of the Royal college of Physcians. London: Royal College of Physicians, 2000

Smoking makes stress worse! dattar-zadeh@nhs.net 07961393032

Keep the message simple! Varenicline at the  4  2 receptor Partial agonist Antagonist • Prevents stimulation of the receptor • Binds with high affinity to the  4  2 receptor, only partially stimulating by nicotine dopamine release 1 • This reduces the pleasurable effects • Provides relief from craving and of smoking and potentially the risk of withdrawal symptoms 1-3 full relapse after a temporary lapse 1-4 1 . Coe JW. J Med Chem 2005; 48:3474-3477. 2 . Gonzales D et al. JAMA 2006; 296:47-55. 3 . Jorenby DE et al. JAMA 2006; 296:56-63. 4 . Foulds J. Int J Clin Pract 2006; 60:571-576.

What does equal 1 st line mean? • Promoting Medications • There are 2 Non- Nicotine treatments • 8 forms of NRT (There is the patch, gum......) Varenicline & Buproprion. • 2 Non – Nicotine • Also there are 8 NRT Treatments products (patch, • Varenicline & gum......) Buproprion • Varenicline works by...... What treatments have you heard about? Have you tried anything in the past?

DOSING OF VARENICLINE

Varenicline (Champix) Contraindications • Allergy to varenicline or excipients • Not licensed for use in people under 18 Pregnancy & Breast feeding • Champix should not be used during pregnancy. • Breast feeding: Decision based on consideration of benefit of breast- feeding to the child and benefit of CHAMPIX therapy to the mother Special populations • Renal impairment: – Mild: No dosage adjustment necessary – Moderate; No dosage adjustment necessary unless intolerable adverse event symptoms experienced (reduce dose to 1mg/day) – Severe: Reduce dose to 1mg/day – End Stage Renal Disease: Not recommended CHAMPIX Summary of Product Characteristics June 23 rd 2015. Accessed September 2015

Special warnings and precautions for use • Changes in behaviour or thinking, anxiety, psychosis, mood swings, aggressive behaviour, depression, suicidal ideation and behaviour and suicide attempts have been reported in patients attempting to quit smoking with CHAMPIX in the post-marketing experience. 1 Clinicians should be aware of the possible emergence of significant depressive symptomatology in patients undergoing a smoking cessation attempt, and should advise patients accordingly. • CHAMPIX should be discontinued immediately if agitation, depressed mood or changes in behaviour or thinking that are of concern to you, your patient, their family or their caregivers are observed, or if the patient develops suicidal ideation or suicidal behaviour. 1 • Depressed mood, rarely including suicidal ideation and suicide attempt, may be a symptom of nicotine withdrawal. In addition, smoking cessation, with or without pharmacotherapy, has been associated with exacerbation of underlying psychiatric illness (e.g. depression). • Since the initial reports of serious neuropsychiatric events emerged, analyses of pooled clinical trial data and independent observational data have been conducted (See section 5.1). • Patients taking CHAMPIX should be instructed to notify their doctor of new or worsening cardiovascular symptoms and to seek immediate medical attention if they experience signs and symptoms of myocardial infarction or stroke 1 • CHAMPIX smoking cessation studies have provided data in patients with major depressive disorder and limited data in patients with stable schizophrenia or schizoaffective disorder (see section 5.1). Care should be taken with patients with a history of psychiatric illness and patients should be advised accordingly. 1 • At the end of treatment, discontinuation of CHAMPIX was associated with an increase in irritability, urge to smoke, depression, and/or insomnia in up to 3% of patients. The prescriber should inform the patient accordingly and discuss or consider the need for dose tapering # CHAMPIX Summary of Product Characteristics June 23 rd 2015. Accessed September 2015