
- Vol 38, Issue 3
- Volume 03
Addressing Smoking: Is Varenicline the Answer?
Many patients with bipolar and other psychiatric disorders believe it is better to wait to address cigarette and other nicotine use. Here is why that is not necessarily the case.
BIPOLAR UPDATE
Many patients with bipolar disorder (BD) have comorbid substance use disorders, including nicotine use. Some
The most effective smoking cessation medication is
The safety results may surprise some clinicians and patients. No differences were reported in moderate to severe neuropsychiatric adverse effects (eg, depression, suicidality, aggression) between varenicline and placebo in either cohort. In fact, as a result of the EAGLES findings, the US Food and Drug Administration removed the longstanding black box warning regarding such adverse effects. Interestingly, these neuropsychiatric adverse events can occur, but they are not more common if the patient is on varenicline. The effects are proposed to be due to
If smoking cessation fails on varenicline, controlled studies have shown augmentations with NRT or bupropion can add efficacy.6,7 Bupropion, however, is probably not a good choice for a patient with BD. The preferred augmentation would be NRT with patch and oral agents followed by slow taper; this strategy may blunt the nicotine withdrawal and increase success rates.
One minor adverse effect of varenicline is insomnia.
The hydrocarbons in cigarette smoke increase the activity of cytochrome P450 1A2, which metabolizes olanzapine and clozapine. Smoking cessation will, therefore, result in gradual deinduction of this enzyme, and plasma levels of these antipsychotics will increase over a week or 2.
Dr Osser is associate professor of psychiatry at Harvard Medical School and colead psychiatrist at the US Department of Veterans Affairs, National Telemental Health Center, Bipolar Disorders Telehealth Program, Brockton, Massachusetts.
References
1. George TP, Wu BS, Weinberger AH.
2. Kandel ER, Kandel DB.
3. Leão RM, Cruz FC, Vendruscolo LF, et al.
4. Anthenelli RM, Benowitz NL, West R, et al.
5. Evins AE.
6. Rose JE, Behm FM. Combination treatment with varenicline and bupropion in an adaptive smoking cessation paradigm. Am J Psychiatry. 2014;171(11):1199-1205.
7. Koegelenberg CF, Noor F, Bateman ED, et al. Efficacy of varenicline combined with nicotine replacement therapy vs varenicline alone for smoking cessation: a randomized clinical trial. JAMA. 2014;312(2):155-161.
8. Raskind MA, Peterson K, Williams T, et al. A trial of prazosin for combat trauma PTSD with nightmares in active-duty soldiers returned from Iraq and Afghanistan. Am J Psychiatry. 2013;170(9):1003-1010.❒
Articles in this issue
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The Age of Cannabis Has Arrived: Issues for Older Adultsover 4 years ago
Clinical Management of Cannabis Complicationsover 4 years ago
Navigating New Challenges in the Management of ADHDover 4 years ago
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