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Dr. Bob is Robert Hsiung, MD,
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Posted by jrbecker on November 12, 2004, at 10:31:00
http://www.medscape.com/viewarticle/493582?rss
Transdermal Nicotine Plus Nortriptyline May Be a Reasonable Option for Smoking Cessation
News Author: Laurie Barclay, MD
CME Author: Charles Vega, MD, FAAFPRelease Date: November 11, 2004
Nov. 11, 2004 — The combination of transdermal nicotine and nortriptyline is a reasonable alternative for smoking cessation, according to the results of a randomized, double-blind trial published in the November issue of the Archives of Internal Medicine."Smoking cessation rates with current therapy are suboptimal," write Allan V. Prochazka, MD, MSc, from the Denver Veterans Affairs Medical Center in Colorado, and colleagues. "Tricyclic antidepressants improve cessation rates. We hypothesized that addition of nortriptyline hydrochloride to transdermal nicotine would enhance cessation rates."
At a Department of Veterans Affairs medical center, 158 adults who smoked 10 or more cigarettes per day were randomized to nortriptyline or to matched placebo. Subjects were aged 18 to 65 years and did not have current major depression. Nortriptyline hydrochloride was started at 25 mg for 14 days before quit day, titrated to 75 mg/day as tolerated, and continued for 12 weeks after quit day, whereas transdermal nicotine, 21 mg/day, was started on quit day and continued for eight weeks. Subjects also received a behavioral intervention consisting of 12 brief individual visits.
Based on a daily diary, there was no significant reduction in withdrawal symptoms with nortriptyline. Smoking cessation at six months, defined as self-reported abstinence, expired carbon monoxide level of 9 ppm or less, and a six-month urine cotinine level less than 50 ng/mL (284 nmol/L), occurred in 18 (23%) of 79 of the nortriptyline group and 8 (10%) of 79 of the placebo group (absolute difference, 13%; 95% confidence interval, 1.3% to 24.5%; P = .05).
Nortriptyline was associated with dry mouth in 38% of patients and sedation in 20%, as well as other adverse effects. There was a greater rate of drug discontinuation in the nortriptyline group than in the nicotine replacement group. One subject with a normal baseline electrocardiogram developed asymptomatic prolongation of the QT interval, suggesting the need to obtain an electrocardiogram while patients are receiving nortriptyline therapy.
"Nortriptyline combined with transdermal nicotine resulted in an increased cessation rate with little effect on withdrawal symptoms," the authors write. "This combination may represent an option for smokers in whom standard therapy has failed."
Study limitations include a baseline imbalance in cigarettes smoked per day, reduction in cigarettes smoked before the formal "quit date" in some patients, blinding only partially effective, small sample size, and relatively low success rate with transdermal nicotine alone.
"There are several possible mechanisms of action for nortriptyline’s effect in enhancing smoking cessation," the authors conclude. "Nortriptyline may reduce depressive symptoms and the need for ‘negative affect’ reduction smoking.... It is also possible that antidepressants suppress the symptoms of nicotine withdrawal with central noradrenergic receptor systems."
The Department of Veterans Affairs, Washington, DC, supported this study. The authors report no financial disclosure.
Arch Intern Med. 2004;164:2229-2233
Learning Objectives for This Educational Activity
Upon completion of this activity, participants will be able to:Compare the use of bupropion, nicotine patches, and a combination of both treatments to facilitate smoking cessation.
Describe the efficacy of nortriptyline in helping patients quit smoking.
Clinical Context
Smoking cessation is a top priority for any patient who smokes, but most attempts at quitting are unsuccessful. Pharmacologic agents, such as bupropion and nicotine replacement patches, may help patients faced with the challenge of smoking cessation. A study by Jorenby and colleagues in the March 2, 1999, issue of the New England Journal of Medicine compared these treatments with placebo in a cohort of smokers. The authors found that 12-month cessation rates were 15.6%, 16.4%, 30.3%, and 35.5% in the placebo, nicotine patch, bupropion, and the bupropion plus nicotine patch groups, respectively. The combination of bupropion and the patch and bupropion alone were statistically equally effective in improving cessation rates compared with placebo, but the nicotine patch alone was no more effective than placebo in improving quit rates.The authors of the current study evaluate another antidepressant, nortriptyline, in combination with nicotine patches in helping patients to quit smoking.
Study Highlights
Patients eligible for the study included adults who currently smoked at least 10 cigarettes per day. All subjects set a quit date within 3 weeks of study entry. Patients were generally healthy and had no history of substance abuse, major depression, or other psychiatric disorder.
Participants were randomized to receive either nortriptyline or placebo beginning 14 days before their set quit date. Nortriptyline was titrated from 25 mg/day to 75 mg/day, and dosage was also adjusted in response to serum drug levels. Both placebo and nortriptyline were continued for 10 weeks after the quit date, and then these treatments were tapered off for 2 weeks.
All subjects received a nicotine patch (maximum dosage, 21 mg/24 hours) for 8 weeks.
The main study outcome was smoking cessation, as defined by patient self-report within one week of the quit date, expired carbon dioxide concentration of 9 ppm or less at follow-up visits, and a urine cotinine level of less than 50 ng/mL at 6 months after randomization.
158 patients underwent randomization. The mean age was 44.5 years, and subjects in the nortriptyline group smoked significantly fewer cigarettes per day than the placebo group (mean, 21 vs 23.7 cigarettes per day, respectively). The mean number of previous quit attempts was nearly 5.
The mean daily dosage of nortriptyline was 62.5 mg/day at one week after the quit day.
Nortriptyline did not improve any withdrawal symptom, including craving, irritability, or restlessness, compared with placebo.
The nortriptyline group had a 6-month rate of smoking cessation of 23%, which was significantly improved compared with the 10% rate of the placebo group.
In a backward stepwise logistic regression procedure, only therapy with nortriptyline was associated with higher rates of smoking cessation. Sex, number of cigarettes smoked per day, expired carbon monoxide levels, and estimates of baseline nicotine dependence did not affect the success of cessation attempts.
Subjects were followed up with the Beck Depression Inventory. Few patients had baseline significant levels for depression, and there was no correlation between baseline scores on the Beck Depression Inventory and rates of smoking cessation.
In a model that accounted for the higher number of cigarettes per day smoked at baseline in the placebo group, nortriptyline lost its significant benefit over placebo.
Nortriptyline was associated with more adverse events than placebo, especially dry mouth and sedation. There was evidence that the blinded study nurse could determine the patient's randomized study treatment, probably based on these adverse events. The withdrawal rates due to adverse events were 13% and 1% for the nortriptyline and placebo groups, respectively.
Pearls for Practice
Bupropion and the combination of bupropion plus the nicotine patch appear effective in helping smokers to quit, but the efficacy of nicotine patches alone in promoting long-term cessation is more questionable.
Nortriptyline in combination with nicotine patches can increase rates of smoking cessation, but anticholinergic adverse effects associated with nortriptyline are common.
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