Patient instructions The patch should be applied to a clean, dry, hairless area of skin on the upper chest, upper arm, or hip. It should not be placed on areas of irritated, oily, scarred, or broken skin. Body hair at the application site will interfere with the effectiveness and adhesion of the patch, but the area should not be shaved as this may cause skin irritation and may alter the amount of drug absorbed. The patch should be applied to a different area each day to minimize the potential for local skin reactions. If mild redness occurs at the patch site, it may respond to treatment with an over-the- counter hydrocortisone cream (1%) or oral antihistamines. Hand washing is essential following patch application, as the nicotine on the hands may be transferred to the eyes or nose, causing stinging or redness. The patch may be worn while bathing, swimming, or exercising. If a skin rash develops after using a nicotine patch, or if the skin under the patch becomes swollen or very red, another patch should not be applied and the healthcare provider should be contacted. 65 and efficacy of the continued use of a nicotine inhaler for periods longer than 6 months have not been studied. 66 Contraindications Use of the nicotine inhaler is contraindicated in patients with known hypersensitivity or allergy to nicotine or to menthol. The inhaler has not been specifically studied in asthma or chronic pulmonary disease. Nicotine is an airway irritant that may precipitate bronchospasm, and therefore the nicotine inhaler should be used with caution in patients with bronchospastic disease. Patients should be informed that if they continue to smoke while using the product, they may experience adverse effects because peak nicotine levels will be higher than those experienced from smoking alone. 66 Side effects The most common side effects are nausea, diarrhea, and hiccups. Local irritation in the mouth and throat was reported by 40% of patients. Coughing and rhinitis have also been reported, although these effects declined with continued use. Other side effects may include alterations in taste, pain in jaw and neck, and sinusitis. 66 Patient instructions The patient should be instructed to align the marks on the mouthpiece and pull to separate the mouthpiece into two parts. The nicotine-containing cartridge should be inserted and pressed firmly into the bottom of the mouthpiece until the seal breaks. Shallow puffing releases and vaporizes the nicotine, which then becomes absorbed through the buccal mucosa. The nicotine in the cartridge is delivered over approximately 20 minutes with vigorous puffing. Each cartridge can provide up to 300 to 400 puffs. If the inhaler is used for a shorter period of time, the same cartridge may be reused. However, once a cartridge is opened it is only good for one day. The inhaler should not be used within 15 minutes of eating or drinking as the acidic pH of the mouth will interfere with the absorption of the nicotine through the buccal mucosa. The nicotine inhaler is supplied with 42 cartridges and a plastic storage case. 66 spray are comparable (but lower) to those achieved by smoking. The nasal spray has a faster onset of action (11-13 minutes) compared to the gum, lozenge, patch, or inhaler. 64 The titrated dose of 1 mg of nicotine is delivered through two sprays, one 0.5-mg spray in each nostril. The recommended starting regimen is one or two doses per hour for 6-8 weeks, depending on the patient’s ability to manage withdrawal symptoms. This may be increased up
The recommended dose is based on the number of cigarettes smoked per day as well as the nicotine dependence level. For those who smoke more than 15 cigarettes per day, use of a 21-mg patch is recommended for 4 weeks, followed by step-down dosing to 14 mg for 2 weeks, followed by a 7-mg patch for 2 weeks. 65 Contraindications Patients with dermatologic conditions (e.g., psoriasis, eczema, atopic dermatitis) are more likely to experience skin irritation and should not use the nicotine patch. 65 Side effects The most common side effect of the patch is vivid dreams or sleep disturbances. 64 This reaction can be addressed by removing the patch before going to bed. Other side effects include dizziness, headache, nausea, vomiting, diarrhea, and redness or swelling at the patch site. 65 The nicotine inhaler is available only by prescription and at present only as a brand-name product. It consists of a two-piece plastic unit designed to deliver nicotine contained in individual cartridges. Each foil-sealed cartridge contains a porous plug impregnated with 10 mg of nicotine. Sharp spikes found on the interior of both mouthpiece components pierce the protective covering, allowing the release of nicotine vapor following inhalation. Given that the usual pack-a-day smoker repeats the hand-to-mouth motion up to 200 times per day, many smokers trying to quit find they miss the physical manipulation of the cigarette. The nicotine inhaler was designed to provide nicotine replacement in a manner similar to smoking while addressing the sensory and ritualistic factors that are important to many smokers. When a patient puffs on the inhaler mouthpiece, nicotine vapor is released and is absorbed through the buccal mucosa. 66 Contrary to what the term “inhaler” implies, very little of the nicotine reaches the lower respiratory tract (less than 5% of a dose). The absorption of nicotine takes place through the buccal mucosa. With an intensive inhalation regimen (80 puffs over 20 minutes), approximately 4-mg of nicotine are delivered, and of that, 2-mg are absorbed. Plasma nicotine levels are 50% to 70% lower than those achieved with cigarette smoking, and peak nicotine concentrations occur after 30 minutes compared to 5 minutes after cigarette smoking. 66 The initial dose for the inhaler should be individualized. The dose may be titrated to alleviate withdrawal symptoms. Generally, 6 to 16 cartridges should be used throughout the day. The best effects are achieved by frequent, continual puffing (for 20 minutes). 62 Initial dosing should begin with at least 6 cartridges per day and can be increased as needed to a maximum of 16 cartridges per day for 3 to 12 weeks. The recommended duration of treatment is 3 months, after which use may be decreased by gradual reduction of the daily dose over the following 6 to 12 weeks. The safety Nicotine inhaler Use and dosage
Nicotine nasal spray Use and dosage
Nicotine nasal spray is available only by prescription and is currently available only as a brand-name product. A metered-spray pump contains an aqueous solution of nicotine for administration to the nasal mucosa. When the pump is depressed, 50 µL of spray containing 0.5 mg of nicotine is dispensed. Nicotine is rapidly absorbed, and plasma nicotine concentrations attained via the nasal
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