in the treatment of heart failure, may require an increased dosage. 67 The amount of nicotine that is tolerated by an adult can produce symptoms of poisoning and could prove fatal if nicotine nasal spray is used or ingested by children or pets. A full bottle of nicotine nasal spray contains 100 mg of nicotine, some of which will still be in the bottle when it is discarded. Both used and unused containers should be kept out of the reach of children and pets. 67 Side effects The most common side effects of the nasal spray are a hot, peppery feeling in the back of the nose or throat, a running nose, throat irritation, watering eyes, sneezing, and coughing. 67 Patient instructions The thumb and index finger should be used to press the circles on the sides of the bottle to remove the child- resistant cap. Prior to use, the pump should be primed into a tissue by holding the bottle and pressing firmly on the glass bottom with the thumb until a fine spray is visible (about six to eight times). The tissue should be safely discarded after use. Before using the spray, ensure that the nose is clear. The head should be tilted back slightly, and the tip of the bottle inserted into the nostril as far as is comfortable. While breathing through the mouth, one metered dose should be dispensed in each nostril. Sniffing, swallowing, or inhaling through the nose while administering the medication increases the irritating effects of the spray. Allow 2-3 minutes before blowing the nose to allow the nicotine to be absorbed across the nasal mucosa. Contact with skin, eyes, and mouth should be avoided. If contact occurs, immediately rinse with water, as nicotine is readily absorbed across the skin and mucous membranes. 67 Contraindications Use of bupropion SR is contraindicated in patients with a history of seizures, anorexia, or bulimia nervosa; patients being treated with Wellbutrin SR or MAO inhibitors; and patients undergoing abrupt discontinuation of alcohol or sedatives (including benzodiazepines). Three hundred fifty-one major drug interactions have been identified with concomitant use of bupropion SR; therefore, a thorough drug history should be completed prior to prescribing its use. 71 Bupropion SR should be used with extreme caution in patients with severe hepatic cirrhosis. Serious neuropsychiatric symptoms have been reported in patients taking bupropion SR for smoking cessation. These symptoms include changes in mood (including depression and mania), psychosis, hallucinations, paranoia, delusions, homicidal ideation, hostility, agitation, aggression, anxiety, and panic, as well as suicidal ideation, attempted suicide, and completed suicide. 69 The association between bupropion and depression can be complicated for patients taking bupropion for smoking cessation, because depression may be a symptom of nicotine withdrawal. 72 Depression that rarely includes suicidal ideation has been reported in smokers undergoing a smoking cessation attempt without medication. 69 However, some of these symptoms have occurred in patients taking bupropion SR who continue to smoke. Most reported that symptoms occurred during treatment with bupropion SR, but some occurred after discontinuation of treatment with the drug. These events occurred in patients with and without mental disorders. Some patients experienced worsening of their psychiatric illnesses. All patients being treated with
to a maximum recommended dose of 40 mg (80 sprays, about half a bottle) per day. For best results, patients should be encouraged to use a minimum of eight doses per day during the first 6 to 8 weeks of therapy. The daily dose should be gradually decreased over an additional 4-6 weeks. If relapse is a concern, the duration of use can be extended to 6 months. Recommended strategies for discontinuing use include using only half a dose (one spray) at a time and using the spray less frequently. The nicotine nasal spray has the highest drug dependence profile of the nicotine replacement medications. 67 The extent of absorption is slightly reduced in patients with the common cold/rhinitis. In patients with rhinitis, the peak plasma concentration is reduced by approximately 20% and the time period to peak concentration prolonged. The use of a nasal vasoconstrictor will further prolong the time interval before peak plasma levels. 67 Contraindications Use of nicotine nasal spray is not recommended in patients with known chronic nasal disorders (e.g., allergy, rhinitis, nasal polyps, and sinusitis). Exacerbation of bronchospasm in patients with preexisting asthma has been reported. Use of the spray in patients with severe reactive airway disease is not recommended. Topical application of either nicotine or tobacco products irritates nasal mucosa. Tachycardia has been reported in association with nicotine nasal spray, although no serious cardiovascular events have been reported. Nicotine nasal spray therapy should be used with caution in patients with hyperthyroidism, pheochromocytoma, or insulin-dependent diabetes. 67 Concomitant use of acetaminophen, caffeine, imipramine, oxazepam, pentazocine, propranolol or other beta-blockers, theophylline, insulin, and adrenergic antagonists may require a decrease in dose. Use of adrenergic agonists such as dobutamine (Dobutrex, Inotrex), commonly employed Bupropion SR, a sustained-release antidepressant, is a non- nicotine aid to smoking cessation. Bupropion SR has been demonstrated to increase the likelihood of abstinence from smoking for as long as six months compared to treatment with a placebo. 68,69 In a 2005 study done by general practitioners in Italy, bupropion SR more than doubled the odds of continuous abstinence from smoking. 70 Bupropion SR is available only by prescription and is dispensed in both generic and brand-name forms. The mechanism by which bupropion SR enhances the ability of patients to abstain from smoking is unknown. However, it is believed to be a weak inhibitor of the neuronal uptake of norepinephrine and dopamine. Reductions of the following withdrawal symptoms are most pronounced: irritability, frustration, or anger; anxiety; difficulty concentrating; restlessness; and depressed mood or negative affect. Bupropion SR is supplied in 150-mg tablets. Therapy should be initiated one week prior to the quit date to assure that therapeutic plasma levels of the drug are achieved. The titration dose is 150 mg by mouth in the morning for three days followed by 150 mg twice per day for the duration of therapy (7 to 12 weeks). The daily dose of bupropion SR for smoking cessation should not exceed 300 mg per day. For patients who remain abstinent after 7 to 12 weeks of treatment, ongoing therapy should be considered. Maintenance therapy at 300 mg bupropion SR per day can be continued for up to six months to prevent relapse. Dose tapering is not required when discontinuing treatment. If significant progress toward abstinence is not achieved by the seventh week of therapy, treatment should be discontinued. 69 Bupropion SR (Zyban) Use and dosage
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