ABC | Volume 113, Nº4, October 2019

Updated Updated Cardiovascular Prevention Guideline of the Brazilian Society Of Cardiology – 2019 Arq Bras Cardiol. 2019; 113(4):787-891 Chart 7.2 – Non-nicotine therapy 300 Bupropion hydrochloride • Simulates some of the effects of nicotine on the brain by blocking the neuronal uptake of dopamine and norepinephrine. It may be used in combination with nicotine replacement therapy with patch • Excellent option for subgroups of relapse-prone smokers with depression after smoking cessation, and for women and those with a high degree of dependence. Success rates for smoking cessation range 30 to 36% • Therapeutic scheme: Start treatment 8 days before smoking cessation – 150 mg in the morning for three days, followed by 150 mg in the morning and afternoon at 8-hour intervals for 3 months, which may be extended for up to 6 months. Control blood pressure and, if elevated, the dose may be reduced to 150 mg/day before stopping in refractory cases. Reduce doses in renal and hepatic impairment to 150 mg/day. Monoamine oxidase inhibitors should be discontinued for up to 15 days before starting bupropion. Use with caution or avoid in patients on antipsychotics, theophylline and systemic steroids, as it favors the onset of seizures • Contraindications: – Absolute: history of convulssions (even febrile), epilepsy, brain injury, electroencephalogram abnormalities, brain tumor, severe alcoholism, anorexia nervosa and bulimia, pregnancy and breasfeeding – Relatives: Combined use of barbiturate, benzodiazepines, cimetidine, pseudoehedrine, phenytoin, oral hyproglycemic agents or insulin Varenicline tartarate • α4β2 nicotinic acetylcholine receptor partial agonist, which mediates the release of dopamine in the brain • Has double effect: reduces withdrawal symptoms and the desire to smoke • Therapeutic schedule: start 1 week before the cessation date, with 0.5 mg for 3 days in the morning, followed by 0.5 mg from the 4th to 7th morning (7 h) and in the afternoon (19 h) and 1 mg/day for 3 months in the morning (7 h) and in the afternoon (19 h), which may be extended to 6 months in cases without complete cessation of smoking or risk of relapse. Varenicline is administered orally and does not undergo hepatic metabolism, and it isrenally excreted practically unchanged • Adverse effects: nausea (20%), headache, vivid dreams and weight gain. Rarely, mood changes, agitation, restlessness, and aggressiveness • Because it is not metabolized by the liver, varenicline does not interfere with concomitant use of digoxin, metformin or warfarin. Cimetidine may increase varenicline bioavailability • It should be used with caution in patients with renal failure • Contraindication: pregnancy, breastfeeding, less than 18 years old, bipolar disorder, schizophrenia or epilepsy The combination of varenicline and bupropion appears to be the most effective of all (Evidence B); 285 however, randomized studies 286 of greater consistency need to be performed. 7.6. Future Proposals The use of serotonin reuptake inhibitors has not proven to be an option for treatment of withdrawal symptoms, 281 but considering how often depressive symptoms manifest during smoking cessation, 285 with or without drugs, 286 randomized trials to test concomitant use of this drug should be conducted to assess whether results are improving, as nicotine has an action on monoaminoxidase A, which is responsible for serotonin degradation, among many other neurotransmitters, which would explain the high frequency of this condition. smoking cessation, with or without anti-smoking medication. Bupropion and varenicline have no action on serotonin, explaining the higher frequency of mood disorders in drug users compared to those on nicotine replacement. We believe that this event is more likely to occur in varenicline users due to the high antagonist potency in the α 4 β 2 receptor, thus preventing nicotinic action, even if the patient smokes. From this perspective, the longitudinal, observational study that evaluated the effectiveness of the combination of varenicline, bupropion and sertraline 287 had a better success rate among those that used all three drugs. These findings warrant corroboration through a randomized, placebo-controlled study, so that there is indeed robust evidence of the benefit of these combinations, as well as testing whether the use of serotonin reuptake inhibitors is confirmed as an ancillary strategy in anti-smoking treatment in patients who manifest depressive symptoms during smoking treatment. 288,289 Nicotine vaccines, 290 long awaited to comprise the therapeutic arsenal, are still under study. They act by stimulating the immune system to produce specific antibodies that bind with great affinity to nicotine in plasma and extracellular fluids.Nicotine bound to antibodies cannot cross the blood-brain barrier because of its size, the vicious circle of gratification for brain receptor activation is broken. The main brands under study are: Nic-VAX®, TA-Nic® and Nic-Qb®. 7.7. Nicotine Electronic Devices (Electronic Cigarette, Heated Cigarette, Pen Drives) These devices were launched in 2006 and have since been refined by their manufacturers to replace the 826