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 7.3 – Nicotine Replacement Therapy 300 Rapid Nicotine Replacement: chewing gum and lozenge • Used when craving (imperative need to smoke) or at 1- to 2-hour intervals • Promotes faster release of nicotine. It can be combined with nicotine patch or combined with bupropion and varenicline • The approximate time for nicotine release is 5 minutes with the lozenge and 10 minutes with the gum • The maximum tolerated dose is around 10 gums or lozenges per day • Patients should chew/suck the gum/lozenge until it tastes spicy. At this point, they should stop for 2 minutes (time to absorb nicotine) until the taste disappears and then chew/suck again by repeating the cycle within 20 minutes for a second nicotine release. They should drink a glass of water before use to neutralize oral pH, which changes with food intake, and to remove food residues, which may decrease absorption by the oral mucosa • Side effects: hypersalivation, nausea, hiccups, gingival ulceration (which may lead to tooth softening) and temporomandibular joint (TMJ) pain • Contraindication: inability to chew/suck, oral mucosa lesions, peptic ulcer, TMJ subluxation and use of mobile dental prostheses Slow Replenishment: Nicotine Patch • The patches are provided in boxes of seven units each, in doses ranging from 7 to 25 mg • They are indicated to maintain a continuous level of circulating nicotine for 24 hours, in a process of gradual smoking cessation • They may be indicated as pre-cessation therapy for 2 to 4 weeks in smokers who have a hard time reducing the number of cigarettes and setting a date to quit • The patches should be applied in the morning to covered areas on the upper chest or anterior, posterior and upper lateral regions of the arm, rotating between these sites and changing at the same time of day. Sun exposure should be avoided at site • They may be used in combination with bupropion or varenicline • Therapeutic scheme: – Smoker of 20 cigarettes/day and/or with Fagerström score of 8-10 points: A patch of 21 to 25 mg/day from the 1st to 4th week; 14 to 15 mg/day from 5th to 8th week; 7 mg/day from 9th to 10th week. It is suggested to put the patch on in the morning just after waking up. In cases of insomnia, it should be removed after 16 hours of use. In special cases of high dependence and in the absence of contraindication, up to two 21-mg patches may be used – Smoker of 10-20 cigarettes/day and/or with Fagerström score of 8-10 points: A patch of 14-15 mg/day in the first 4 weeks followed by 7 mg/day from the 5th to 8th week • Side effects: pruritis, rash, erythema, headache, nausea dyspepsia, myalgia and tachycardia with overdose • Contraindications: history of recent myocardial infarction (in last 15 days), severe cardiac arrhythmias, unstable angina pectoris, peripheral vascular disease, peptic ulcer, skin diseases, pregnancy and breastfeeding Chart 7.4 – Standard pharmacological treatment for smoking 300 Medication Start of treatment Therapeutic scheme Duration (weeks) Nicotine replacement therapy: patch On date chosen for smoking cessation 21-25 mg/day - 4 weeks 14-15 mg/day - 4 weeks 7 mg/day - 2 weeks Smokers with greater dependence may need doses higher than 21 mg 8 to 10 Nicotine replacement therapy: gum or lozenge On date chosen for smoking cessation 2 or 4 mg: 1 to 4 times a day 8 to 10 Non-nicotine therapy: bupropion One week before date chosen for smoking cessation First to third day - 150 mg, 1 x day Fourth to last day- 150 mg, 2 x a day 12 Non-nicotine therapy: varenicline One week before date chosen for smoking cessation First to third day – 0.5 mg, 1 x day Fourth to seventh day – 0.5 mg every 12 hours Eighth to last day - 1 mg every 12 hours 12 828