A 45 year old male is a patient at your ambulatory care clinic. He has been interested in quitting smoking but expresses to you that he would like to stop today. He reports smoking 30 cigarettes per day and smokes his first cigarette within 10 minutes after waking up. You decide that nicotine replacement therapy (NRT) is the best option for this patient. Select the most appropriate NRT to begin today along with appropriate counseling for him.

a. Nicotine transdermal patch 14 mg patch daily; the patch should be applied on a clean, hairless portion of the upper body and the application site should be rotated daily

b. Nicotine gum 4 mg piece chewed every 1-2 hours; the patient should avoid coffee, juice, and other acidic substances for at least 15 minutes before chewing each piece

c. Nicotine lozenge 2 mg every 1-2 hours; the patient be placed between the gums and the cheek and rotated to a new site in the mouth periodically to avoid mucosal irritation 

d. Nicotine nasal inhaler 0.5 mg/spray 6-7 sprays each hour; common side effects of this medication include a peppery sensation, sneezing, coughing, watery eyes, or runny nose

Answer with rationale:

The correct answer is B.

Pharmacists are often involved in helping patients with smoking cessation. Because of the various dosage forms of nicotine, it is important to provide sound advice to patients wishing to being NRT. Additionally, maximal smoking cessation occurs with medications as part of a comprehensive program including counseling.

Option A is incorrect because the starting dose of the nicotine patch is 21 mg daily for all patients who smoke more than 10 cigarettes daily. This dose is then titrated down after 6 weeks to 14 mg daily for 2 weeks, then 7 mg daily for 2 weeks (Nicoderm CQ). For the Habitrol product, you can titrate down from 21 mg daily to 14 mg daily after 4 weeks. 

Option B is the correct choice. Since this patient smokes more than 25 cigarettes per day, the starting dose of the nicotine gum is the 4 mg dose. For patients who smoke less than 25 cigarettes per day, the starting dose is 2 mg every 1-2 hours. The patient should be counseled to avoid acidic substances before chewing the gum to avoid a decreased absorption.

The dose in option C is incorrect due to this patients smoking habits. For the nicotine lozenges, the 2 mg dose is only recommended for patients who smoke later than 30 minutes after awakening while the 4 mg is recommended for patients who smoke within 30 minutes of awakening.

Option D is incorrect as the starting dose is 1-2 sprays per hour and the patient should not exceed 5 sprays per hour or 40 doses per day.

The counseling points for each option are correct for the dosage form it is matched with.

Important counseling information and more details regarding smoking cessation therapies can be found here in the NAPLEX Review Guide: Chapter 67: Smoking Cessation.

Congratulations to those of you who have passed the exam! Good luck to all those who will be taking it soon!