A 43-year-old man comes to the office to discuss smoking cessation. He is motivated to quit but has been unable to do so on his own and thinks that he needs help. The patient has smoked 1-2 packs of cigarettes a day over the past 20 years and has been able to stop for varying periods. He has tried bupropion, nicotine replacement, and varenicline. He found them all to be helpful to some degree but had the most success with varenicline. Medical history includes coronary artery disease and a myocardial infarction 4 months ago. At that time he underwent an urgent right coronary artery revascularization with placement of a drug-eluting stent. The left anterior descending artery had a 70% mid-segment obstruction, which was not revascularized. Since then he has felt well and has had no further chest pain. The patient has a history of depression in his early 30s. He has occasional anxiety that he might "get another heart attack" as he still has "a blockage in the artery." Medications include simvastatin, metoprolol, aspirin, and prasugrel.
Blood pressure is 132/78 mm Hg and pulse is 62/min. BMI is 29 kg/m². Physical examination is unremarkable.
Appropriate behavioral support is provided, and the risks and benefits of various treatment options are discussed during the visit.
Which of the following is the most appropriate course of action to address this patient's smoking?

Question

Quizplus · Accepted Answer

Varenicline is a partial agonist at the alpha-4 beta-2 nicotinic acetylcholine receptor and the most effective single intervention for smoking cessation. Partial agonism of the nicotinic receptor decreases nicotine withdrawal and cravings for smoking. Despite initial concerns about possible serious adverse neuropsychiatric effects from varenicline, the black box warning for these adverse effects was removed in 2016. Based on newer findings, varenicline does not appear to increase the risk of suicidality or depression compared to placebo. There also appear to be no differences between the rates of serious psychiatric symptoms in patients taking bupropion, nicotine replacement therapy (NRT), or varenicline. A history of depression is not a contraindication to varenicline treatment (Choice A). However, a cautious approach would suggest a discontinuation of varenicline if any new neuropsychiatric symptoms emerge soon after starting this medication. Varenicline should be avoided in patients with current unstable psychiatric status or recent suicidal ideation. Varenicline has also been associated with a possible increase in cardiac events (eg, myocardial ischemia, arrhythmia), especially in patients with known cardiac disease; but the risks are minimal. Any risk is likely outweighed by the benefits of smoking cessation, and cardiac disease is not an absolute contraindication (Choice B). (Choice C) Varenicline is not associated with significant liver function abnormalities, and routine monitoring is not needed. Statins may cause increases in hepatic transaminases after initiation or dose change, but severe hepatotoxicity is rare. (Choice D) Given the effectiveness of varenicline (particularly in this patient's history) and the absence of any absolute contraindications to its use, there is no clear reason to favor bupropion and/or NRT. Educational objective: Varenicline is an effective treatment for smoking cessation. Despite initial concerns about adverse neuropsychiatric symptoms, varenicline does not appear to increase the risk of suicide or depression in patients with past psychiatric symptoms. Although adverse cardiovascular events (eg, myocardial ischemia, arrhythmia) are possible, the risks are thought to be less than those from continued smoking. __________ References: Neuropsychiatric safety and efficacy of varenicline, bupropion, and nicotine patch in smokers with and without psychiatric disorders (EAGLES): a double-blind, randomised, placebo-controlled clinical trial. (http://www.ncbi.nlm.nih.gov/pubmed/27116918) Risk of neuropsychiatric adverse events associated with varenicline: systematic review and meta-analysis. (http://www.ncbi.nlm.nih.gov/pubmed/25767129)

A 43-Year-Old Man Comes to the Office to Discuss Smoking