A 65-year-old woman with moderate chronic obstructive pulmonary disease and hypertension comes to the office for dyspnea that occurs when she walks more than 2 or 3 blocks. The dyspnea is not new and she has a chronic cough. The patient has a 40-pack-year smoking history and wants to know if there is anything she can do to stop. "I want to be done with these damn cigarettes." She briefly tried nicotine replacement therapy and cognitive-behavioral therapy for smoking cessation but found them to be only partially helpful. The patient also has a history of bipolar disorder and a chronic eating disorder. Her last episode of depression was a year ago. Medications include albuterol, salmeterol, fluticasone, and hydrochlorothiazide. She takes no psychiatric medications.
The patient is afebrile. Blood pressure is 138/88 mm Hg and pulse is 94/min. Physical examination shows decreased breath sounds and expiratory wheezes, which are not new.
Which of the following is the most appropriate next step in management of this patient's smoking?

Question

A 65-year-old woman with moderate chronic obstructive pulmonary disease and hypertension comes to the office for dyspnea that occurs when she walks more than 2 or 3 blocks.  The dyspnea is not new and she has a chronic cough.  The patient has a 40-pack-year smoking history and wants to know if there is anything she can do to stop.  "I want to be done with these damn cigarettes."  She briefly tried nicotine replacement therapy and cognitive-behavioral therapy for smoking cessation but found them to be only partially helpful.  The patient also has a history of bipolar disorder and a chronic eating disorder.  Her last episode of depression was a year ago.  Medications include albuterol, salmeterol, fluticasone, and hydrochlorothiazide.  She takes no psychiatric medications.
The patient is afebrile.  Blood pressure is 138/88 mm Hg and pulse is 94/min.  Physical examination shows decreased breath sounds and expiratory wheezes, which are not new.
Which of the following is the most appropriate next step in management of this patient's smoking?

Quizplus · Accepted Answer

11ec193a_98b1_a821_853d_538aeea03f4b_MD0002_00 Smoking cessation is beneficial, even in those who have smoked for many years. Most smokers attempt to quit several times, using different pharmacological and behavioral approaches, before they are finally successful. Varenicline is a high-affinity nicotine receptor partial agonist that increases long-term success rates for smoking cessation. It is more effective than nicotine replacement therapy (NRT) and bupropion. Despite initial concerns about increasing the risk of suicide and/or depression, newer findings have shown no increased neuropsychiatric risk from varenicline, so this patient's psychiatric history is not a contraindication to its use. There is a possible increase in cardiovascular risk, but the benefits of smoking cessation often outweigh this. Bupropion, a norepinephrine and dopamine reuptake inhibitor and antidepressant, can be effective for smoking cessation and may help reduce post-cessation weight gain. However, it is contraindicated in patients with active eating disorders or a history of seizures, and it may destabilize mood in patients with bipolar disorder (Choice B). NRT is used to decrease withdrawal symptoms and reduce nicotine cravings. Combining a long-acting NRT (eg, patch) with a short-acting NRT (eg, gum, lozenge, nasal spray), termed a "patch-plus" regimen, is more effective than either modality alone. In a patient with poor previous response to NRT, the use of short-acting NRT alone is likely to be suboptimal (Choice E). (Choice A) Behavioral interventions have a significant but small benefit for smoking cessation. Even brief counseling (3 minutes) has been shown to increase quit rates by approximately 5%. However, pharmacotherapy is indicated as this patient has smoking-related complications and insufficient response to past behavioral treatments. (Choice D) Combining varenicline and NRT should not be considered unless the patient has already failed varenicline monotherapy. Also, study results have been inconsistent regarding added clinical benefit from this combination over varenicline alone, and there is questionable justification for this combination, given that nicotine and varenicline compete for the same nicotinic receptor. Educational objective: Varenicline is the most effective intervention for smoking cessation, and the small increased risk of cardiovascular events is outweighed by the risks of continued smoking for most patients. Bupropion is a good option for patients who are concerned about post-cessation weight gain, but it is contraindicated in those with seizure or eating disorders. __________ References: Cardiovascular and neuropsychiatric risks of varenicline and bupropion in smokers with chronic obstructive pulmonary disease. (http://www.ncbi.nlm.nih.gov/pubmed/28473506) Risk of neuropsychiatric adverse events associated with varenicline: systematic review and meta-analysis. (http://www.ncbi.nlm.nih.gov/pubmed/25767129)

A 65-Year-Old Woman with Moderate Chronic Obstructive Pulmonary Disease and Hypertension