A 36-year-old woman comes to the clinic for smoking cessation counseling. She has smoked 2 packs of cigarettes daily for 18 years. The patient has tried to quit multiple times but failed. She works as a corporate attorney and has 2 important cases she is closing this month. The patient says, "Every time I try to quit smoking, I start shaking really badly. I can't sleep, and I get very anxious, depressed, and frustrated. I can't seem to concentrate, which is bad because my job is very demanding. I need to perform well and show my boss that I can handle the more difficult cases she gives me. I'm also concerned about gaining weight if I stop smoking." The patient is recently married. Her husband does not smoke and has asthma, which is worsened by her smoking. The patient feels motivated to stop but concerned about her ability to do so. She has a history of a seizure disorder but discontinued anticonvulsant therapy 5 years ago after a few years of being seizure free. She also has a history of depression successfully treated with psychotherapy in her 20s. Which of the following is the most appropriate next step in management of this patient?

Question

A 36-year-old woman comes to the clinic for smoking cessation counseling.  She has smoked 2 packs of cigarettes daily for 18 years.  The patient has tried to quit multiple times but failed.  She works as a corporate attorney and has 2 important cases she is closing this month.  The patient says, "Every time I try to quit smoking, I start shaking really badly.  I can't sleep, and I get very anxious, depressed, and frustrated.  I can't seem to concentrate, which is bad because my job is very demanding.  I need to perform well and show my boss that I can handle the more difficult cases she gives me.  I'm also concerned about gaining weight if I stop smoking."  The patient is recently married.  Her husband does not smoke and has asthma, which is worsened by her smoking.  The patient feels motivated to stop but concerned about her ability to do so.  She has a history of a seizure disorder but discontinued anticonvulsant therapy 5 years ago after a few years of being seizure free.  She also has a history of depression successfully treated with psychotherapy in her 20s.  Which of the following is the most appropriate next step in management of this patient?

Quizplus · Accepted Answer

Explanation: 11ec2b69_c062_bee1_8f63_e7f6980ad6aa_MD0005_00 Withdrawal symptoms are common in patients attempting to quit smoking, especially those with a heavy smoking history. Common symptoms include restlessness, anxiety, irritability, decreased concentration, insomnia, and depressed mood. Withdrawal symptoms and the associated craving for cigarettes are responsible for the majority of relapses. The best initial approach for patients wishing to quit smoking is a combination of behavioral (eg, problem solving, skill building, support, follow-up) and pharmacological therapy. Nicotine replacement therapy (NRT) (eg, gum, patch, inhaler) acts by maintaining a low level of nicotine in the blood and is indicated for amelioration of withdrawal symptoms during the early stages of smoking cessation. Combining a long-acting NRT (eg, patch) with a short-acting NRT (eg, gum, lozenge, nasal spray), a "patch-plus" regimen, is more effective than either modality alone. Varenicline, a partial nicotine receptor agonist, would be another option for this patient. Despite initial concerns about depression and increased suicidality with varenicline, newer findings have not substantiated this, and the black box warning for these adverse effects was removed in 2016. (Choice B) Bupropion is an effective therapy for smoking cessation and can help decrease the weight gain seen in smokers who quit. However, it reduces the seizure threshold and would be contraindicated in this patient with a history of seizure disorder. (Choice C) Motivational interviewing is a useful intervention to increase motivation in patients who are not ready to quit. Buspirone, however, is used in the treatment of generalized anxiety disorder. It has not been shown to be effective for smoking cessation. (Choice D) Selective serotonin reuptake inhibitors (eg, sertraline) are indicated for depression and anxiety, but they have not been proven effective for smoking cessation. (Choice E) Setting a quit date is an important aspect of cessation. However, a date should be set within 2-4 weeks to keep the patient motivated and prevent second-guessing. In addition, a low-dose nicotine patch is unlikely to ameliorate the withdrawal symptoms in a patient with a history of heavy smoking. This patient should initially receive combination nicotine replacement therapy. Educational objective: Smoking cessation is best managed with a combination of behavioral support and pharmacotherapy, which decreases craving and withdrawal, helping to prevent relapse. Pharmacological options include nicotine replacement therapy, varenicline, and bupropion. References: Optimising nicotine replacement therapy in clinical practice. (http://www.ncbi.nlm.nih.gov/pubmed/23781531) Nicotine replacement therapy for smoking cessation. (http://www.ncbi.nlm.nih.gov/pubmed/23152200) Pharmacological interventions for smoking cessation: an overview and network meta-analysis. (http://www.ncbi.nlm.nih.gov/pubmed/23728690)

A 36-Year-Old Woman Comes to the Clinic for Smoking Cessation