What are the recommendations for smoking cessation medications in patients with schizophrenia?

From the Guidelines

For patients with schizophrenia who want to quit smoking, varenicline (Chantix) and bupropion (Zyban, Wellbutrin) are recommended as first-line medications, as they have been shown to be safe and effective in this population, with no significant increase in neuropsychiatric adverse events compared to nicotine patches or placebo 1. When considering smoking cessation medications for patients with schizophrenia, it's crucial to weigh the benefits against potential risks. The evidence suggests that the side effects of preferred smoking cessation medications are minimal and acceptable compared to the risks of continued smoking 1. Key points to consider when prescribing these medications include:

• Starting with standard doses of varenicline (0.5 mg daily for 3 days, then 0.5 mg twice daily for 4 days, followed by 1 mg twice daily for 12 weeks) or bupropion (150 mg daily for 3 days, then 150 mg twice daily for 7-12 weeks)
• Monitoring for potential interactions with antipsychotics, as smoking cessation can increase blood levels of some antipsychotics, potentially requiring dose adjustments
• Close monitoring for psychiatric symptom exacerbation during the quitting process, as nicotine withdrawal may temporarily worsen symptoms
• Considering extended treatment durations beyond standard protocols, as patients with schizophrenia often have higher nicotine dependence and more difficulty quitting
• Combining pharmacotherapy with cognitive behavioral therapy specifically tailored for patients with schizophrenia to achieve the best outcomes. A recent multicenter RCT examined the neuropsychiatric safety of varenicline and bupropion in patients with diagnosed psychiatric disorders, including schizophrenia, and found no significant increase in neuropsychiatric adverse events compared to nicotine patches or placebo [1, specifically the study by Anthenelli et al, 2016, referenced in 1].

From the FDA Drug Label

In the trial of patients with stable schizophrenia or schizoaffective disorder (5), 128 smokers on antipsychotic medication were randomized 2:1 to varenicline (1 mg twice daily) or placebo for 12 weeks with 12-week non-drug follow-up The most common treatment emergent adverse events reported in this trial are shown in Table 3 below. Table 3 Common Treatment Emergent AEs (%) in the Trial of Patients with Stable Schizophrenia or Schizoaffective Disorder Varenicline 1 mg BID N=84 Placebo N=43 Adverse Events ≥10% in the varenicline group Nausea 24 14 Headache 11 19 Vomiting 11 Psychiatric Adverse Events ≥5% and at a higher rate than in the placebo group Insomnia 10 5

The recommendations for smoking cessation medications in patients with schizophrenia are to use varenicline with caution, as it has been studied in this population.

• Common adverse events in patients with stable schizophrenia or schizoaffective disorder include nausea, headache, vomiting, and insomnia.
• Psychiatric adverse events such as insomnia were reported at a higher rate in the varenicline group compared to the placebo group. 2

From the Research

Smoking Cessation Medications in Patients with Schizophrenia

The following are recommendations for smoking cessation medications in patients with schizophrenia:

• Smokers with schizophrenia spectrum disorders should receive varenicline or bupropion with or without nicotine replacement therapy in combination with behavioral treatment 3, 4, 5
• Clinical practice guidelines recommend a duration of treatment of at least 12 weeks, with maintenance pharmacotherapy for 1 year improving sustained abstinence rates 3, 5
• Controlled trials have found no evidence that the use of pharmacotherapeutic cessation aids worsens psychiatric symptoms or increases the rate of psychiatric adverse events in patients with schizophrenia 3, 5, 6, 7

Effective Interventions

Effective interventions for smoking cessation in patients with schizophrenia include:

• Bupropion, which increases smoking abstinence rates without jeopardizing mental state 6, 7
• Varenicline, which may improve smoking cessation rates, but its possible psychiatric adverse effects cannot be ruled out 6
• Contingent reinforcement (CR) with money, which may increase smoking abstinence rates and reduce the level of smoking in patients with schizophrenia, although its long-term benefits are uncertain 6, 7

Safety and Efficacy

The safety and efficacy of smoking cessation interventions in patients with schizophrenia have been evaluated in several studies:

• Nicotine replacement therapy, bupropion, and varenicline have all proven their effectiveness in promoting smoking abstinence or reducing cigarette use 4
• There is no evidence of benefit for other pharmacological therapies, including nicotine replacement therapy, and psychosocial interventions in helping smokers with schizophrenia to quit or reduce smoking 6, 7