Can nicotine replacement therapy (NRT) be used with varenicline (Chantix)?

From the Guidelines

Using nicotine replacement therapy (NRT) with varenicline is not recommended as a standard approach for smoking cessation due to the potential for increased side effects and limited evidence of additional benefits. The most recent and highest quality study on this topic found that the addition of nicotine patch to varenicline therapy did not significantly increase cessation rates at 12 and 24 weeks follow-up, and did not cause significant changes in side effect profiles 1. While one study found that the combination of varenicline and nicotine patch significantly increased cessation rates at the end of treatment and at 6-month follow-up, this was not consistently replicated in other studies 1.

Some key points to consider when evaluating the use of NRT with varenicline include:

• The potential for increased side effects, such as skin reactions, with combination therapy 1
• The lack of consistent evidence supporting the use of NRT with varenicline for smoking cessation 1
• The importance of close medical supervision if combination therapy is considered
• The standard varenicline regimen, which involves starting with 0.5 mg once daily for days 1-3, then 0.5 mg twice daily for days 4-7, followed by 1 mg twice daily for the remainder of the treatment period (typically 12 weeks)

Overall, the current evidence suggests that varenicline should be used alone as the primary treatment for smoking cessation, and NRT should only be considered in specific cases under close medical supervision. If you're struggling with smoking cessation despite using varenicline as prescribed, it's best to consult your healthcare provider about adjusting your treatment plan rather than adding NRT products on your own 1.

From the FDA Drug Label

1. 1 Use with Other Drugs for Smoking Cessation Safety and efficacy of varenicline in combination with other smoking cessation therapies have not been studied. ... Nicotine replacement therapy (NRT) Although co-administration of varenicline (1 mg twice daily) and transdermal nicotine (21 mg/day) for up to 12 days did not affect nicotine pharmacokinetics, the incidence of nausea, headache, vomiting, dizziness, dyspepsia, and fatigue was greater for the combination than for NRT alone In this study, eight of twenty-two (36%) patients treated with the combination ofvarenicline and NRT prematurely discontinued treatment due to adverse events, compared to 1 of 17 (6%) of patients treated with NRT and placebo.

The use of nicotine replacement therapy (NRT) with varenicline is not recommended due to increased incidence of adverse events such as nausea, headache, vomiting, dizziness, dyspepsia, and fatigue. Additionally, a higher percentage of patients discontinued treatment due to adverse events when using the combination of varenicline and NRT compared to NRT alone 2.

From the Research

Nicotine Replacement Therapy with Varenicline

• The use of nicotine replacement therapy (NRT) with varenicline for smoking cessation has been studied in several clinical trials 3, 4, 5, 6, 7.
• A randomized clinical trial published in JAMA in 2021 found that combining varenicline with the nicotine patch did not significantly increase cessation effectiveness compared to varenicline monotherapy 3.
• However, a randomized clinical trial published in JAMA Network Open in 2024 found that the combination of varenicline and NRT lozenges improved self-reported abstinence compared to varenicline alone, without compromising safety 4.
• Another study published in Addiction in 2008 found that varenicline was more effective than NRT for smoking cessation, with higher short-term cessation rates and lower craving to smoke 5.
• A Cochrane review published in 2023 found that varenicline helps more people to quit smoking than placebo, bupropion, or a single form of NRT, and may be as or more effective than dual-form NRT 6.
• A double-blind, randomized, placebo-controlled trial published in Nicotine & Tobacco Research in 2013 found that varenicline combined with counseling was effective in helping long-term NRT users to quit NRT 7.

Safety and Efficacy

• The safety and efficacy of using NRT with varenicline have been evaluated in several studies, with mixed results 3, 4, 6.
• Some studies have found that the combination of varenicline and NRT is safe and effective, with no significant increase in adverse events 4, 7.
• However, other studies have found that varenicline may be associated with a higher risk of serious adverse events, including cardiac and neuropsychiatric events 6.
• The evidence suggests that the use of NRT with varenicline may be beneficial for some smokers, but more research is needed to fully understand the safety and efficacy of this combination 3, 4, 6.

Clinical Implications

• The use of NRT with varenicline may be considered for smokers who are unable to quit with varenicline alone or who experience severe withdrawal symptoms 4, 7.
• However, the decision to use NRT with varenicline should be made on a case-by-case basis, taking into account the individual smoker's medical history, smoking habits, and preferences 3, 6.
• Healthcare providers should carefully monitor smokers who are using NRT with varenicline for adverse events and adjust treatment as needed 4, 6.