What is the best approach for managing nicotine withdrawal in a patient with a significant smoking history undergoing urgent hip replacement surgery?

From the Guidelines

The best approach for managing nicotine withdrawal in a patient with significant smoking history undergoing urgent hip replacement surgery is a combination of pharmacotherapy and behavioral support, with nicotine replacement therapy (NRT) as the first-line treatment, as recommended by the National Comprehensive Cancer Network (NCCN) guidelines 1.

Key Considerations

• Nicotine replacement therapy (NRT) should be initiated immediately, preferably with a 21mg nicotine patch applied daily, supplemented with short-acting NRT such as 2mg nicotine gum or 2mg lozenges as needed for breakthrough cravings (up to 10-12 pieces daily) 1.
• For patients with severe dependence, varenicline (Chantix) 0.5mg daily for 3 days, then 0.5mg twice daily for 4 days, followed by 1mg twice daily can be considered if surgery timing allows for the titration period 1.
• Bupropion SR 150mg daily for 3 days, then 150mg twice daily is another option, particularly beneficial for patients with comorbid depression 1.
• Perioperative counseling should address the importance of abstinence for improved surgical outcomes, including reduced wound complications and faster healing 1.
• Hospital staff should monitor withdrawal symptoms using a standardized scale and adjust medication accordingly 1.

Rationale

The physiological basis for this approach is that nicotine withdrawal peaks within 24-48 hours of cessation and can increase postoperative pain, agitation, and complications 1. Providing adequate nicotine replacement helps maintain patient comfort while preventing the vasoconstriction and hypoxemia associated with continued smoking, thereby improving tissue perfusion and healing at the surgical site 1.

Behavioral Support

• Motivational counseling is beneficial for all patients, including those unwilling to quit 1.
• High-intensity behavior therapy with multiple counseling sessions is most effective, but at least a minimum of brief counseling is highly recommended 1.
• Smoking status should be documented in the patient health record, and patient health records should be updated at regular intervals to indicate changes in smoking status, quit attempts made, and interventions utilized 1.

From the FDA Drug Label

Varenicline is a nicotinic receptor partial agonist indicated for use as an aid to smoking cessation treatment.

For patients who are sure that they are not able or willing to quit abruptly, a gradual approach to quitting smoking with varenicline may be considered

Patients should begin varenicline dosing and reduce smoking during the first 12 weeks of treatment, then quit by the end of that period and continue treatment for an additional 12 weeks for a total of 24 weeks

The best approach for managing nicotine withdrawal in a patient with a significant smoking history undergoing urgent hip replacement surgery is varenicline. However, given the urgent nature of the surgery and the patient's significant smoking history, it's crucial to consider the patient's overall health status and potential interactions with other medications.

• Varenicline can be considered as it is indicated for smoking cessation treatment.
• Nicotine replacement therapy may also be an option, but the provided drug labels do not directly support its use in this specific scenario.
• Bupropion is not mentioned in the provided drug labels as a treatment option for nicotine withdrawal in the context of urgent surgery.
• Behavioral therapy is mentioned as a component of support for quitting smoking but not as a standalone treatment for nicotine withdrawal in the context of urgent surgery.

It's essential to consult with a healthcare professional to determine the best course of treatment, considering the patient's medical history, current health status, and the urgency of the surgery 2, 2, 2.

From the Research

Managing Nicotine Withdrawal in a Patient Undergoing Hip Replacement Surgery

The patient in question is a 72-year-old with a significant smoking history who requires hip replacement surgery. Given this context, managing nicotine withdrawal is crucial to ensure the best possible outcomes for the patient.

• Nicotine Replacement Therapy (NRT): Studies have shown that NRT can significantly increase the chances of successfully stopping smoking 3, 4, 5. NRT works by reducing the intensity of craving and withdrawal symptoms, making it an effective tool for managing nicotine withdrawal in patients undergoing surgery.
• Forms of NRT: Various forms of NRT are available, including patches, gum, lozenges, inhalers, and nasal sprays. The choice of NRT form does not substantially differ in effectiveness, allowing the patient to select the most suitable form 4, 5.
• Combination NRT: There is high-certainty evidence that combination NRT (fast-acting form + patch) results in higher long-term quit rates than single-form NRT 3. This could be a beneficial approach for a patient with a significant smoking history.
• Bupropion and Varenicline: While bupropion and varenicline are effective smoking cessation aids, the evidence regarding their use in the context of surgery and nicotine withdrawal management is less clear compared to NRT 6, 5.
• Behavioral Therapy: Behavioral therapy, including counseling, can be an effective component of smoking cessation interventions, especially when combined with NRT 7. However, in the context of urgent hip replacement surgery, the immediate focus may be on managing nicotine withdrawal symptoms rather than long-term behavioral change.

Recommendations

Given the evidence, the most appropriate recommendation for managing nicotine withdrawal in this patient would be:

1. Nicotine Replacement Therapy (NRT): Offer NRT, potentially in a combination form, to help manage nicotine withdrawal symptoms and reduce the risk of smoking-related complications during and after surgery.
2. Assessment and Monitoring: Continuously assess the patient's nicotine withdrawal symptoms and adjust the NRT as necessary to ensure adequate management of these symptoms.
3. Consideration of Other Interventions: Depending on the patient's response to NRT and their overall condition, consider adding other smoking cessation aids like bupropion or varenicline, or behavioral therapy, as part of a comprehensive approach to smoking cessation.