What is the most appropriate over-the-counter (OTC) pharmacotherapy option for a 69-year-old female patient with a history of stable Cardiovascular Disease (CVD), Hypertension (HTN), Diabetes Mellitus (DM), Hypothyroidism, and Temporomandibular Joint (TMJ) disease, who wears dentures and smokes 15 cigarettes per day?

Nicotine Patch + Nicotine Lozenge is the Most Appropriate OTC Pharmacotherapy for This Patient

For this 69-year-old female patient with stable CVD, hypertension, diabetes, hypothyroidism, TMJ disease, and dentures, the combination of nicotine patch + nicotine lozenge is the most appropriate over-the-counter pharmacotherapy option for smoking cessation. 1, 2

Rationale for Recommendation

Patient-Specific Considerations:

• Dentures: The patient wears dentures on both upper and lower jaws, making nicotine gum problematic due to potential interference with dentures and difficulty with proper chewing technique
• TMJ disease: Further contraindication for nicotine gum due to jaw fatigue and potential exacerbation of TMJ symptoms
• Cardiovascular status: Despite stable CVD, NRT appears safe in patients with cardiovascular disease 1
• Smoking pattern: 15 cigarettes/day with first cigarette 1 hour after waking indicates moderate nicotine dependence requiring effective therapy

Evidence Supporting Combination NRT:

1. Superior efficacy: Combination NRT (patch + short-acting form) is more effective than single NRT products 1, 2

   • The patch provides steady background nicotine levels
   • The lozenge addresses breakthrough cravings and is easier to use with dentures than gum

2. Safety in cardiovascular disease: Evidence shows NRT is safe in patients with cardiovascular disease 1

   • Meta-analyses of safety data found no evidence of increased risk of cardiac events with NRT treatment in patients with CVD

3. OTC availability: Both nicotine patches and lozenges are available over-the-counter, meeting the patient's need for an OTC option

Why Not Other Options?

Bupropion SR:

• Requires prescription (not OTC)
• Less effective than combination NRT for many patients
• Potential drug interactions with patient's likely multiple medications for comorbidities

Varenicline:

• Requires prescription (not OTC)
• Despite higher efficacy compared to single NRT products, it's not available OTC

Nicotine Patch + Nicotine Gum:

• Gum is contraindicated due to TMJ disease and dentures
• Potential for jaw soreness, improper technique with dentures

Implementation Plan

1. Dosing Recommendations:

   • Nicotine patch: Start with 21mg/24hr patch (standard dose) for first 6 weeks
   • Nicotine lozenge: 4mg strength (for moderate dependence), at least 9 pieces per day during the first six weeks 2

2. Duration:

   • Minimum 12-week treatment course
   • Consider longer treatment (>14 weeks) for better outcomes 1

3. Usage Instructions:

   • Apply patch to clean, dry, hairless skin each morning
   • Use lozenge for breakthrough cravings (allow to dissolve completely, do not chew)
   • Avoid acidic beverages 15 minutes before and during lozenge use

4. Follow-up:

   • Schedule follow-up within 2-3 weeks to assess proper usage, side effects, and smoking status
   • Continue periodic follow-up at 12-week intervals 2

Potential Side Effects to Monitor

• Patch: Skin irritation, sleep disturbances if worn overnight
• Lozenge: Hiccups, heartburn, nausea, throat irritation
• Both: Nausea, headache

Additional Support

Combine pharmacotherapy with behavioral counseling for optimal results:

• Identify smoking triggers and develop coping strategies
• Provide resources for telephone quitlines or web-based support
• Consider referral to smoking cessation program if available

This combination approach of nicotine patch + nicotine lozenge provides the most appropriate balance of efficacy, safety, and practicality for this patient with her specific medical conditions and need for an OTC solution.