What is the recommended pharmacotherapy regimen for a 76-year-old female patient with a history of Chronic Obstructive Pulmonary Disease (COPD), hypertension, hyperlipidemia, and sarcopenia, who smokes 2 packs per day, for smoking cessation?

Pharmacotherapy for Smoking Cessation in a 76-Year-Old Female with COPD

Varenicline is the recommended pharmacotherapy regimen for this 76-year-old female patient with COPD who smokes 2 packs per day and has her first cigarette within 10 minutes of waking. 1, 2

Rationale for Varenicline Selection

Varenicline is the preferred option for this patient for several key reasons:

1. Superior Efficacy: Varenicline has demonstrated significantly higher cessation rates compared to both bupropion (39% higher) and nicotine replacement therapy (31% higher) 2, 3

2. COPD Considerations: For patients with COPD, smoking cessation is particularly crucial to slow disease progression and reduce exacerbations. Varenicline has shown effectiveness in patients with stable respiratory conditions 1, 4

3. Dental Concerns: The patient has an upper removable dental bridge and loose bottom molars, which would make nicotine gum uncomfortable and potentially damaging to her dental work

4. High Nicotine Dependence: Her smoking 2 packs daily and having her first cigarette within 10 minutes of waking indicates high nicotine dependence, requiring the most effective pharmacotherapy option 2

Dosing and Administration

• Begin varenicline 1 week before the target quit date 5
• Titration schedule:
  • Days 1-3: 0.5 mg once daily
  • Days 4-7: 0.5 mg twice daily
  • Day 8 onward: 1 mg twice daily 5
• Continue treatment for 12 weeks, with potential extension for another 12 weeks if successful 5
• Take after eating with a full glass of water to minimize gastrointestinal side effects 5

Monitoring and Side Effect Management

• Common side effects: Nausea (30-40%), insomnia, abnormal dreams, and headache 6
• Nausea management: Taking medication after meals, with a full glass of water, and dose reduction if necessary 5, 6
• Neuropsychiatric monitoring: While rare, monitor for mood changes, agitation, or unusual behavior 5, 6
• Follow-up: Schedule follow-up within 2-3 weeks to assess proper usage, side effects, and smoking status 2

Why Not Other Options?

1. Bupropion SR: While effective, it has lower cessation rates than varenicline 1, 3 and potential concerns with the patient's low weight (82 pounds)

2. Nicotine patch plus nicotine gum: Contraindicated due to the patient's dental issues (removable bridge and loose molars) making gum use problematic

3. Bupropion SR plus nicotine patch: While combination therapy can be effective, varenicline alone has shown superior efficacy and avoids potential drug interactions with the patient's current medications 1, 3

Behavioral Support

• Combine pharmacotherapy with behavioral counseling for optimal results 1
• Identify smoking triggers and develop coping strategies 2
• Provide resources for telephone quitlines or web-based support 2
• Schedule regular follow-ups to reinforce cessation efforts and address challenges 2

Special Considerations for This Patient

• Age: At 76 years old, smoking cessation will still provide significant health benefits, particularly for her COPD management
• COPD: Smoking cessation is the most effective intervention to slow COPD progression
• Low weight: Monitor closely for side effects due to her low body weight (82 pounds)
• Medication interactions: Varenicline has minimal drug interactions with her current medications (lisinopril, tiotropium, atorvastatin) 5

By selecting varenicline for this patient, you're providing the most effective pharmacotherapy option that accommodates her specific medical conditions and dental concerns while maximizing her chances of successful smoking cessation.