What is the recommended first-line treatment for smoking cessation in a patient with stable Cardiovascular Disease (CVD), diabetes, and hypertension, who has previously tried Nicotine Replacement Therapy (NRT)?

First-Line Smoking Cessation Treatment for a Patient with Stable CVD, Diabetes, and Hypertension

Varenicline is the recommended first-line treatment for smoking cessation in this 66-year-old male patient with stable cardiovascular disease, diabetes, and hypertension who has previously tried and disliked nicotine replacement therapy. 1

Rationale for Varenicline as First Choice

Varenicline offers several advantages for this specific patient:

1. Superior Efficacy: Varenicline has demonstrated the highest estimated abstinence rates (33.2%) compared to other smoking cessation medications, with an odds ratio of 3.1 versus placebo and 1.6 versus nicotine patch therapy 2.

2. Cardiovascular Safety: Despite initial concerns, varenicline has been shown to be safe in patients with stable cardiovascular disease. In clinical trials, there was no significant difference in cardiovascular mortality between varenicline and placebo groups (0.3% vs 0.6%) 3.

3. Patient Preference Alignment: This patient specifically mentioned disliking having to take something "every few hours," making varenicline's twice-daily dosing preferable to the frequent dosing required with nicotine lozenges or gum 1.

4. Effectiveness in Comorbidities: The American College of Cardiology and American Heart Association recognize smoking cessation as crucial for patients with cardiovascular disease, and varenicline has shown superior efficacy in these populations 1.

Dosing and Administration

• Start with a 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 (target dose) 2, 4

• Set a quit date for 1 week after starting treatment 4

• Minimum treatment duration of 12 weeks, with consideration for longer treatment (>14 weeks) for better outcomes 1

Alternative Options

If varenicline is contraindicated or not tolerated:

1. Bupropion SR: 150 mg twice daily, but has lower cessation rates compared to varenicline (24.2% vs 33.2%) and carries risks of seizures and allergic reactions 2, 1, 4.

2. Combination NRT: Nicotine patch plus short-acting NRT (lozenge or gum) is more effective than single NRT products and appears safe in patients with cardiovascular disease 1. However, this patient has already expressed dissatisfaction with short-acting NRT forms.

Monitoring and Follow-up

• Schedule follow-up within 2-3 weeks to assess:

  • Proper medication usage
  • Side effects (particularly nausea, which occurs in 27-30% of patients)
  • Smoking status 1, 4

• Monitor for potential neuropsychiatric symptoms, although the risk is low in patients without psychiatric history 4

• Continue periodic follow-up at 12-week intervals 1

Common Side Effects and Management

• Nausea: Most common side effect (27-30%). Usually mild to moderate and often transient. Initial dose titration helps reduce occurrence 4.

• Other common side effects: Insomnia (14.2%), headache (14.2%), abnormal dreams 4, 5.

• Cardiovascular monitoring: While generally safe in stable CVD, advise patient to report any new or worsening cardiovascular symptoms 4.

Behavioral Support

• Combine pharmacotherapy with behavioral counseling for optimal results:

  • Identify smoking triggers
  • Develop coping strategies for high-risk situations
  • Create emergency plans for cravings 1

• Provide resources for telephone quitlines or web-based support to supplement treatment 1

By following this approach with varenicline as first-line therapy, this patient has the best chance of successful smoking cessation while minimizing the inconvenience of frequent dosing that he previously disliked with nicotine replacement therapy.