What is the appropriate treatment for a smoker with erythrocytosis who is experiencing difficulty with smoking cessation?

From the Guidelines

A smoker with erythrocytosis who is experiencing difficulty with smoking cessation should be treated with a combination of pharmacologic therapy and behavioral therapy, as this approach has been shown to be the most effective in achieving long-term smoking cessation 1. The elevated hematocrit in this patient is likely due to chronic carbon monoxide exposure from smoking, which reduces oxygen-carrying capacity and triggers increased red blood cell production.

Treatment Approach

• A medical evaluation should be conducted to rule out other causes of polycythemia, and potentially therapeutic phlebotomy if symptoms of hyperviscosity are present.
• For smoking cessation, the following options can be considered:
  • Nicotine replacement therapy (NRT)
  • Varenicline (Chantix)
  • Bupropion (Zyban)
• Behavioral support through counseling, support groups, or quitlines (1-800-QUIT-NOW) significantly improves success rates.

Pharmacologic Therapy

• The choice of pharmacotherapy should take into account the patient's medical stability, clinical needs, other medical factors, and patient preferences 1.
• NRT, varenicline, and bupropion are considered first-line therapy for smoking cessation 1.

Behavioral Therapy

• 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. Quitting smoking will likely normalize the hematocrit over time as carbon monoxide levels decrease and oxygen-carrying capacity improves, reducing the body's need to produce excess red blood cells.

Key Considerations

• Smoking cessation should be offered as part of comprehensive care and continued throughout the entire care continuum 1.
• Providers should discuss the possibility of smoking relapse and brief slips with patients and provide guidance and support to encourage continued smoking cessation attempts 1.

From the FDA Drug Label

Varenicline is a nicotinic receptor partial agonist indicated for use as an aid to smoking cessation treatment. Begin varenicline tablets dosing one week before the date set by the patient to stop smoking. Alternatively, the patient can begin varenicline tablets dosing and then quit smoking between days 8 and 35 of treatment. Consider a gradual approach to quitting smoking with varenicline tablets for patients who are sure that they are not able or willing to quit abruptly.

The appropriate treatment for a smoker with erythrocytosis who is experiencing difficulty with smoking cessation is to use varenicline as an aid to smoking cessation treatment.

• The patient should set a date to stop smoking and begin varenicline dosing one week before this date.
• A gradual approach to quitting smoking can be considered for patients who are not able or willing to quit abruptly.
• Patients should be provided with appropriate educational materials and counseling to support the quit attempt 2.

From the Research

Treatment Options for Smokers with Erythrocytosis

• The treatment of tobacco smoking is a chronic disorder maintained by physical nicotine dependence and learned behaviors, and both behavioral counseling and pharmacotherapy are effective treatments when used individually, but they are most effective when combined 3.
• First-line therapy should include both pharmacotherapy and behavioral support, with varenicline or combination NRT as preferred initial interventions 3.
• Nicotine replacement therapy (NRT), varenicline, bupropion, and cytisine are the main pharmacological strategies available for smoking cessation, and their efficacy and safety have been proved even in patients with chronic cardiovascular disease 4.
• Combination pharmacotherapy is indicated for highly nicotine-dependent smokers, patients who have failed with monotherapy, and patients with breakthrough cravings 5.

Pharmacological Strategies

• Varenicline is a partial agonist at nicotinic alpha4beta2 receptors and has been shown to be at least as good as and probably more effective than bupropion for smoking cessation 6.
• Bupropion is an inhibitor of the neuronal uptake of noradrenaline and dopamine and is effective for smoking cessation, with effectiveness improved by a moderate level of counseling 6.
• NRT is available in various formulations, including gum, lozenge, transdermal, nasal spray, and inhaler, and has been shown to increase smoking cessation rates by approximately 1.5- to 2-fold after 12 months 6.

Considerations for Patients with Erythrocytosis

• Patients with erythrocytosis who are experiencing difficulty with smoking cessation should be provided with counseling and pharmacologic smoking cessation aids, unless contraindicated 5.
• The clinician should customize the smoking cessation strategy based on currently available scientific evidence and patient's preference, paying particular attention to those patients having specific cardiovascular and psychiatric comorbidities 4.