How to Write an Order for Nicotine Replacement Inhaler
Order the nicotine inhaler with an initial dosage of 6-16 cartridges per day for up to 12 weeks, followed by gradual dose reduction over 6-12 weeks, with patients instructed to stop smoking completely on the start date. 1
Essential Order Components
Basic Prescription Format
- Medication: Nicotine Inhaler (NICOTROL Inhaler) 1
- Initial dose: 6-16 cartridges per day 1
- Duration: Up to 12 weeks initial treatment 1
- Quantity: Dispense sufficient cartridges for initial treatment period (typically 180-480 cartridges for first month) 1
- Refills: As needed for 12-week initial treatment period 1
Critical Patient Instructions to Include
Smoking cessation requirement: Patient must stop smoking completely when beginning inhaler use 1. This is non-negotiable for treatment success.
Dosing strategy:
- Most successful patients use 6-16 cartridges daily 1
- Encourage at least 6 cartridges per day for first 3-6 weeks 1
- Each cartridge should be puffed continuously for 20 minutes for best effect 1
- Maximum 16 cartridges per day 1
Patient Selection Criteria
Who Should Receive This Treatment
- All smokers motivated to quit, regardless of setting 2
- Particularly effective for those smoking ≥15 cigarettes per day, though lighter smokers can benefit 2
- The inhaler permits more control over dose and delivery speed compared to patches 2
- Consider for patients who value the hand-to-mouth ritual of smoking 1
Contraindications to Document
Absolute contraindications:
Relative contraindications requiring risk assessment:
- Cardiovascular disease including recent myocardial infarction 2
- However, NRT is safer than continued smoking even in these patients 2
- Document risk-benefit discussion when prescribing to these populations 2
Treatment Protocol
Initial Phase (Weeks 1-12)
- Start with 6-16 cartridges daily 1
- Average successful quit rate uses >6 cartridges daily 1
- Regular use during first week helps patients adapt to irritant effects 1
- Reassess at week 4: If patient has not stopped smoking, discontinue treatment and counsel for future attempt 1
Tapering Phase (Weeks 13-24)
- Begin gradual reduction after 12 weeks 1
- Tapering period: 6-12 weeks 1
- Strategies include: using product less frequently, keeping daily tally, setting reduction targets, or planning a quit date for inhaler discontinuation 1
- Do not continue beyond 6 months total: Safety and efficacy not established beyond this period 1
Expected Efficacy
The nicotine inhaler approximately doubles cessation rates compared to placebo 3, with an odds ratio of 2.14 (95% CI: 1.44-3.18) 3. This effectiveness is largely independent of the intensity of additional support provided 3.
Combination Therapy Consideration
Combination with nicotine patch may be superior: One high-quality trial showed 60.5% abstinence at 6 weeks with inhaler plus 15mg patch versus 47.5% with inhaler alone (p=0.009), and 19.5% versus 14.0% at 12 months (p=0.14) 4. Consider ordering both products for highly dependent smokers 4.
Common Pitfalls to Avoid
Insufficient dosing: Patients often underdose themselves 1. Emphasize using at least 6 cartridges daily, not just "as needed" 1.
Premature discontinuation: Patients must complete the full 12-week initial treatment 1. Stopping earlier reduces success rates 1.
Incorrect puffing technique: Nicotine is absorbed through oral mucosa, not lungs 5. Instruct patients to puff continuously for 20 minutes per cartridge 1.
Concurrent smoking: Treatment fails if patients continue smoking 1. Set a firm quit date that coincides with starting the inhaler 1.
Side Effects to Counsel
- Most common: Throat irritation (expected and usually transient) 1, 6
- Other effects: Nausea, sweating, mood changes, sleep disturbances 7
- Reassurance: Most adverse effects are mild, transient, and dose-dependent 7, 6
- Symptoms resolve within 12 hours if exposure discontinued 7
Documentation Requirements
Include in order or chart: