What medication can be used to help a patient quit smoking who has tried nicotine patches and is taking Plaquenil (hydroxychloroquine) and mirtazapine?

Recommended Smoking Cessation Medication

For this patient who experienced shortness of breath with nicotine patches and is taking Plaquenil and mirtazapine, varenicline is the preferred first-line medication, with bupropion as an alternative if varenicline is contraindicated or not tolerated. 1

Primary Recommendation: Varenicline

Varenicline should be the first choice as it demonstrates the highest abstinence rates (33.2% at 6 months) compared to all other monotherapies, with an odds ratio of 3.1 versus placebo and 1.6 versus nicotine patch. 1 This makes it significantly more effective than the patch the patient already tried.

Dosing Strategy

• Start 1-2 weeks before quit date 1
• Days 1-3: 0.5 mg once daily
• Days 4-7: 0.5 mg twice daily
• Week 2-12: 1 mg twice daily (target dose) 1
• Flexible dosing option: Allow self-titration between 0.5 mg/day minimum and 1 mg twice daily maximum, as most adverse effects are dose-dependent and lower doses retain efficacy while reducing side effects 1

Important Considerations with Current Medications

• No significant drug interactions exist between varenicline and either Plaquenil (hydroxychloroquine) or mirtazapine 1
• Monitor for neuropsychiatric symptoms (depression, agitation, suicidal thoughts), though these are uncommon 1
• Nausea is the most common side effect and may require management, particularly given the patient's history of shortness of breath with patches 1

Alternative Option: Bupropion SR

If varenicline is not appropriate, bupropion SR is the next best choice with a 24.2% abstinence rate at 6 months (OR 2.0 vs placebo). 1

Dosing

• Start 1 week before quit date
• 150 mg once daily for 3 days
• Then 150 mg twice daily for 7-12 weeks 1

Critical Contraindication

• Avoid bupropion if the patient has any seizure history or risk factors, as it lowers seizure threshold (0.1% risk) 1, 2
• Exercise caution with mirtazapine co-administration: Both are antidepressants, though bupropion's mechanism differs; monitor for serotonin syndrome and neuropsychiatric effects 1, 2

Why Not Other NRT Forms?

Since the patient had shortness of breath with patches, consider alternative NRT delivery methods only as second-line options:

• Nicotine gum (19.0% abstinence rate) 1
• Nicotine nasal spray (26.7% abstinence rate) 1
• Nicotine inhaler (24.8% abstinence rate) 1
• Nicotine lozenge 1

However, these are all less effective than varenicline monotherapy and should be reserved if both varenicline and bupropion fail or are contraindicated. 1

Treatment Duration and Follow-up

• Minimum 12 weeks of therapy is recommended for initial quit attempt 1
• Follow-up within 2 weeks of starting medication to assess efficacy and side effects 1
• Consider extending therapy to 6-12 months to prevent relapse, as nicotine withdrawal peaks within 1-2 weeks then subsides 1
• Periodic follow-up at minimum 12-week intervals during and after therapy 1

If Initial Therapy Fails

Combination therapy should be the next step if monotherapy with varenicline or bupropion fails:

• Long-term nicotine patch (>14 weeks) + short-acting NRT (gum or spray) achieves 36.5% abstinence rate (highest of all combinations) 1
• Patch + bupropion SR achieves 28.9% abstinence rate 1

Essential Counseling Component

All pharmacotherapy must be combined with behavioral counseling for optimal results, as combination approaches are superior to either alone. 1, 3 Even brief counseling (5-10 minutes) significantly improves outcomes. 1