What are the risks and recommendations for long-term use of nicotine spray in a patient with a history of smoking and pre-existing heart conditions or hypertension?

Long-Term Use of Nicotine Spray in Patients with Heart Disease and Hypertension

Nicotine replacement therapy, including nicotine spray, should not be used long-term beyond 6-12 months, as long-term safety and efficacy data are lacking, and patients with cardiovascular disease should use judicious dosing with careful monitoring. 1

Duration Limits for Nicotine Replacement Therapy

All pharmacological smoking-cessation therapies, including nicotine spray, should be used short-term since long-term safety and efficacy data are lacking. 1 The evidence supports:

• Minimum treatment duration of 12 weeks for initial quit attempts 2, 3
• Maximum recommended duration of 6-12 months to promote continued cessation 2, 3
• Longer duration (>14 weeks) shows superior results to standard 8-12 week courses, but indefinite continuation is not recommended 2
• No evidence supports indefinite continuation beyond 6-12 months 2

Specific Cardiovascular Safety Considerations

Blood Pressure and Heart Rate Effects

Transdermal nicotine has been shown to be safe in mildly hypertensive smokers, with no significant increases in blood pressure or heart rate observed. 4 However:

• The FDA label advises asking a doctor before use if you have heart disease, recent heart attack, irregular heartbeat, or high blood pressure not controlled with medication, as nicotine can increase heart rate and blood pressure 5
• In normotensive smokers and nonsmokers, nicotine patches increased mean arterial pressure and heart rate significantly, but these effects were not observed in hypertensive smokers 4

Cardiovascular Disease Population

Nicotine replacement therapy has been shown to be safe for patients with stable coronary artery disease. 1 Key evidence includes:

• A 10-week outpatient course of transdermal nicotine did not increase cardiovascular events in patients with cardiovascular disease 1
• Blood nicotine levels from NRT remain significantly lower than from smoking cigarettes, making toxicity rare 2, 3
• Both nicotine replacement and bupropion have been shown to be well tolerated in populations with cardiovascular disease 6

Critical Caveat for Acute Events

For patients hospitalized with acute cardiovascular events, judicious use and dosing of nicotine replacement therapy are recommended. 1 The evidence shows:

• In hospitalized patients during CABG, nicotine replacement therapy was associated with increased mortality in a retrospective analysis, though this was limited by observational design and selection bias 1
• Use should be carefully considered on an individualized basis during acute cardiovascular events (Class IIb; Level of Evidence B) 1

Tapering Protocol After Long-Term Use

When discontinuing after prolonged therapy, a step-down dosing schedule should be followed. 2 The recommended approach:

• Reduce to 14 mg/24-hour patch, then to 7 mg/24-hour patch, and finally discontinue after 4 weeks 2
• Counsel patients that mild transient symptoms during tapering are normal and do not indicate treatment failure 2
• Provide behavioral support during tapering, as it enhances outcomes even during the tapering phase 2

Risk of Long-Term Dependence

Very few people become addicted to NRT itself, but long-term dependence is a concern with extended use. 3 Important considerations:

• Nicotine e-cigarettes (not nasal spray, but relevant for comparison) showed 80% of successful quitters still using the device at 1 year 1
• Patients should be warned about risks of developing long-term dependence and encouraged to quit promptly to avoid potential long-term risks 1

Specific Risks with Nasal Spray Formulation

Nicotine nasal spray carries specific respiratory risks that require careful consideration. 7 Key concerns:

• Asthma exacerbation has been reported after administration of nicotine nasal spray, requiring hospitalization 7
• Prudent administration is recommended in patients with underlying respiratory disease 7
• Patients should be counseled on potential adverse effects and proper administration techniques to minimize effects 7

Common Adverse Effects to Monitor

Common side effects of nicotine replacement therapy include local irritation, nausea, vomiting, sweating, mood alterations, and sleep disturbances. 8, 2 Management strategies:

• Consider dose reduction if using high-dose therapy to manage adverse effects 8
• Most nicotine-related adverse effects are dose-dependent 8
• Symptoms of nicotine toxicity typically resolve within 12 hours if exposure is discontinued 8

Critical Pitfalls to Avoid

• Continuing indefinitely without reassessment is not recommended, as there is no evidence supporting indefinite continuation beyond 6-12 months 2
• Failing to provide behavioral support during tapering can negatively impact outcomes 2
• Ignoring respiratory symptoms in patients using nasal spray formulation 7
• Not monitoring cardiovascular status in patients with pre-existing heart conditions during acute events 1, 5