Can an adult patient with a history of smoking and no significant underlying medical conditions, such as severe depression or anxiety, be restarted on Chantix (varenicline)?

Can a Patient Be Restarted on Chantix (Varenicline)?

Yes, patients who previously failed varenicline therapy can be re-treated once factors contributing to the failed attempt are identified and addressed, as varenicline remains effective and well-tolerated for re-treatment. 1

Evidence for Retreatment

The National Comprehensive Cancer Network (NCCN) guidelines explicitly support restarting varenicline in patients who experience relapse or continued smoking after initial therapy. Patients who continue to smoke or experience relapse may continue or resume the initial pharmacotherapy, or switch to the other primary therapy option before trying subsequent therapy options. 2

Clinical Approach to Restarting Varenicline

Initial Assessment Before Retreatment

Before restarting varenicline, identify and address factors that contributed to the previous treatment failure 1:

• Frequent or intense cravings during prior attempt 2
• Elevated anxiety, stress, or depression 2
• Living or working with smokers 2
• Drug or alcohol use/abuse (including marijuana, narcotics, stimulants) 2
• Inadequate behavioral therapy support during first attempt 2
• Poor medication adherence or intolerable side effects 2

Retreatment Protocol

When restarting varenicline, use the standard dosing regimen 2:

• Begin 1-2 weeks before the new quit date 2
• Days 1-3: 0.5 mg orally once daily 2
• Days 4-7: 0.5 mg orally twice daily 2
• Weeks 2-12: 1 mg orally twice daily (if tolerated) 2

A minimum of 12 weeks of treatment is recommended, with therapy potentially extended to 6-12 months to promote continued cessation. 2, 1

Intensify Behavioral Support

As patients progress through multiple lines of treatment, behavior therapy should be progressively intensified with referral to specialty care (e.g., psychiatrist, psychologist) as indicated. 2 This is critical for retreatment success, as inadequate behavioral support may have contributed to the initial failure 2.

• Minimum of 4 sessions of individual/group therapy during the 12-week course 2, 1
• Sessions should last 10-30+ minutes, with longer and more frequent sessions linked to higher success rates 1
• Include skills training, social support, and motivational interviewing 2

Follow-Up Schedule for Retreatment

Follow-up is recommended within 2-3 weeks after restarting pharmacotherapy, with additional periodic follow-up at minimum 12-week intervals during therapy and after completion. 2, 1

At each follow-up, assess 2:

• Smoking status (self-report and CO verification)
• Medication side effects and tolerability
• Risk of relapse
• Need for dose adjustments or therapy modifications

Safety Considerations for Retreatment

Contraindications That Would Preclude Restarting

Varenicline is contraindicated in patients with brain metastases due to seizure risk. 2, 1 Additionally, avoid in patients with 1, 3:

• History of serious hypersensitivity or skin reactions to varenicline 1
• History of seizures or conditions that lower seizure threshold 4, 3

Monitoring Requirements

Monitor for development or worsening of serious neuropsychiatric issues (depression, suicidal ideation/behavior, agitation, behavioral changes) throughout treatment, even in patients without previous psychiatric history. 2, 1, 3 However, the large EAGLES trial found no significant increase in neuropsychiatric events with varenicline compared to nicotine patch or placebo 2, 1, 3.

Discontinue varenicline immediately if any seizure activity occurs or if neuropsychiatric symptoms develop. 4

Managing Common Side Effects

Nausea occurs in 28-40% of patients, typically peaks in weeks 1-2, and diminishes over time. 1, 3 The titration schedule is specifically designed to minimize this dose-dependent effect 1. Other common side effects include insomnia (14-15%) and abnormal dreams (10-13%) 1, 3.

For patients with cancer, especially during chemotherapy, nausea may need careful management. 2, 1, 3 Consider dose adjustments if clinically indicated 2, 3.

Alternative if Varenicline Retreatment Fails

If the patient fails a second course of varenicline, switch to combination nicotine replacement therapy (NRT) before trying subsequent options such as combination NRT with bupropion or bupropion alone. 2 Both preferred primary therapy approaches (varenicline and combination NRT) should be tried before proceeding to other pharmacotherapy options 2.

Common Pitfalls to Avoid

• Do not assume prior failure means varenicline won't work on retreatment – the evidence explicitly supports re-treatment 1
• Do not restart varenicline without intensifying behavioral therapy – this is a critical component for success in retreatment 2
• Do not skip the titration schedule to avoid nausea – the gradual dose escalation is essential for tolerability 2, 1
• Do not use bupropion as an alternative in patients with seizure risk – it is absolutely contraindicated in this population 2, 4