What is the recommended initial step for nicotine replacement therapy in a 54-year-old female patient with Generalized Anxiety Disorder (GAD) and Major Depressive Disorder (MDD) taking Lexapro (escitalopram) 20mg?

Nicotine Patch Instructions for Step 1

For this patient smoking ≥10 cigarettes per day, start with a 21 mg/24-hour nicotine patch combined with 2-4 mg nicotine gum as needed for breakthrough cravings, continuing this combination therapy for a minimum of 12 weeks. 1

Initial Dose Selection

• The National Comprehensive Cancer Network recommends starting with a 21 mg/24-hour patch for smokers consuming ≥10 cigarettes per day. 1
• Combination NRT (patch + short-acting form like gum) is the gold standard first-line treatment, achieving 36.5% abstinence at 6 months versus 23.4% for patch alone (RR 1.25,95% CI 1.15-1.36). 1, 2
• This combination approach nearly doubles cessation success compared to monotherapy and is completely safe, with blood nicotine levels remaining significantly lower than from smoking. 1

Patch Application Instructions

• Apply the 21 mg patch to clean, dry, hairless skin on the upper body or outer arm each morning. 1
• Rotate application sites daily to prevent skin irritation. 1
• For 24-hour patches, wear continuously; do not remove at bedtime. 1
• Patches provide steady nicotine levels throughout the day, preventing withdrawal symptoms from developing rather than providing immediate gratification. 1

Adding Short-Acting NRT (Gum)

• Pair the 21 mg patch with nicotine gum: use 2 mg gum for lighter smokers or 4 mg gum if the patient smokes their first cigarette within 30 minutes of waking (indicating high dependence). 1, 2
• Use 8-12 pieces of gum per day as needed for breakthrough cravings. 1
• Chew slowly until a peppery taste emerges, then "park" the gum between cheek and gum to allow nicotine absorption through the mouth—do not swallow. 1
• Avoid food or beverages 15 minutes before and after using gum, as acidic drinks interfere with absorption. 1

Treatment Duration

• Continue combination NRT for a minimum of 12 weeks for the initial quit attempt. 1
• Therapy may be extended to 6-12 months to promote continued cessation and prevent relapse. 1
• Longer duration (>14 weeks) shows superior results to standard 8-12 week courses. 1

Essential Behavioral Support

• Combine pharmacotherapy with behavioral counseling—this increases quit rates from 8.6% to 15.2% compared to brief advice alone. 1
• Schedule at least 4 counseling sessions over 12 weeks, with sessions lasting 10-30+ minutes. 1
• Counseling should address practical problem-solving, identifying high-risk situations (stress, alcohol use, living with smokers), and developing coping strategies. 1

Follow-Up Schedule

• Schedule follow-up within 2-3 weeks after starting therapy to assess smoking status, medication side effects, and withdrawal symptoms. 1
• Conduct additional follow-up at 12 weeks and at the end of therapy if extended beyond 12 weeks. 1
• Nicotine withdrawal symptoms typically peak within 1-2 weeks of quitting and then subside—encourage continued therapy through brief slips. 1

Special Considerations for This Patient

• NRT is safe for patients with anxiety and depression taking escitalopram—there are no significant drug interactions. 1
• Escitalopram 20 mg is an effective dose for GAD and MDD, and smoking cessation may actually improve anxiety and depression outcomes long-term. 3, 4
• Monitor for any worsening of anxiety or depression during the quit attempt, though this is typically related to nicotine withdrawal rather than NRT itself. 1

Common Pitfalls to Avoid

• Inadequate dosing: Ensure the patient uses sufficient nicotine doses to control withdrawal symptoms—if withdrawal persists with 21 mg patch + gum, consider increasing to 35-42 mg patch. 1
• Premature discontinuation: Encourage continued therapy even through brief slips; a single cigarette does not mean failure. 1
• Insufficient treatment duration: Do not stop at 8 weeks—maintain treatment for at least 12 weeks minimum. 1
• Using patch alone without short-acting NRT: This is suboptimal; combination therapy is the evidence-based standard. 1

If Initial Regimen Fails

• If the patient continues smoking or relapses on combination NRT, switch to varenicline 1 mg twice daily for 12 weeks as the alternative primary therapy. 1
• Alternatively, increase the patch dose to 35-42 mg while continuing short-acting NRT. 1
• Progressively intensify behavioral counseling with referral to specialty smoking cessation programs. 1

Safety Profile

• Combination NRT is safe with no increased cardiovascular risk—blood nicotine levels from NRT remain significantly lower than from smoking cigarettes. 5, 1
• Common side effects include local skin reactions from patches and mouth irritation from gum, both typically mild and manageable. 1
• Very few people become addicted to NRT itself. 1