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Bupropion and Nortriptyline for Smoking Cessation
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Am Fam Physician. 2006 May 15;73(10):1826-1829.
The most effective technique for reducing the risk of developing chronic obstructive pulmonary disease (COPD) is smoking cessation. Patients with COPD who successfully stop smoking have been shown to have an improvement in their forced expiratory volume in one second. In addition, smoking cessation can reduce symptoms of cough and sputum production, decrease airway reactivity, and improve long-term prognosis. Patients with COPD have added barriers to smoking cessation, including higher nicotine addiction scores and a higher prevalence of psychiatric disorders. Wagena and associates evaluated the use of sustained-release bupropion (Wellbutrin SR) and nortriptyline (Pamelor) as adjuvant therapy for smoking cessation in adults who have or are at risk of developing COPD.
This placebo-controlled, double-dummy, randomized trial involved patients 30 to 70 years of age who were interested in smoking cessation and were at risk of developing COPD or had COPD. The participants were current smokers who averaged at least 10 cigarettes per day for the past year. The severity of their COPD was defined using the definition from the Global Initiative for Chronic Obstructive Lung Disease.
The 255 participants who met the inclusion criteria were assigned randomly to treatment with bupropion, nortriptyline, or placebo for 12 weeks. The bupropion group received 150 mg of sustained-release medication once a day for days 1 through 6, followed by 150 mg twice a day for the remainder of the study. The nortriptyline group received 25 mg once a day for days 1 through 3, with the dosage increased to 50 mg once a day for days 3 through 7, and increased again to 75 mg once a day for the remainder of the study. All three groups received smoking cessation counseling. The target quit date was set for the second week of the study. Follow-up assessment was performed at one, three, 12, and 26 weeks after the target quit date. Follow-up included a patient interview, and smoking cessation was confirmed with a urinary cotinine test. The main outcome was prolonged smoking cessation from week 4 through week 26 after the target quit date.
The use of bupropion and nortriptyline resulted in higher prolonged-abstinence rates when compared with placebo. The prolonged-abstinence rates were 28 percent for the bupropion group, 25 percent for the nortriptyline group, and 15 percent for the placebo group. Patients with COPD were more likely to abstain from smoking while receiving bupropion or nortriptyline during the study than those receiving placebo (difference of 18.9 and 12.9 percent, respectively). Abstinence rates of participants who were at risk of developing COPD but did not meet the diagnostic criteria were not significantly different among the three groups. Fifteen percent of patients in the bupropion group and 24 percent in the nortriptyline group discontinued their medication because of adverse effects.
The authors conclude that bupropion and nortriptyline seem to be effective adjuvant therapies for patients with COPD who wish to stop smoking.
Wagena EJ, et al. Efficacy of bupropion and nortriptyline for smoking cessation among people at risk for or with chronic obstructive pulmonary disease. Arch Intern Med. October 24 2005;165:2286–92.
editor's note: Smoking has been identified as one of our patients' deadliest habits. One of the goals for Healthy People 2010 is to decrease the prevalence of cigarette smoking to 12 percent or less.1,2 The good news is that a recent Centers for Disease Control and Prevention (CDC) report stated that approximately 20.9 percent of U.S. adults smoke cigarettes, a decline from a prevalence of 22.5 percent in 2002.2 In addition to this decline, the CDC notes that the number of heavy smokers (i.e., persons who smoke 25 or more cigarettes per day) also has declined in the past few years.2 Despite this positive trend, we still are not at the 2010 goal and at this rate will not reach that goal. According to the CDC, to accomplish this goal all states and territories need to implement an effective, broad-based tobacco-control plan that addresses initiation and cessation of use.2 The final aspect of the CDC report stated that effective smoking cessation interventions are available, including brief clinical counseling, pharmacotherapy, and state quitlines (available by telephone at 800-QUIT-NOW [800–784–8669]). As physicians, we need to partner with our patients, provide adjuvant therapy when indicated, and work with our state governments to reach the 2010 goal. —k.e.m.
1. U.S. Department of Health and Human Services. Healthy people 2010: understanding and improving health. 2nd ed. Washington, D.C.: U.S. Department of Health and Human Services, 2000. Accessed November 21, 2005, at:http://www.healthypeople.gov.
2. Centers for Disease Control and Prevention. Cigarette smoking among adults—United States, 2004. MMWR Morb Mortal Wkly Rep. 2005;54:1121–4.
Copyright © 2006 by the American Academy of Family Physicians.
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