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The Transdermal Nicotine Patch: Hands-free Nicotine Control

Discrete and little trouble, the transdermal nicotine patch delivers continuous nicotine directly to the systemic circulation. Plasma nicotine levels obtained with the patch are approximately 50% lower than those achieved with cigarette smoking. Lower levels of nicotine still alleviate the symptoms of withdrawal but are far less likely to lead to dependence when compared to tobacco or other forms of NRT. There are four marketed transdermal nicotine formulations. Three of the products (Nicoderm CQ and two generic formulations) deliver the labeled dose of nicotine continuously over 24 hours. The Nicotrol formulation provides continuous nicotine delivery over 16 hours. This system, which more closely approximates typical smoking patterns, is applied in the morning and removed at bedtime. The dosing schedules for the nicotine patches vary (Table 2).

Table 2: Nicotine Patch Dosing Nicotrol Less than or equal to 10 cigarettes/day Greater than 10 cigarettes/day Not indicated Step 1 (15 mg x 6 weeks) Step 2 (10 mg x 2 weeks) Step 3 (5 mg x 2 weeks) Nicoderm CQ Less than or equal to 10 cigarettes/day Greater than 10 cigarettes/day Step 2 (14 mg x 6 weeks) Step 3 (7 mg x 2 weeks) Step 1 (21 mg x 6 weeks) Step 2 (14 mg x 2 weeks) Step 3 (7 mg x 2 weeks) Generic (formerly Habitrol) Less than or equal to 10 cigarettes/day Greater than 10 cigarettes/day Step 2 (14 mg x 6 weeks) Step 3 (7 mg x 2 weeks) Step 1 (21 mg x 6 weeks) Step 2 (14 mg x 2 weeks) Step 3 (7 mg x 2 weeks) Generic (formerly ProStep) Less than or equal to 15 cigarettes/day Greater than 15 cigarettes/day 11 mg x 6 weeks 22 mg x 6 weeks

Before recommending a specific product and a dosing schedule, it is important to know how many cigarettes the patient smokes per day and if he or she has strong morning cravings for cigarettes. In general, heavy smokers will require higher strength formulations for a longer duration of therapy. Patients with strong morning cravings for cigarettes might have better success with a 24-hour patch. Some patients may need to switch patch strengths during the first two weeks of therapy to determine correct strength. Patients experiencing substantial withdrawal symptoms or cravings should increase to a higher dose. Patients experiencing side effects (e.g., dizziness, perspiration, nausea, vomiting, diarrhea, headache) should consider a lower dose.

Because the patch is applied directly to the skin, dermatologic conditions become a major concern. Choose an area of skin on the torso or the top outside area of the arm that is naturally hairless, and clean and dry. Do not use an area with inflammation, a burn, or any type of irritation. These conditions interfere with nicotine absorption. Patches should be placed on a different area each time, and no area should be reused for at least 1 week. Patients with psoriasis, eczema, atopic dermatitis, or other similar dermatologic conditions are not good candidates for this method of therapy.

To make sure the patch is firmly in place, apply pressure with the palm of the hand for about 10 seconds. Once the patch is adhered cohesively to skin around all edges, it can almost be forgotten until time to change it. Water and perspiration should not compromise the delivery of nicotine, and patients can bathe, swim, shower, and exercise without worry. However, there is one word of warning: patients should wash their hands carefully after applying the patch because nicotine that haphazardly gets in the eyes or nose from the hands can be irritating.

Immediate side effects include mild itching, burning, and tingling. Later, vivid dreams, sleep disturbances, or headache may cause discomfort. Though it is normal for the covered skin to appear red after patch removal, any inflammation that persists for more than 4 days should be reported to a physician and patch therapy at least temporarily discontinued. Half of patients experience local erythema, burning, and/or pruritus, but less than 5% discontinue therapy.

Table 3: Bottom Line For Transdermal Nicotine Patch Advantages Disadvantages Consistent nicotine levels delivered by the patch help mitigate the severity of withdrawal symptoms. The patch is easily applied and easily concealed. Compliance is easy and less problematic than with other methods. Patients cannot titrate dose to acutely manage withdrawal symptoms. Allergic reactions to adhesives in the patch may occur. Dermal conditions can significantly affect therapy: allergic reactions to adhesives and other skin disorders can cause exclusion from therapy.

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