Project TEAM

Bupropion: An Effective Pharmacotherapy

Sustained-release bupropion (Zyban) fights nicotine dependence by decreasing the craving for cigarettes and ameliorating the symptoms of nicotine withdrawal by affecting dopamine and norepinephrine levels in the brain. To ensure therapeutic plasma levels of drug when patients quit, the manufacturer recommends patients initiate therapy one to two weeks before their quit date. For the first three days, patients take 150 mg every morning. If the medication is tolerated, patients increase the dosage to 150 mg twice a day for 7 to 12 weeks. Because it increases the risk of seizure, it should be avoided in anyone with a history of seizures or those taking medications that lower the seizure threshold. Physicians are advised that bupropion also is contraindicated for patients with a history of anorexia or bulimia nervosa and should be used with extreme caution in severe liver cirrhosis. Patients undergoing therapy with Wellbutrin, Wellbutrin SR, or monoamine oxidase inhibitors, and those abruptly discontinuing alcohol or sedatives (including benzodiazepines) are not candidates for bupropion therapy. Women who are pregnant should try nondrug treatment first.

Table 7: Bottom Line For Bupropion Therapy Advantages Disadvantages Oral formulation; easy to administer Associated with 30% quit rate at more than 5 months. Parallel use of nicotine-replacement therapy permissible and, in fact, encouraged. Beneficial in patients with depression. Seizure risk is increased. Contraindicated in select groups of patients.

Other Therapies

Combining types of nicotine-replacement therapy (e.g., sustained patch therapy combined with therapy in which dose can be titrated (gum, lozenge, inhaler, or nasal spray therapy) is usually reserved for patients for whom monotherapy fails to help them quit. In addition, providers sometimes prescribe second-line agents (clonidine and nortriptyline) for patients unable to use first-line medications.

Summary

Overall, medications for tobacco cessation approximately double the long-term quit rates compared to placebo. Little information is available to substantiate the use of one form of pharmacotherapy over another for a given patient. The choice of therapy is therefore largely based on patient preference and tolerability of the available dosage forms. Pharmacotherapy should be combined with behavioral counseling to further increase patients' chances for success. In the next module, we'll look at smoking among special populations. The groups we will examine include pregnant women, parents of infants and young children, and adolescents. We will also explore the role that genetics plays in tobacco use.

References

Fiore MC, Bailey WC, Cohen SJ, et al. Treating Tobacco Use and Dependence: Clinical Practice Guideline. Rockville, MD: U.S. Department of Health and Human Services, 2000.

Jorenby DE, Leischow SJ, Nides MA, et al. A controlled trial of sustained-released bupropion, a nicotine patch, or both for smoking cessation. N Engl J Med 1999;340(9):685–691

Schneider NG, Olmstead RE, Franzon MA, Lunell E. The Nicotine Inhaler: Clinical Pharmacokinetics and Comparison with Other Nicotine Treatments. Clinical Pharmacokinetics 2001;40(9):661–684. Adis International, Inc.

Shiffman S. Dresler CM, Hajek P, Gilburt SJ, Targett DA, Strahs KR. Efficacy of a nicotine lozenge for smoking cessation. Arch Int Med 2002;162:1267-1276.

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