Pharmacotherapy

CAN-ADAPTT Guideline Webinar Series

March 1, 2011

Lead: Peter Selby, MBBS, CCFP, MHSc, FASAM

Bio and Disclosures

Peter Selby is Clinical Director, Addictions Program and Head of the Nicotine Dependence Clinic at the Centre for Addiction and Mental Health (CAMH). He is an Associate Professor in the Departments of Family and Community Medicine, Psychiatry and Public Health Sciences at the University of Toronto.

Previous funds from Schering Canada to provide buprenorphine training (2000)

Paid consultant and advisory board member- Pfizer consumer health care Canada, Pfizer Inc, Canada, Sanofi-Synthelabo, Canada, GSK, Canada. Genpharm and Prempharm, Canada, CTI.

Grants: Health Canada, SFO, CIHR NO TOBACCO INDUSTRY FUNDS

Guideline Development Group

Peter Selby, MBBS, CCFP, MHSc, FASAM; Gerry Brosky, MD, MSc, CCFP; Charl Els, MBChB, FCPsych, MMed Psych (cum

laude), Cert. ASAM, MRO; Rosa Dragonetti, MSc; Sheila Cote-Meek, BScN, MBA, PhD; Jennifer O’Loughlin, PhD; Paul McDonald, PhD, FRSPH; Alice Ordean, MD, CCFP, MHSc; Robert Reid, PhD, MBA

CAN-ADAPTT

Guideline development, dissemination and engagement project

Integrates practice, policy and research in a collaborative smoking cessation network

Goal: To inform the development of a Pan-Canadian clinical practice guideline (CPG) for smoking cessation

Funded by the Drugs and Tobacco Initiative, Health Canada

Dissemination

& Engagement

National Network

Practice-informedResearch Agenda

Knowledge Translation

PRACTICERESEARCH Clinical Practice Guideline

Appraisal: AGREE4 independent reviewers (practicing physicians)All formally trained on AGREE instrument

HIGH QUALITY CLINICAL PRACTICE GUIDELINESU.S. Department of Health and Human Services Public Health Service: Treating Tobacco Use and Dependence (2008 Update),

New Zealand Smoking Cessation Guidelines (August 2007), Registered Nurses Association of Ontario: Integrating Smoking Cessation into Daily Nursing Practice (March 2007),

Registered Nurses Association of Ontario: Integrating Smoking Cessation into Daily Nursing Practice (October 2003), Institute for Clinical Systems Improvement. Tobacco use prevention and cessation for infants, children and adolescents (June 2004),

Institute for Clinical Systems Improvement Tobacco use prevention and cessation for adults and mature adolescents (June 2004).

The CAN-ADAPTT program engaged the Guidelines Advisory

Committee

COMPREHENSIVE LITERATURE SEARCH 87 Guidelines Found

87 Guidelines Found

Highest scoring CPG’s

included

6 Guidelines Included6 Guidelines Included

Appraisal: AGREE Plus8 Additional questions developed by CAN-ADAPTT to understand the applicability of the recommendations in the Canadian context

Initial LITERATURE REVIEW for existing Clinical Practice Guidelines

5 Guidelines Included

5 Guidelines Included

Version1.0

February 2009

Version1.0

February 2009

HIGH QUALITY CLINICAL PRACTICE GUIDELINES

Clinical Approaches• 7 clinical sections discussed•Workshop held: November 1, 2009

• 100 CAN-ADAPTT members attended and provided feedback

• The Guideline Development Group (GDG) reviewed the section notes and determined revisions to the summary statements.

Population Level approaches

Sections: Population level approaches to tobacco cessation in Canada

Workshop/AGM: Oct 1st, 2010

Version3.0

Release DateJanuary 2011

Version3.0

Release DateJanuary 2011

Input from CAN-ADAPTT Network

Spring – Summer 2010

Input from CAN-ADAPTT Network

Spring – Summer 2010

Version2.0

Currently Posted

Version2.0

Currently PostedNetwork input Network input Network Input Network Input

Levels of Evidence • Attributed levels of evidence and grades of recommendation to each summary statement based on GRADE principles

Guideline Development

Applied principles of ADAPTE…

• Review existing CPGs

• Highest-scoring CPGs included

• Ongoing input from CAN-ADAPTT network

• GRADE framework used

Level of Evidence

Strong

Weak

High Low

1A 2A

1B 2B

1C 2C

Grade of

Recommendation

Aboriginal Peoples/

AutochtonesHospital-based populations/

Populations des hôpitaux

Mental Health and/or Other Addictions/

Santé mentale et/ou autres dépendances

Pregnant and Breastfeeding

Women/ Femmes enceintes et qui

allaitent

Youth (Children and Adolescents)/ Jeunes (enfants et

adolescents)

Ask about tobacco use: How much do you smoke? 0 - ___ cigarettes per day (cpd)?

(one large pack = 25 cpd, one small pack = 20 cpd)

Yes

Motivational InterviewingAssess the 5 R’s:

RelevanceRewardsRiskRoadblocksRepetition

Assess Readiness: Given everything going on in your life, on a scale of 0-10, where 0 is lowest…How important is it for you to quit smoking? How confident are you that you can quit smoking?Low importance or confidence

(≤ 5)

Assist in Quit Attempt: Would you like to quit abruptly?

High importance or confidence (>5)

Have you tried quitting cold turkey?

Yes

Cold Turkey

No

No response

YesNo

Yes

Reduce to Quit (RTQ)Step 1: (0-6 weeks) - Smoker sets a target for no. of cigarettes per day to cut down and a date to achieve it by (at least 50% recommended)- Smoker uses gum to manage cravingsStep 2: (6 weeks up to 6 months)- Smoker continues to cut down cigarettes using gum- Goal should be complete stop by 6 months- Smoker should seek advice from HCP if smoking has not stopped within 9 monthsStep 3: (within 9 months)- Smoker stops all cigarettes and continues to use gum to relieve cravingsStep 4: (within 12 months)- Smoker cuts down the amount of gum used, then stops gum use completely (within 3 months of stopping smoking)

No

Pharmacotherapy

Advise: As your physician, I am concerned about your tobacco use, and advise you to quit. Would you like my help?

Algorithm for Tailoring Pharmacotherapy in Primary Care Settings

Consider combination pharmacotherapy, based on:1. failed attempt with monotherapy2. breakthrough cravings3. level of dependence4. multiple failed attempts5. experiencing nicotine withdrawal

Has bupropion/NRT failed? YIs weight gain a concern? N …History of unstable mental illness? N...Allergic to Varenicline? N...Previous non-responder? NWant to quit within 7 days? N

= Varenicline

Has NRT failed? Y/NIs weight gain a concern? Y…History of seizures? N ...History of unstable mental illness? N…Eating disorder? N...Allergic to bupropion? N...Previous non-responder? N…Want to quit in 7 days? N

= Bupropion SR

Has bupropion/NRT failed? NIs weight gain a concern? NWant to quit within 7 days? Y = NRT (Gum, Patch, Lozenge or Inhaler)

Choose the following combinations:1. Two or more forms of NRT a. patch (15mg) + gum (2mg) b. patch + inhaler c. patch + lozenge2. Bupropion + form of NRT

a. Bupropion + patchb. Bupropion + gum

No Varenicline with NRT

Arrange Follow Up1. Monitor carefully2. Consider contraindications3. Consider comorbidities and specific pharmacotherapy4. Consider dual purpose medications5. If after 4 weeks no response, consider alternative 1st line medications.*

@ 4 weeksPartial response

*N.B. for 2nd line medications (clonidine and nortriptyline), see guidelines.

Developed by Peter Selby, MBS, CCFP. This algortihm is based on:

Bader, McDonald, Selby, Tobacco Control, 2009; 18:34-42. Fiore MC et al., Clinical Practice Guideline: Treating Tobacco Use and Dependence, May 2008. Gray, Therapeutic Choices: 5th Ed., 2007, Chapter 10: 147-157. Version 2, revised December 8, 2010.

Have additional feedback?

1. Join the network

2. Review the current version of the guideline

3. Provide your feedback online• Clinical considerations; tools/resources

For more information

CAN-ADAPTT

Centre for Addiction and Mental Health

175 College St.

Toronto, ON M5T 1P7

T: 416-535-8501 ext. 7427

www.can-adaptt.net

Note: These presentation slides may be used or reproduced for educational purposes only. Please acknowledge authorship of this content to CAN-ADAPTT and CAMH.