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.