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CPD


For many years we have been successfully guiding patients in our pharmacies through their stop smoking journeys, with support and nicotine replacement therapy (NRT), but latterly we have been able to access another tool in our arsenal to help us in the crusade to support our patients to a successful quit attempt.


Varenicline (Champix) has recently been made available for use in a smoking cessation quit attempt in the pharmacy scheme, prescribed by pharmacists.


The decision came after a review that recommended the service could be improved by increasing the range of products available and by making follow-up arrangements more robust. Varenicline has been successfully used in smoking cessation for a number of years by the medical profession, general practitioners and independent prescribing pharmacists.


An update to the public health service (PHS) specification in June 2014 for smoking cessation services, now allows varenicline to be supplied to smokers who have already attempted to quit using nicotine replacement therapy (NRT). Patients should be monitored by the pharmacist each week for twelve weeks, and


the patient’s GP informed of the supply. This weekly follow-up by the pharmacist is crucial to the patient succeeding. Pharmacists should be aware that some patients request varenicline when it is not appropriate for them, and should therefore follow their local patient group direction (PGD) closely.


MODE OF ACTION OF VARENICLINE Varenicline(Champix) became available in the UK in 2006. It binds with high affinity and selectivity to the a4ß2 nicotinic acetylcholine receptor, acting as a partial agonist that has lower intrinsic efficacy than nicotine and has antagonist activity in the presence of nicotine. Varenicline helps break the pharmacological basis of addiction in two ways helping patients to be smoke-free and nicotine-free.


When smoking, the nicotine inhaled attaches itself to the a4ß2 receptors in the brain, which then causes the release of dopamine. Varenicline blocks the nicotine’s ability to fully activate these receptors and so the reward experience upon smoking is not realised. It is also believed that varenicline causes less dopamine to be released than with nicotine on activation of nicotine receptors. (Figure 1)


Figure 1: VARENICLINE (CHAMPIX) IS A NON-NICOTINE TREATMENT WITH A DUAL MODE OF ACTION


SUPPLY OF VARENICLINE Varenicline may be supplied as part of the national public health service (PHS) contract to support quit attempts where the pharmacist has completed the patient group direction (PGD) training relevant to this product. The monthly payments associated with supply in this way will be made through the national scheme. Varenicline must be supplied using a CPUS prescription. In order for a patient to be considered, they must have tried nicotine replacement therapy (NRT) on one or more than one occasion, along with support from a recognised stop smoking service. Varenicline must be supplied along with weekly support. The patient must be assessed for suitability before being signed up to the scheme and should be informed of the risks and benefits of using varenicline to support a smoking cessation attempt. Medicine counter staff must be trained to refer each request for varenicline to that pharmacist. The pharmacist must have successfully completed training approved by NES Pharmacy MCQ2 or the local health board. The service can only be provided in an approved pharmacy, which must have a suitable area for consultation with patients.


DOSING


Following the one week titration, the recommended dose is 1mg twice daily; patients who are unable to tolerate the adverse effects may have the dose lowered to 0.5mg twice daily. The patient should set a quit date to stop smoking, during week two of the course, those unwilling or unable to set a quit date at this time, can chose a flexible quit date up to week four, if no quit is set at this point, the patient should be withdrawn from the service and told to try again at a future date when they are ready for another quit attempt.


The standard course is for twelve weeks. (Figure 4)


Where a patient is struggling at week ten to twelve to stop (taking varenicline), in order to titrate down, you may discuss the option to dose taper at week ten with the aim of stopping varenicline after twelve weeks of treatment.


Where local NHS Board guidelines allow we can supply beyond the twelve weeks, this is another option Figure 2


This should be a consultation room (or quiet area within the pharmacy if a room is not available).


INCLUSION CRITERIA


The Patient must be over 18 years of age, a dependent smoker, identified as sufficiently motivated to quit and agrees to receive behavioural support according to the agreed protocol. A full medical history is taken and documented and there are no contraindications or cautions for treatment with varenicline.


EXCLUSION CRITERIA Smokers who are not sufficiently motivated to quit; are under 18 years of age; pregnant or breastfeeding women (or a women likely to be trying for a baby); have a sensitivity to varenicline or any of its excipients; have a history of severe renal impairment or end stage renal disease; patients with a history of serious psychiatric illness such as schizophrenia, bipolar disorder and major depressive disorder; patients who have epilepsy; and patients on theophylline or warfarin.


Varenicline should not be used in conjunction with other smoking cessation therapies.


for the pharmacist to consider and discuss with the patient, However, you will only be remunerated for the cost of the medication supplied.


Note: A fourteen-day starter pack (11 x 500microgram tabs with 14 x 1mg tabs) can be supplied for the last two weeks of treatment either at week ten or twelve [as above]. Ensure the patient has clear instructions to take the tablets in the starter pack in reverse order to facilitate tapered discontinuation [unless on 24 weeks of therapy]. Alternatively, where no local NHS Boards scheme is in place, and the patient requires advice beyond the twelve-week period, then they should be advised that they can also seek support from the local specialist smoking cessation services and the national telephone support line Smokeline on 0800 848 484. The service is open every day from 8am – 10pm and is supported by a website which offers interactive web chat with trained support staff www.canstopsmoking.com


32 - SCOTTISH PHARMACIST


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