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The Early Recognition and Management of Chronic Obstructive Pulmonary Disease

Index:

 Introduction

COPD Definitions and Pathogenesis

The National Lung Health Education Program

Methods of Smoking Cessation

Maintenance Management of Symptomatic COPD

Treatment of Advanced Disease

The New Era

Methods of Smoking Cessation

Smoking cessation is essential in preventing and slowing the progression of COPD. Smoking tobacco causes 85% of COPD cases and an equal percentage of lung cancer cases in the U.S. Tobacco use is the leading cause of preventable deaths in the United States, claiming 430,000 lives annually and is also a major risk factor for cancers and cardiovascular diseases. There is clear evidence that smoking cessation relieves symptoms, slows the progression of COPD, reduces the risk of lung and other cancers, and increases life expectancy. The primary care physician has both the opportunity and responsibility to offer treatment to patients addicted to tobacco. An estimated 70% of smokers see a physician annually, providing an ideal opportunity for the primary care physician to selectively screen for COPD by performing office spirometry, screen for lung cancer, and initiate treatment for tobacco addiction.

Most patients are aware of the adverse health affects of tobacco but lack the motivation to quit. Others, particularly those with COPD, have repeatedly tried to quit but are seemingly powerless to do so. Traditionally, physicians and other healthcare workers have relied primarily on counseling to treat tobacco addiction. However combining counseling with pharmacotherapy therapy has been shown to achieve the highest quit rates.

Benefits of Smoking Cessation

COPD affects 16 million Americans and is the fourth leading cause of death. Tobacco smoking is the prime cause of COPD. Smoking cessation reduces the accelerated rate of pulmonary function decline seen in smokers. In mild COPD cases, the FEV₁ may improve following smoking cessation. Symptoms of cough and excess mucus production decrease significantly within a few months of stopping smoking.

Tobacco use is responsible for 90% of lung cancers in males and 80% in women. Head and neck cancer is seen primarily in smokers. Those patients who continue to smoke after treatment are at increased risk for a second head and neck primary cancer. Smoking cessation can decrease the risk of these cancers.

Smoking cessation has been demonstrated to substantially reduce the risk of deaths from cardiovascular diseases. There is a rapid decrease in risk for myocardial events in patients with and without previous cardiovascular disease after smoking cessation.

Physician Counseling

The physician and his or her staff can significantly increase rates of smoking cessation with simple and brief office based programs. The elements of such a plan should include the following:

• Document smoking history in the chart in all patients
• Motivate quitting
• Ask about smoking with each encounter and advise to quit
• Offer referral for counseling
• Offer pharmacotherapy

Many patients become motivated to stop smoking after spirometry results indicate abnormalities of lung function related to smoking. Some patients are also motivated to quit after a telephone call or a personal letter from their physician with “how to quit literature” enclosed. (See Table 1.)

Table 1

Nicotine Addiction

Nicotine is a powerfully psychoactive drug, and users become physically and psychologically dependent. Addicting drugs, including tobacco, have the following characteristics:

• There is a compulsion to use a substance in face of the knowledge of negative health and social consequences.
• The user progressively needs more frequent and larger doses to experience the same effect.
• Uncomfortable symptoms occur when the drug is withdrawn or the dose is reduced.

Recent research into tobacco addiction has focused on the effects of nicotine on the brain. Cigarette smoke delivers sudden jolts of nicotine to the brain within 7 seconds of its inhalation. This rapidly increases levels of the neurotransmitter dopamine in brain tissue, leading to a feeling of pleasure and a sense of well being. These pleasurable feelings are transient—lasting only a few seconds. As nicotine levels fall, the smoker experiences intense craving, often described as the “nicotine fit”.

Symptoms of withdrawal include:

• Anxiety
• Depression
• Insomnia
• Irritability
• Difficulty concentrating
• Restlessness
• Anger

Pharmacotherapy

Nicotine replacement therapy and bupropion have been approved for treatment of tobacco addiction. Both drugs used alone or in combination have been shown to increase quit rates when compared to placebo. Nortriptyline and clonidine have also been found to be beneficial but have not been approved by the FDA for the indication of smoking cessation.

Nicotine Replacement Therapy

Nicotine is the substance in tobacco known to cause dependence. Nicotine replacement therapy (NRT) can reduce the severity of withdrawal symptoms and cravings in patients abstaining from tobacco and has been shown to double quit rates compared to placebo. NRT can potentially reduce exposure to carbon monoxide, carcinogens, and the more than 4000 other compounds found in tobacco. Pure nicotine delivered in proper doses is safe and effective in treating patients with tobacco addiction and in patients with stable cardiovascular diseases.

In the United States, five delivery systems are available for NRT:

• Nicotine transdermal patches - Nicoderm CQ Patch, Habitrol Transdermal System, Nicotrol Patch
• Nicotine chewing gum - Nicotine Polacrilex, Nicorette Gum
• Nicotine inhalers - Nicotrol Inhaler
• Nicotine nasal spray - Nicotrol Nasal Spray
• Nicotine lozenge - Nicotine Polacrilex

Transdermal Nicotine Systems:
Transdermal nicotine systems are available over the counter and deliver a fixed dose of the drug over 16 to 24 hours. Dosages vary from 7mg to 21mg. Heavily addicted smokers may fail NRT because they are unable to achieve nicotine blood levels sufficient to suppress withdrawal symptoms. Nicotine blood levels achieved by the 21mg patch are 40% to 50% of the levels found in a subject smoking 30 cigarettes daily (one and a half packs a day). Therefore, this dose of nicotine may not be sufficient to decrease the patient’s nicotine requirement. The use of combined NRT delivery methods should be considered if there are no medical contraindications (See next page).  The nicotine patch is usually removed at bedtime, but in heavily addicted patients, early morning cravings may be avoided by leaving the patch on during the night. Side effects include:

Headache
Insomnia
Nightmares
Nausea
Dizziness
Blurred vision
Redness and pruritus at the site of the patch

The dose is usually reduced every 4 to 6 weeks. The physician may safely combine nicotine patches with other NRT products. supplementing the patches with nicotine gum, nicotine inhaler, nicotine spray or nicotine lozenge.

Nicotine Polarcrilex
Nicotine gum was the first NRT product approved by the FDA and is available over the counter in doses of 2mg and 4mg. The higher dose is usually required initially. When nicotine cravings are felt, the gum is chewed until a tingling sensation in the mouth is noted, after which the gum is “parked” between the cheek and gum until the cravings return, then the process is repeated. When used in conjunction with an intense behavioral modification program, quit rates have doubled when compared to placebo. Many patients have difficulty chewing the gum, especially those with dentures.

Nicotine Nasal Spray
Nicotine nasal spray (Nicotrol NS®) is an aqueous solution of nicotine delivering approximately 0.5 mg of nicotine to the nasal mucosa with each spray. The usual dose is one spray in each nostril every 1 to 2 hours. Absorption is rapid, with venous concentrations of 2 to 12 ng/ml of nicotine achieved in 4-15 minutes - mimicking the levels reached by the smoking of one cigarette. (7-17 ng/ml). This may abort craving in heavily addicted patients. The maximal recommended dose is 40 mg per 24 hours. Nasal irritation is common, affecting 80% to 90% of users. Other side effects include sneezing, lacrimation and cough. Clinical trials have shown favorable quit rates, but the dependence and abuse potential is greater when compared to other NRT products (but still lower than cigarettes).

Nicotine Inhaler
The Nicotrol® Inhaler (nicotine inhalation system) consists of a mouthpiece and plastic cartridges, each containing 10 mg of nicotine. One cartridge is inserted into the mouthpiece, and nicotine is released by inhaling. The majority of the nicotine is deposited in the oral mucosa, and maximum blood levels are achieved more slowly when compared to the nasal spray or cigarettes. The most common side effects are cough and irritation of the mouth and throat. The inhaler should be avoided in patients with history of asthma. Some patients prefer this system, because the hand-to-mouth activity mimics cigarette use.

Nicotine Lozenges
These lozenges also contain 2 mg nicotine polacrilex. Up to 20 lozenges can be safely dissolved under the tongue over a 24 hour period. One lozenge per hour is a common dosing schedule.

Combining NRT Systems-Compliance
None of the NRT systems are as effective as the cigarette in delivering nicotine to the brain. Heavily addicted patients may not achieve adequate blood levels using a single NRT system. Combining NRT products has been shown to be effective and safe. The combination of transdermal nicotine patches with nicotine gum provides steady state levels of nicotine and a jolt of nicotine to treat break-through cravings. Compliance with NRT products is highest with the nicotine patch and lowest with the nicotine inhaler.

Bupropion SR (Zyban)
Bupropion was originally marketed in the United States as an antidepressant drug with dopaminergic and noradrenergic activity. In clinical trials some of the test subjects treated for depression noted a decrease in their desire to smoke, leading investigators to explore the usefulness of the drug in the treatment of tobacco addiction. Studies with patients who had failed in efforts to quit have revealed that bupropion SR (Zyban), either alone or in combination with NRT, significantly achieved higher short-term and long-term quit rates when compared to placebo.

Bupropion SR should be started at least two weeks before the quit date with a dose of 150 mg a day for three days and then twice daily. The doses should be separated by at least eight hours and the second dose should be given no later than 6:00 PM. Bupropion SR is contraindicated in patients with a history of seizure disorder or uncontrolled hypertension. The drug should be continued for up to 6 months to maintain abstinence. Side effects include insomnia, dry mouth and agitation.

Weight Gain

Many smokers avoid quitting or relapse because of weight gain. Weight gain ranges from 2.3 to 4.5 kg (5 to 10 lb), but some individuals gain considerably more. Patients should be counseled to follow a healthy diet and to start a regular exercise program to help minimize weight gain. Patients should not try to lose weight and stop smoking at the same time. The physician should point out that a modest weight gain is a small price to pay compared to the benefits that are derived from stopping smoking.

Summary and Conclusions

It is clear that smoking cessation diminishes the risk of developing COPD, slows the accelerated decline in pulmonary function due to cigarette smoking, and improves symptoms in patients with COPD. Every tobacco user should be offered treatment to quit. The process begins by identifying all smokers in your practice, not just those with smoking-related diseases. You should motivate each patient to quit by asking at each encounter about his/her tobacco habits and pointing out the advantages of quitting. Performing spirometry to identify early COPD can be a great motivator and should be done on all smokers. However, if spirometry results are normal, reinforce with those patients that they are one of the lucky ones who do not yet have a significant loss of lung function. This may occur if they continue to smoke, but more importantly, they remain at an increased risk for having a heart attack, stroke, and/or lung cancer. Treatment should routinely include counseling as well as pharmacotherapy. Combinations of NRT products are safe and effective, and frequently are required to reduce craving in heavily addicted patients. NRT added to bupropion SR, combined with behavioral therapy, achieves the highest smoking cessation rates. Smokers frequently try acupuncture or hypnosis for tobacco dependence, but scientific merit is lacking to support these treatments.

Research is ongoing to find more effective pharmacotherapy in the treatment of nicotine addiction. Studies are currently underway to develop an ”anti-nicotine vaccine”. This experimental drug is injected into the patient, and the antibodies subsequently produced prevent nicotine molecules from reaching the brain, blunting the nicotine high. Another approach is being evaluated that decreases dopamine levels in the brain. The anti-convulsant drug Vigabatrin, marketed in Europe, decreases dopamine levels and has shown promising results in nicotine addiction.

References

Rigotti Nancy A, Treatment of Tobacco Use and Dependence, New England of Medicine, Vol. 346, No. 7, February 14, 2002 pp 506-512. An excellent, concise review clinical approach to treatment of tobacco abuse.

ATS Guidelines: cigarette smoking and health 1999, Comprehensive review of tobacco use and treatment.

Raw. M, McNeil, A, Weat, R. Smoking cessation guidelines for health professionals. A guide to effective cessation interventions for the health care system. Thorax; 1998; 53 (supplement 5: S1.) Provides a simple behavioral approach for smoking cessation endorsed by the British Thoracic Society and out lines the “5 A’s” approach of smoking cessation for office practices.

Selected Additional References

Bohadana A, Nilsdson F, Rasmussen T, et al: Nicotine Inhaler and Nicotine Patch as a Combination Therapy for Smoking Cessation: a randomized, double-blind, placebo trial.  Archives of Internal Medicine. 2000;160:3128-34. A comparison of the nicotine inhaler and patch, suggesting roughly equal effectiveness.

Fiore MC, Bailey WC, Cohen SJ, et al. Treating Tobacco Use and Dependence. Rockville, MD. Department of Health and Human Services, Public Health , Public Health vice, 2000. A comprehensive review of strategies useful in smoking cessation.

Nicotine Replacement Therapy for Patients With Coronary Artery Disease. Working Group for the Study of Transdermal Nicotine in Patients With Coronary Artery Disease.. New England Journal of Medicine, 1996; 335:1792.Evidence that use of nicotine replacement is safe in patients with coronary artery disease.

Physicians Desk Reference, 2000. Contains a listing of smoking cessation products.

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