Nicotine patches are a useful tool in the management of smoking cessation. The success and tolerability of this form of nicotine replacement does require some pharmacology knowledge. I lay out my most important nicotine patch clinical pearls below.
Nicotine Patch Clinical Pearls – Dosing
Let’s start with the dosing of nicotine patches. A clinician must first assess the number of cigarettes used per day. This is going to help us determine the appropriate starting dose. The 21 mg starting dose should be used if the patient uses more than 10 cigarettes per day. If the number of cigarettes used per day is 10 or less, the starting dose is 14 mg.
Nicotine patches should not be dosed on an as-needed basis. The time to peak concentration is 2-8 hours so obviously, this won’t be an advantageous agent to use for acute relief of cravings.
You have to be aware of insomnia. The first reason is that you don’t want to contribute to polypharmacy if you can avoid it. Patients will often reach for OTC sleep aids to manage adverse effects. Be sure to ask about insomnia. If patients wear the patch for 24 hours, they are more likely to experience this adverse effect. Vivid dreams can also be a complaint of patients who leave a nicotine patch on overnight. In those patients, you may have them try to take it off at night to see if this alleviates the problem.
As with virtually any topical medication, skin irritation can occur. Some patients will attempt to place the patch in the exact location every time. This should not be done. Rotation of the patches are recommended to help reduce the risk of irritation.
Nicotine Patch Clinical Pearls – Morning Cravings
Leaving the nicotine patch on overnight has the potential to help with morning cravings, but nighttime adverse effects may be more likely to occur as mentioned above. Asking about morning cravings can allow you to assess if you want the patient to try to keep the patch on overnight. This information can also help give you a small sense of the severity of the addiction as well. If the morning cravings are powerful, this can be a potential sign of a patient who may have a more difficult time getting off cigarettes.
If the patch has to be removed at night due to adverse effects, there are other actions we can take. One of those options involves using a short-acting nicotine replacement agent (i.e. gum, lozenge, etc.) to deal with acute relief of her cravings when she wakes up.
Hopefully these nicotine patch clinical pearls will help you take care of your smoking cessation patients. If you are looking for more on this topic, check out these varenicline clinical pearls!