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Over 43 million adults in the United States have hypertension, but 31% are unaware of their elevated blood pressure; 17% are aware but untreated; 29% are being treated but have not controlled their blood pressure (still greater than 140/90 mm Hg); and only 23% are well controlled In every adult age group, higher values of systolic and diastolic blood pressure carry greater risks of stroke and congestive heart failure
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Table 1 7 Suggestions for the clinical use of nicotine gum
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Parameter of Clinical Use Patient selection Precautions Suggestions Appropriate as a primary pharmacotherapy for smoking cessation Pregnancy: Pregnant smokers should first be encouraged to attempt cessation without pharmacologic treatment Nicotine gum should be used during pregnancy only if the increased likelihood of smoking cessation, with its potential benefits, outweighs the risk of nicotine replacement and potential concomitant smoking Cardiovascular diseases: Although not an independent risk factor for acute myocardial events, nicotine gum should be used only after consideration of risks and benefits among particular cardiovascular patient groups: those in the immediate (within 2 weeks) post-myocardial infarction period, those with serious arrhythmias, and those with serious or worsening angina pectoris Adverse effects: Common adverse effects of nicotine chewing gum include mouth soreness, hiccups, dyspepsia, and jaw ache These effects are generally mild and transient and can often be alleviated by correcting the patient s chewing technique (see Prescribing instructions below) Nicotine gum is available in doses of 2 mg and 4 mg per piece Patients who smoke less than 25 cigarettes per day should be prescribed the 2-mg gum initially The 4-mg gum should be prescribed to patients who express a preference for it, have failed with the 2-mg gum but remain motivated to quit, and/or smoke more than 25 cigarettes per day The gum is most commonly prescribed for the first few months of a quit attempt Clinicians should tailor the duration of therapy to fit the needs of each patient Patients using the 2-mg strength should use not more than 30 pieces per day, whereas those using the 4-mg strength should not exceed 20 pieces per day Abstinence from smoking: The patient should refrain from smoking while using the gum Chewing technique: The gum should be chewed slowly until a peppery taste emerges, then parked between cheek and gum to facilitate nicotine absorption through the oral mucosa Gum should be slowly and intermittently chewed and parked for about 30 minutes Absorption: Acidic beverages (eg, coffee, juices, soft drinks) interfere with the buccal absorption of nicotine, so eating and drinking anything except water should be avoided for 15 minutes before and during chewing Scheduling of dose: A common problem is that patients do not use enough gum to get the maximum benefit: they chew too few pieces per day and do not use the gum for a sufficient number of weeks Instructions to chew the gum on a fixed schedule (at least 1 piece every 1 to 2 hours) for at least 1 to 3 months may be more beneficial than ad lib use
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Reproduced, with permission, from: The Agency for Health Care Policy and Research Smoking Cessation Clinical Practice Guideline JAMA 1996 Apr 24;275(16):1270 80 Updated and revised from Treating Tobacco Use and Dependence US Public Health Service wwwsurgeongeneralgov/tobacco/ defaulthtm
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Table 1 8 Suggestions for the clinical use of bupropion SR
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Parameter of Clinical Use Patient selection Precautions Suggestions Appropriate as a first-line pharmacotherapy for smoking cessation Pregnancy: Pregnant smokers should be encouraged to quit first without pharmacologic treatment Bupropion SR should be used during pregnancy only if the increased likelihood of smoking abstinence, with its potential benefits, outweighs the risk of bupropion SR treatment and potential concomitant smoking Similar factors should be considered in lactating women (FDA Class B) Cardiovascular diseases: Generally well tolerated; infrequent reports of hypertension Side effects: The most common side effects reported by bupropion SR users were insomnia (35 40%) and dry mouth (10%) Contraindications: Bupropion SR is contraindicated in individuals with a history of seizure disorder, a history of an eating disorder, who are using another form of bupropion (Wellbutrin or Wellbutrin SR), or who have used an MAO inhibitor in the past 14 days Patients should begin with a dose of 150 mg every morning for 3 days, then increase to 150 mg bid Dosing at 150 mg bid should continue for 7 12 weeks following the quit date Unlike nicotine replacement products, patients should begin bupropion SR treatment 1 2 weeks before they quit smoking For maintenance therapy, consider bupropion SR 150 mg bid for up to 6 months Cessation prior to quit date: Recognize that some patients will lose their desire to smoke prior to their quit date, or will spontaneously reduce the amount they smoke Scheduling of dose: If insomnia is marked, taking the evening dose earlier (in the afternoon, at least 8 hours after the first dose) may provide some relief Alcohol: Use alcohol only in moderation
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