Side-effects of specific nicotine preparations
Mild local reactions at the beginning of treatment are
common because of the irritant effect of nicotine. Oral
preparations andinhalation cartridgescan cause irritation of
the throat,gum,lozenges, andoral spraycan cause increased
salivation, andpatchescan cause minor skin irritation. The
nasal spraycommonly causes coughing, nasal irritation,
epistaxis, sneezing, and watery eyes; theoral spraycan cause
watery eyes and blurred vision.
Gastro-intestinal disturbances are common and may be
caused by swallowed nicotine. Nausea, vomiting, dyspepsia,
and hiccup occur most frequently. Ulcerative stomatitis has
also been reported. Dry mouth is a common side-effect of
lozenges,patches,oral spray, andsublingual tablets.Lozenges
cause diarrhoea, constipation, dysphagia, oesophagitis,
gastritis, mouth ulcers, bloating,flatulence, and less
commonly, taste disturbance, thirst, gingival bleeding, and
halitosis. Theoral spraymay also cause abdominal pain,
flatulence, and taste disturbance.
Palpitations may occur with nicotine replacement therapy
and rarelypatchesandoral spraycan cause arrhythmia.
Patches,lozenges, andoral spraycan cause chest pain. The
inhalatorcan very rarely cause reversible atrialfibrillation.
Paraesthesia is a common side-effect oforal spray.
Abnormal dreams can occur withpatches; removal of the
patch before bed may help.Lozengesandoral spraymay
cause rash and hotflushes. Sweating and myalgia can occur
withpatchesandoral spray;thepatchescan also cause
arthralgia.Neonatal abstinence syndrome
Neonatal abstinence syndrome occurs at birth as a result of
intra-uterine exposure to opioids or high-dose
benzodiazepines. Treatment is usually initiated if:
.feeding becomes a problem and tube feeding is required;
.there is profuse vomiting or watery diarrhoea;
.the baby remains very unsettled after two consecutive
feeds despite gentle swaddling and the use of a pacifier.
Treatment involves weaning the baby from the drug on
which it is dependent. Morphine p. 282 or methadone
hydrochloride p. 299 can be used in babies of mothers who
have been taking opioids. Morphine is widely used because
the dose can be easily adjusted, but methadone
hydrochloride may provide smoother control of symptoms.
Weaning babies from opioids usually takes 7 – 10 days.
Weaning babies from benzodiazepines that have a long
half-life is difficult to manage; chlorpromazine
hydrochloride p. 244 may be used in these situations but
excessive sedation may occur. For babies who are dependent
on barbiturates, phenobarbital p. 216 may be tried, although
it does not control gastro-intestinal symptoms.7.1 Nicotine dependence
NICOTINIC RECEPTOR AGONISTS
Nicotine
lINDICATIONS AND DOSE
Nicotine replacement therapy in individuals who smoke
fewer than 20 cigarettes each day
▶BY MOUTH USING CHEWING GUM
▶Child 12–17 years: 2 mg as required, chew 1 piece of gum
when the urge to smoke occurs or to prevent cravings,
if attempting smoking cessation, treatment should
continue for 3 months before reducing the dose
▶BY SUBLINGUAL ADMINISTRATION USING SUBLINGUAL TABLETS
▶Child 12–17 years: 1 tablet every 1 hour, increased to
2 tablets every 1 hour if required, if attempting
smoking cessation, treatment should continue for upto 3 months before reducing the dose; maximum
40 tablets per day
Nicotine replacement therapy in individuals who smoke
more than 20 cigarettes each day or who require more
than 15 pieces of 2 -mg strength gum each day
▶BY MOUTH USING CHEWING GUM
▶Child 12–17 years: 4 mg as required, chew 1 piece of gum
when the urge to smoke occurs or to prevent cravings,
individuals should not exceed 15 pieces of 4 -mg
strength gum daily, if attempting smoking cessation,
treatment should continue for 3 months before
reducing the dose
Nicotine replacement therapy in individuals who smoke
more than 20 cigarettes each day
▶BY SUBLINGUAL ADMINISTRATION USING SUBLINGUAL TABLETS
▶Child 12–17 years: 2 tablets every 1 hour, if attempting
smoking cessation, treatment should continue for up
to 3 months before reducing the dose; maximum
40 tablets per day
Nicotine replacement therapy
▶BY INHALATION USING INHALATOR
▶Child 12–17 years:As required, the cartridges can be
used when the urge to smoke occurs or to prevent
cravings, individuals should not exceed 12 cartridges of
the 10 -mg strength daily, or 6 cartridges of the 15 -mg
strength daily
▶BY MOUTH USING LOZENGES
▶Child 12–17 years: 1 lozenge every 1 – 2 hours as required,
one lozenge should be used when the urge to smoke
occurs, individuals who smoke less than 20 cigarettes
each day should usually use the lower-strength
lozenges; individuals who smoke more than
20 cigarettes each day and those who fail to stop
smoking with the low-strength lozenges should use the
higher-strength lozenges; If attempting smoking
cessation, treatment should continue for 6 – 12 weeks
before attempting a reduction in dose; maximum
15 lozenges per day
▶BY MOUTH USING OROMUCOSAL SPRAY
▶Child 12–17 years: 1 – 2 sprays as required, individuals
can spray in the mouth when the urge to smoke occurs
or to prevent cravings, individuals should not exceed 2
sprays per episode (up to 4 sprays every hour);
maximum 64 sprays per day
▶BY INTRANASAL ADMINISTRATION USING NASAL SPRAY
▶Child 12–17 years: 1 spray as required, individuals can
spray into each nostril when the urge to smoke occurs,
up to twice every hour for 16 hours daily, if attempting
smoking cessation, treatment should continue for
8 weeks before reducing the dose; maximum 64 sprays
per day
▶BY TRANSDERMAL APPLICATION USING PATCHES
▶Child 12–17 years:Individuals who smoke more than
10 cigarettes daily should apply a high-strength patch
daily for 6 – 8 weeks, followed by the medium-strength
patch for 2 weeks, and then the low-strength patch for
thefinal 2 weeks; individuals who smoke fewer than
10 cigarettes daily can usually start with the medium-
strength patch for 6 – 8 weeks, followed by the low-
strength patch for 2 – 4 weeks; a slower titration
schedule can be used in individuals who are not ready
to quit but want to reduce cigarette consumption
before a quit attempt; if abstinence is not achieved, or
if withdrawal symptoms are experienced, the strength
of the patch used should be maintained or increased
until the patient is stabilised; individuals using the
high-strength patch who experience excessive side-
effects, that do not resolve within a few days, should
change to a medium-strength patch for the remainder
of the initial period and then use the low-strength
patch for 2 – 4 weeks296 Substance dependence BNFC 2018 – 2019
Nervous system4