Interactions Between Cigarette Smoking and Administration of Psychopharmaceuticals

cigarette฀consumption฀in฀schizophrenic฀and฀non-schizophrenic฀patients฀because฀of฀admin- istration฀of฀haloperidol฀was฀measured฀on฀the฀basis฀of฀reliable฀parameters฀CO,฀nicotine฀ [200] .฀ The฀ combination฀ of฀ neuroleptics฀ and฀ smoking฀ reduces฀ the฀ frequency฀ of฀ parkin- sonism-like฀symptoms฀in฀these฀patients฀and฀can฀reduce฀the฀anticholinergic฀doses฀required฀ in฀some฀cases.฀On฀the฀other฀hand,฀the฀eficacy฀of฀haloperidol฀in฀these฀patients฀is฀reduced฀ because฀of฀raised฀elimination฀rates฀ [228–230] .฀Unfortunately,฀this฀interaction฀is฀usually฀not฀ taken฀ into฀ account฀ when฀ calculating฀ the฀ haloperidol฀ dosage.฀ Similarly,฀ smoking฀ also฀ increases฀the฀elimination฀of฀antidepressants฀amitriptyline,฀nortriptyline,฀imipramine฀and฀ desipramine฀ [220] ฀by฀inducing฀the฀hepatic฀breakdown฀of฀these฀substances฀via-CYP1A2.฀ Plasma฀protein฀binding฀by฀nortriptyline฀is฀clearly฀reduced฀as฀a฀result฀ [231] . Thus,฀smoking฀cessation฀can฀be฀expected฀to฀result฀in฀a฀paradoxical฀increase฀in฀the฀eficacy฀ of฀ neuroleptics฀ and฀ antidepressants:฀ this฀ is฀ manifested฀ most฀ particularly฀ in฀ an฀ increase฀ of฀ adverse฀effects฀e.g.฀parkinsonoid฀effects฀of฀neuroleptics,฀seizures฀caused฀by฀clozapine฀ [232] .

11.5.6 Pre-operative Smoking Cessation

Up฀to฀10฀of฀patients฀develop฀respiratory฀tract฀or฀cardiovascular฀complications฀during฀the฀ post-operative฀period.฀Men฀and฀women฀who฀smoke฀are฀especially฀at฀risk฀in฀this฀respect฀ [233] :฀they฀have฀a฀3฀to฀6-fold฀increased฀risk฀of฀intra-operative฀pulmonary฀complications฀ [234] ฀and฀there฀is฀a฀2฀to฀5-fold฀increased฀risk฀of฀perioperative฀complications฀in฀smokers฀ with฀chronic฀cardiovascular฀or฀pulmonary฀disease.฀The฀consequences฀of฀cigarette฀smoking฀ on฀the฀various฀organ฀systems฀are฀discussed฀in฀Chaps.฀5–7. Smoking฀disturbs฀post-operative฀wound฀healing฀ [235–237] ฀and฀increases฀the฀risk฀of฀ anastomotic฀leakage฀in฀colorectal฀surgery฀ [238] .฀To฀date,฀there฀exists฀only฀one฀evidence- based฀study฀conirming฀that฀pre-operative฀smoking฀cessation฀1฀or฀6–8฀weeks฀eliminates฀ Drug Interactive฀effects Benzodiazepines฀diazepam,฀ lorazepam,฀midazolam,฀ chlordiazepoxide No฀effect฀ [206–208] Bupropion No฀effect฀ [94] Chlorpromazine AUC฀ß฀−36,฀serum฀concentration฀ß฀−24;฀฀ clinical฀signiicance?฀ [209,฀210] Clorazepate AUC฀ß,฀t 0.5 ฀of฀N-desmethyldiazepam฀ß฀ [211] Clozapine Induction฀of฀CYP 1A2 ,฀clearance฀Ý,฀plasma฀concentration฀ß฀ −28฀ [205,฀212–215] Fluvoxamine Induction฀of฀CYP 1A2 ,฀metabolic฀clearance฀Ý,฀AUC฀ß฀−44,฀ plasma฀concentration฀ß฀−47฀ [216] Haloperidol Clearance฀Ý฀+44,฀serum฀concentration฀ß฀−70.฀Clinical฀ signiicance?,฀no฀observed฀differences฀in฀dose฀ [191,฀217,฀218] Imipramine Serum฀concentration฀ß,฀no฀clinical฀effect฀ [219] Nortriptyline Unclear,฀no฀clinical฀effect฀ [220,฀221] Olanzapine Induction฀of฀CYP 1A2 ,฀clearance฀Ý฀+98,฀great฀variability฀in฀ plasma฀clearance฀over฀a฀fourfold฀range฀ [222–224] Table 11.8 ฀฀฀Pharmacokinetic฀interactions฀between฀smoking฀and฀drugs฀inluencing฀the฀CNS the฀risks฀of฀peri-฀and฀post-operative฀tobacco-associated฀complications฀ [217] .฀This฀study฀in฀ 120฀patients฀indicates฀that฀an฀effective฀smoking฀intervention฀programme฀6–8฀weeks฀before฀ surgery฀reduces฀postoperative฀morbidity:฀the฀overall฀complication฀rate฀was฀18฀in฀the฀ smoking฀intervention฀group฀and฀52฀in฀the฀control฀group฀p฀=฀0.0003.฀The฀median฀length฀ of฀ hospital฀ stay฀ was฀ 11฀ 7–57฀ vs.฀ 13฀ 8–69฀ days฀ intervention฀ vs.฀ controls฀ [217] .฀ According฀to฀estimates฀in฀one฀series฀of฀studies,฀smoking฀cessation฀should฀be฀implemented฀ 8฀weeks฀prior฀to฀surgery฀ [218] .฀The฀period฀before฀and฀after฀surgery฀is฀a฀good฀time฀to฀insti- tute฀interventional฀measures฀with฀regard฀to฀smoking฀cessation.฀In฀particular,฀peri-operative฀ complications฀can฀be฀reduced฀by฀pre-operative฀smoking฀cessation.฀Alongside฀behavioural฀ therapy฀interventions,฀NRT฀is฀probably฀the฀method฀of฀choice.

11.6 Concluding Remarks

It฀is฀assumed฀that,฀despite฀pharmacotherapy,฀medical฀counselling฀of฀the฀smoker฀is฀neces- sary฀but฀that฀this฀achieves฀independent฀smoking฀cessation฀in฀a฀fraction฀of฀smokers฀only. • ฀ Among฀ the฀ pharmacological฀ options,฀ numerous฀ studies฀ indicate฀ that฀ treatment฀ with฀ nicotine฀products฀appears฀to฀be฀a฀reliable฀method,฀leading฀to฀successful฀smoking฀cessa- tion฀in฀30–40฀of฀cases฀see฀Table฀ 11.9 ฀for฀list฀of฀products. • ฀ The฀level฀of฀the฀nicotine฀dose฀administered฀initially฀is฀a฀critical฀problem฀area฀simulta- neous฀combination฀of฀two฀or฀three฀formulations฀may฀be฀required฀in฀the฀initial฀phase฀of฀ treatment. • ฀ Depending฀ on฀ the฀ level฀ of฀ dependence,฀ NRT฀ should฀ be฀ continued฀ for฀ 4–12฀ weeks,฀ decreasing฀the฀nicotine฀dose฀over฀time. • ฀ Nicotine฀chewing฀gum฀4฀mg,฀nasal฀spray฀and฀inhaler฀are฀more฀suitable฀than฀the฀nico- tine฀patch฀for฀the฀relief฀of฀craving. Agent Formulation Daily฀dose฀[mg] Nicotine Patch฀maximum฀release฀1.5฀mgh Maximum฀21 a Chewing฀gum,฀2฀mg Maximum฀32 a Chewing฀gum,฀4฀mg Maximum฀64 a Sublingual฀tablet,฀2฀mg Maximum฀60 a Nasal฀spray฀10฀mgml 1–2฀mgh,฀maximum฀30 a Inhaler฀10฀mg฀cartridge 20–40 a Lozenge,฀2฀mg Maximum฀18–30 a Lozenge,฀4฀mg Maximum฀36–60 a Bupropion Sustained-release฀tablets Maximum฀2฀´฀150 Table 11.9 ฀฀฀A฀selection฀of฀agents฀used฀as฀aids฀to฀promote฀smoking฀cessation,฀together฀with฀dosage฀ details a Irrespective฀of฀bioavailability