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Zorluk: OrtaSubstance-Related and Addictive Disorders

A 3434-year-old man comes to the clinic requesting assistance with smoking cessation. He has smoked one and a half packs of cigarettes daily for the past 1515 years. His past medical history is significant for bipolar I disorder. His last manic episode occurred 44 years ago, and he is currently stable on valproate monotherapy without any recent depressive or manic symptoms. The patient states, 'I tried using nicotine patches and nicotine gum together last year, but the cravings were too strong and I went back to smoking within a week.' He is highly motivated to quit and asks for an oral prescription medication to help reduce his cravings. Physical examination and vital signs are within normal limits. Which of the following is the most appropriate pharmacotherapy for this patient?

  1. VareniclineCevap
  2. B
    Bupropion
  3. C
    Nortriptyline
  4. D
    Sertraline
  5. E
    Buspirone

Cevap

Varenicline is the most appropriate medication for this patient.
Varenicline is the most appropriate next step for this patient. He has severe Tobacco Use Disorder and has already failed combination nicotine replacement therapy (NRT). Varenicline is a partial agonist at the α4β2\alpha_4\beta_2 nicotinic acetylcholine receptor, relieving withdrawal symptoms while blocking the rewarding effects of nicotine. Large randomized trials have demonstrated that varenicline is highly effective for smoking cessation and is safe to use in patients with stable psychiatric conditions, including bipolar disorder, without a significant risk of mood destabilization.

Adım Adım Çözüm

1
Identify the primary diagnosis and the patient's goal.
The patient has severe Tobacco Use Disorder and wants to quit smoking using an oral prescription medication.
Establishes the clinical objective and guides the choice of pharmacotherapy.
2
Review the patient's past treatment trials.
The patient has already failed combination nicotine replacement therapy (patches and gum).
Eliminates NRT as the optimal next step, indicating a need to step up to first-line non-nicotine oral therapies.
3
Evaluate the patient's comorbidities and medication safety.
The patient has bipolar I disorder. Oral options like bupropion act as antidepressants and can precipitate mania. Varenicline does not have this risk.
Ensures the selected pharmacotherapy does not destabilize the patient's underlying psychiatric condition.

Anahtar Kavram

Management of Tobacco Use Disorder in patients with comorbid Bipolar Disorder involves utilizing varenicline while avoiding antidepressant-based cessation therapies (such as bupropion) that carry a risk of precipitating a manic episode.
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Substance-Related and Addictive Disorders

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