Varenicline


Article Author:
Dharminder Singh


Article Editor:
Abdolreza Saadabadi


Editors In Chief:
Rodrigo Kuljis
Oleg Chernyshev
Aninda Acharya


Managing Editors:
Orawan Chaigasame
Carrie Smith
Abdul Waheed
Frank Smeeks
Kristina Soman-Faulkner
Benjamin Eovaldi
Radia Jamil
Sobhan Daneshfar
Saad Nazir
William Gossman
Pritesh Sheth
Hassam Zulfiqar
Navid Mahabadi
Steve Bhimji
John Shell
Matthew Varacallo
Ahmad Malik
Mark Pellegrini
James Hughes
Beata Beatty
Hajira Basit
Phillip Hynes


Updated:
12/3/2018 4:38:15 PM

Indications

Smoking is a leading cause of morbidity and mortality in the human population and poses as one of the most modifiable risk factors towards preventing human disease. More than 400,000 individuals die prematurely each year in the United States from cigarette use. This represents almost one of every 5 deaths in the United States. The major diseases caused by cigarette smoking include premature atherosclerosis, coronary artery disease, cerebrovascular disease, aortic aneurysms, chronic airway obstruction, malignancies, and sudden infant death syndrome. It is a preventable risk factor that can be modified through counseling and pharmacotherapy to decrease the burden of disease caused by smoking impacting the human population.

Nicotine is the principal constituent of tobacco responsible for its addictive behavior.[1] A comprehensive approach to education including cessation advice, pharmacologic assistance, and counseling can increase smoking cessation success by almost threefold. Various first-line agents have been used to aid in smoking cessation including nicotine and bupropion. However, they have minimal long-term efficacy.[2] One of the newest agents introduced to the market is varenicline.

First trials of varenicline were introduced in 2006. Varenicline acts as a partial nicotine receptor agonist similar to cytisine. Varenicline is used as a smoking cessation aid to help people stop smoking and is used in conjunction with education and counseling. Varenicline is the first drug of choice for smoking cessation because it has been found to have a significant effect in preventing both short-term and long-term relapse.  Varenicline has been shown superior to bupropion and has equal efficacy to nicotine replacement therapy.[3] Varenicline due to its partial agonist properties has also been shown to have a lower risk of withdrawal symptoms compared to other drugs.

Mechanism of Action

Nicotine works through the dopamine receptor to cause drug reinforcement. The components of the midbrain that play a pivotal role in drug reinforcement, motility, and associative motor learning include the ventral tegmental area and substantial migration pars compacta.[4] An increase in the release of dopamine from ventral tegmental area neurons onto their targets in the nucleus accumbens contributes to addiction. Nicotine acts on dopaminergic receptors in the ventral tegmental area causing a burst firing of dopamine neurons leading to drug reinforcement.

Varenicline works by blocking the effects of nicotine on the brain.[5] It is a partial agonist and blocks alpha-4-beta-2 nicotinic acetylcholine receptor subtypes. Through partial agonism, varenicline inhibits dopaminergic activation produced by smoking and decreases the craving and withdrawal syndrome that occurs with cessation attempts. It prevents nicotine stimulation of mesolimbic dopamine system associated with nicotine addiction.

Administration

Varenicline is prescribed only to patients 18 years or older. Varenicline is taken as a tablet and comes in an oral formulation. Varenicline can be taken 0.5 mg orally once daily on day 1 to 3 and increased to 0.5 mg twice daily on days 4 through 7 and 1 mg twice daily after day 8 for 11 weeks. Therapy should be started 1 week before the target quit date. The medication should be taken with a full glass of water after eating to decrease gastric upset. In patients with renal impairment (CrCL less than 30), a maximum dose of 0.5 mg twice daily is recommended.[5] In end-stage renal disease (ESRD) patients on hemodialysis, a maximum dose of 0.5 mg once daily is recommended. Treatment duration can be up to 6 months and even longer in certain patients. Further trials are needed to determine efficacy and outcomes in those using varenicline beyond 12 months.

Adverse Effects

The most common adverse effects experienced with varenicline are nausea, insomnia, abnormal vivid dreams, and headaches. The adverse effect of nausea can be mitigated by starting at lower doses and up-titrating the dose as tolerated. Patients also complain of disturbed sleep, sleepwalking, agitation, drowsiness, and constipation.[5] Varenicline has also been implicated in certain skin syndromes such as stevens-johnson syndrome, erythema multiforme,  and photosensitivity. Renal function also must be monitored as varenicline can cause renal failure and kidney stones. Varenicline may also increase the risk of pancreatitis and patients taking varenicline should be monitored for abdominal symptoms of pancreatitis.[6]

Contraindications

There is an FDA-mandated warning for severe psychiatric symptoms, including suicidal ideation, as such adverse outcomes have been reported with varenicline. Patients taking varenicline should have closer therapeutic supervision to monitor for these behavioral symptoms.[6] It is not a contraindication to use varenicline in patients with underlying psychiatric illnesses; however, symptoms should be monitored for further deterioration. Patients exhibiting worsening of psychiatric behaviors or suicidal ideation should promptly be taken off varenicline. Serious hypersensitivity reactions or skin reactions to varenicline may occur and patients exhibiting Steven-Johnson syndrome or erythema multiforme should be advised not to take varenicline. Take caution and monitor closely if the patient has a history of renal impairment, psychiatric disorder or seizure disorder.

Monitoring

Varenicline is excreted renally, and thus it is very important to monitor renal function.  Before initiating a patient on varenicline, baseline creatinine should be obtained.[7] Patients on varenicline should be closely monitored for signs or symptoms of depression, agitation, behavior changes, skin reactions or suicidal ideation. Smoking in pregnancy is very common and posts a significant public health issue.  Varenicline and other newer pharmacologic agents have not been studied well and generally are not used to promote cessation during pregnancy. Because varenicline is a fairly new drug on the market, there are not many studies that have shown strong evidence for either major positive or negative outcomes associated with gestational use of varenicline. Currently, no evidence of increased risk of spontaneous abortion, major congenital malformation or intrauterine death has been provided from controlled studies.  Due to limited efficacy and pregnancy safety date, varenicline is not routinely recommended as a smoking cessation aid for pregnant women. Further studies are needed on this topic. If a patient has been exposed to varenicline inadvertently during the first trimester, a detailed fetal anomaly scan is recommended.[8]

Toxicity

There are currently no antidotes to varenicline. If serious adverse effects including psychiatric conditions or skin hypersensitivity reaction occur, varenicline should be discontinued immediately.[8] Varenicline may be abruptly stopped with no side effects, and there is no need for taper. Evaluation of prolonged exposure to varenicline in adult has not revealed any alteration of hematological, biochemical and anatomicopathological parameters.

Enhancing Healthcare Team Outcomes

An interprofessional approach to using varenicline is recommended.

Smoking remains a major public health problem, and despite decades of research, there is no definitive solution to help people quit this social habit. There are many drugs on the market touted to help people quit smoking, but none works consistently, and relapse rates are high. Because smokers can present with various medical disorders, the onus is on healthcare workers to educate them on the dangers of smoking. Varenicline is a relatively new drug on the market and data indicate that it can help people quit smoking in the short term; however, the patient also has to be provided with psychosocial support at the same time.[9][10]


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Varenicline - Questions

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A individual taking varenicline for smoking cessation should be warned of which of the following side effects?



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Varenicline acts by which of the following mechanisms?



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A patient has been prescribed varenicline for smoking cessation. Which of the following should be monitored when prescribing varenicline?



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Varenicline works by blocking the effects of nicotine on the brain. Nicotine is the key component that leads to addiction to tobacco. By which neurotransmitter does nicotine act?



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How is varenicline excreted from the body and what baseline lab test should be obtained prior to initiating treatment with varenicline?



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Varenicline blocks the nicotinic acetylcholine receptor subtypes. What component(s) of the midbrain play a pivotal role in drug reinforcement?



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To which patient population can varenicline be prescribed safely for smoking cessation?



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What is the mechanism of action of varenicline?



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Varenicline - References

References

Kalkhoran S,Benowitz NL,Rigotti NA, Prevention and Treatment of Tobacco Use: JACC Health Promotion Series. Journal of the American College of Cardiology. 2018 Aug 28     [PubMed]
McCarthy DE,Versella M, Quitting Failure and Success With and Without Using Medication: Latent Classes of Abstinence and Adherence to Nicotine Monotherapy, Combination Therapy, and Varenicline. Nicotine     [PubMed]
Bozinoff N,Le Foll B, Understanding the implications of the biobehavioral basis of nicotine addiction and its impact on the efficacy of treatment. Expert review of respiratory medicine. 2018 Sep     [PubMed]
Rollema H,Hurst RS, The contribution of agonist and antagonist activities of α4β2* nAChR ligands to smoking cessation efficacy: a quantitative analysis of literature data. Psychopharmacology. 2018 Sep     [PubMed]
Turner E,Jones M,Vaz LR,Coleman T, Systematic Review and Meta-Analysis to Assess the Safety of Buproprion and Varenicline in Pregnancy. Nicotine     [PubMed]
Cinciripini PM,Minnix JA,Green CE,Robinson JD,Engelmann JM,Versace F,Wetter DW,Shete S,Karam-Hage M, An RCT with the combination of varenicline and bupropion for smoking cessation: clinical implications for front line use. Addiction (Abingdon, England). 2018 Apr 21     [PubMed]
Zaccarelli-Magalhães J,Moreira N,Sandini TM,de Abreu GR,Sánchez-Sarmiento AM,Ricci EL,Fukushima AR,de Souza Spinosa H, Evaluation of Prolonged Exposure to Varenicline in Adult Rats: Haematological, Biochemical and Anatomopathological Studies. Basic     [PubMed]
Varenicline null. 2006     [PubMed]
Klemperer EM,Hughes JR,Naud S, Study characteristics influence the efficacy of substance abuse treatments: A meta-analysis of medications for smoking cessation. Nicotine & tobacco research : official journal of the Society for Research on Nicotine and Tobacco. 2018 Oct 20     [PubMed]
Goulden R,Nguyen QD,Azoulay L, Risk of Bias in Study of Varenicline and Cardiovascular Outcomes. American journal of respiratory and critical care medicine. 2018 Sep 1     [PubMed]

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