Download Any change in tobacco use status may affect

TOBACCO’S INTERACTION
WITH DRUGS
Julie C. Kissack, Pharm.D., BCPP, FCCP
Harding University College of Pharmacy
May 14, 2015
LEARNING OBJECTIVES
1. Recognize nicotine product attributes that are
implicated in drug-drug interactions.
2. Describe how ingestion of tobacco products
impact medication levels.
3. Analyze and apply techniques to manage
medication therapy when a person stops smoking
cigarettes.
AS A CLINICIAN, HAVE YOU…..
Worked with patients who are tobacco users?
Provided support to help smoker quit?
Recognized that efficacy and/or side effects
associated with medication treatment for chronic
illness changes when a person quits smoking?
ARKANSAS CIGARETTE USE 2013
Overall cigarette use in adults - 25.9% (males = 26.7%,
females = 25.2%)
Overall use in high school age students – 19.1% (males
= 22.2%, females = 16.1%) vs national – 15.1%
e-cigarette use by middle school students in 2013
1.1% - increase to 3.9% in 2014; in high school
students 2013 use 4.5% - increase to 13.4% in 2014
CDC: Behavioral Risk Factor Surveillance System (BRFSS). CDC Annual Youth Tobacco Survey
NICOTINE ATTRIBUTES
Toxic substance
Psychoactive component of tobacco products
Genetic makeup individualizes a person’s response
to nicotine
GENETIC INFLUENCE
 Nicotinic receptor α 5 subunit (CHRNA5 ) =
NICOTINE DEPENDENCE and Cytochrome P450
2A6 (CYP2A6 ) genotypes influence smoking
cessation success and response to
pharmacotherapy.
Slow vs fast metabolism
Gender
DRUG-DRUG INTERACTIONS
 Combustible products from tobacco smoke cause the
clinically significant drug interactions, not nicotine.
 Constituents in tobacco smoke (e.g., polycyclic aromatic
hydrocarbons) may enhance the metabolism of other drugs,
resulting in an altered pharmacologic response.
 Pharmacokinetic interactions
 Pharmacodynamic action
Any change in tobacco use status may
affect clinical response to medications
CYTOCHROME P-450 ENZYMES
1A2
2D6
3A4
Cigarette smoke may stimulate these
enzyme systems thus causing a decreased medication effect
CAFFEINE
Metabolized through cyp1A2 enzyme system
Smoking cessation allows the cyp1A2 system to
normalize
Essential to discuss caffeine intake and adjustment
when a smoker is attempting a quit attempt.
SPECIFIC DISEASE STATES FOCUS
Cancer
Cardiovascular Disease
Psychiatric Illness
CIGARETTE SMOKE IMPACT ON
CANCER TREATMENTS
Oncology Agents
Effect
irinotecan (Camptosar)
Decreased efficacy
erlotinib (Tarceva)
Decreased efficacy
anastrozole (Arimidex)
Decreased efficacy
bicalutamide (Casodex)
Decreased efficacy
everolimus (Afinitor)
Decreased efficacy
exemestane (Aromasin)
Decreased efficacy
docetaxel (Docefrez)
Decreased efficacy
SMOKING EFFECTS ON SELECT
CARDIOVASCULAR MEDICATIONS
Cardiovascular
Medications
Effect
propranolol (inderal)
Increased clearance of propranolol
thus it is less efficacious
verapamil (Calan)
flecanide (Tambocor)
mexiletine (Mexitil)
warfarin (Coumadin)
Increased clearance; may need to
increase flecanide dose
Increased clearance lowering
mexiletine level approximately 25%
Decreased efficacy
RX FOR CHANGE
rxforchange.ucsf.edu/
Drug Interaction Sheet
SMOKING EFFECTS ON MEDICATIONS
USED TO TREAT MENTAL ILLNESS
See Table 1
PATIENT CASE
32 year old treated for diabetes mellitus with insulin.
Other medications include lisinopril 20 mg, and
propranolol. On May 5, 2015 lab report reveals HbA1c
– 6%. She informs you today that she plans to try
again to quit smoking. She asks for your advice about
medications to help her quit.
How will you manage her medication treatment if she
is successful in her quit attempt?
ARKANSAS TOBACCO QUITLINE
1-800-QUIT-NOW (1-800-784-8669)
http://www.healthy.arkansas.gov/programsservices/t
obaccoprevent/pages/tobaccoquitline.aspx
REFERENCE LIST
1.
Arrojo-Romero, M., et al., Caffeine consumption in a long-term psychiatric hospital: Tobacco smoking may explain in large part the apparent association between schizophrenia
and caffeine use. Schizophr Res. 2015 Feb 20. pii: S0920-9964(15)00072-9. doi: 10.1016/j.schres.2015.01.042. [Epub ahead of print]
2.
Chaudhary KR, Batchu SN, Seubert JM. Cytochrome P450 enzymes and the heart. IUBMB Life 2009 Oct;61(10):954-60. doi: 10.1002/iub.241.
3.
Chena L, Bierut LJ. Genomics and personalized medicine: CHRNA5-CHRNA3-CHRNB4 and smoking cessation treatment. J Food Drug Anal. 2013 December ; 21(4): S87–S90.
doi:10.1016/j.jfda.2013.09.041.
4.
Chen L, Bloom AJ, Baker TB, Smith SS, Piper ME, Martinez M, et al. Pharmacotherapy effects on smoking cessation vary with nicotine metabolism gene (CYP2A6). Addiction.
2014;109(1):128–137. doi:10.1111/add.12353.
5.
Clerici M, Colombo G, Secundo F, Gagliano N, Colombo R, Portinaro N, Giustarini D, Milzani A, Rossi R, Dalle-Donne I. Cigarette smoke induces alterations in the drugbinding properties of human serum albumin. Blood Cells Mol Dis. 2014 Apr;52(4):166-74. doi: 10.1016/j.bcmd.2013.12.001.
6.
de Jong FA, Sparreboom A, Verweij J, Mathijssen RHJ. Lifestyle habits as a contributor to anti-cancer treatment failure. Eur J Cancer 2008;44:374-82.
7.
Elsherbiny ME, Brocks DR. The ability of polycyclic aromatic hydrocarbons to alter physiological factors underlying drug disposition. Drug Metab Rev 2011 Nov;43(4):457-75.
doi: 10.3109/03602532.2011.596204. Epub 2011 Aug 8.
8.
Gagne JJ, Bykov K, Choudhry NK, Toomey TJ, Connolly JG, Jerry Avorn J. Effect of smoking on comparative efficacy of antiplatelet agents: systematic review, meta-analysis, and
indirect comparison. BMJ 2013;347:f5307. doi: 10.1136/bmj.f5307 (Published 17 September 2013)
9.
Hukkanen J1, Jacob Iii P, Peng M, Dempsey D, Benowitz NL. Effects of nicotine on cytochrome P450 2A6 and 2E1 activities. Br J Clin Pharmacol. 2010 Feb;69(2):152-9. doi:
10.1111/j.1365-2125.2009.03568.x.
10.
Kennedy WK, Jann MW, Kutscher EC. Clinically significant drug interactions with atypical antipsychotics. CNS Drugs (2013) 27:1021–1048. DOI 10.1007/s40263-013-0114-6.
11.
Kumar S, Rao PS, Earla R, Kumar A. Drug-drug interactions between anti-retroviral therapies and drugs of abuse in HIV systems. Expert Opin Drug Metab Toxicol. 2015
Mar;11(3):343-55. doi: 10.1517/17425255.2015.996546. Epub 2014 Dec 24.
12.
Nadkarni A, Oldham MA, Howeard M, Berenbaum I. Drug-drug interactions between warfarin and psychotropics: updated review of the literature. Pharmacotherapy. 2012
Oct;32(10):932-42. doi: 10.1002/j.1875-9114.2012.01119.
13.
Petros WP, Younis IR, Ford JN, Weed SA. Effects of tobacco smoking & nicotine on cancer treatment pharmacotherapy. Pharmacotherapy 2012 Oct;32(10):. doi:10.1002/j.18759114.2012.01117.10.1002/j.1875-9114.2012.01117.
14.
Schaffer SD1, Yoon S, Zadezensky I. A review of smoking cessation: potentially risky effects on prescribed medications. J Clin Nurs. 2009 Jun;18(11):1533-40. doi:
10.1111/j.1365-2702.2008.02724.x.
15.
Zale EL, Dorfman ML, Hooten WM, Warner DO, Zvolensky MJ, Ditre JW. Tobacco smoking, nicotine dependence, and patterns of prescription opioid misuse: results from a
nationally representative sample. Nicotine Tob Res. 2014 Oct 25. pii: ntu227. [Epub ahead of print]