Smoking Cessation  |  Bupropion (Zyban)




Smoking Cessation

Bupropion (Zyban)

Background:

Bupropion (Zyban®) is an atypical anti-depressant that has been found effective for aiding smoking cessation. It acts to reduce the severity of withdrawal symptoms thereby increases the chances of stopping smoking long-term.1 Zyban is fully funded in New Zealand as a smoking cessation treatment and is available on prescription without special authority.

Evidence of efficacy:

A Cochrane systematic review shows that use of bupropion for 7-12 weeks significantly increases long-term quit rates compared with placebo (19% vs. 11%, Risk Ratio = 1.69, 95% CI: 1.53-1.85). 1


Prescribing bupropion HCL SR (Zyban) 150 mg tablets:

  • Zyban should be started at least 1 week prior to the target quit date.
  • Days 1-3: one tablet daily
  • Day 4 onwards: take one tablet twice daily, keeping at least 8 hours between each dose
  • Patients should be treated for at least 7 weeks, but discontinuation should be considered if the patient has not made significant progress towards abstinence by the seventh week of therapy.

Things to tell your patients:

  • It’s not a magic cure, but it will make quitting easier.
  • Smoke as normal for the first week, then aim not to have a single puff from your quit day (day 8) onwards.
  • Headache, dry mouth, and difficulty sleeping are the most common side effects, but are usually tolerable.
  • Sometimes people experience drowsiness when they start taking medications like Zyban. Patients should be advised not to drive or use heavy machinery if they experience this effect.

Contraindications:

Current seizure disorder or any history of seizures

A known central nervous system (CNS) tumour

Abrupt alcohol or sedative withdrawal

Use of Monoamine Oxidase Inhibitors within 14 days

Hypersensitivity to any ingredients in Zyban

Bulimia, anorexia nervosa (or history)

Cautions:

  • Use extreme caution in patients with severe hepatic cirrhosis, a reduced dosing frequency is recommended.
  • Treatment of patients with renal impairment should be initiated at reduced frequency and/or dose.
  • Zyban must not be used in patients with predisposing risk factors for seizures unless there is a compelling clinical justification for which the potential medical benefit of smoking cessation outweighs the potential increased risk of seizure. In these patients, a maximum dose of 150mg should be considered for the duration of treatment. Predisposing risk factors for seizures include: use of medicines known to lower the seizure threshold (e.g. antipsychotics, antidepressants, antimalarials, tramadol, theophylline, systemic steroids, quinolones and sedating antihistamines); excessive use of alcohol or sedatives; history of head trauma; diabetes treated with hypoglycaemics or insulin; use of stimulants or anorectic products.
  • Depression, rarely including suicidal ideation, has been reported in patients undergoing a smoking cessation attempt, including during early stages of treatment. Patients should be advised accordingly.
  • The safety of Zyban for use during pregnancy has not been established. Use of Zyban should only be considered during pregnancy if the expected benefits are greater than the potential risks.
  • Zyban is excreted in human breast milk; mothers should be advised not to breast feed while taking Zyban.
  • The safety and efficacy of Zyban in patients under 18 years of age have not been established.
  • Anoretic drugs
  • Citalopram
  • Carbamazepine
  • Phenobarbitone
  • Phenytoin
  • Levodopa
  • Amantadine
  • Ritonavir
  • Alcohol
  • Drugs affecting CYP2B6 (e.g. orphenadrine, cyclophosphamide, ifosfamide, ticlopidine, clopidogrel)
  • Drugs affecting CYP2D6 substrates (e.g. antidepressants, antipsychotics, metoprolol, flecainide)

Drug interactions:

  • Anoretic drugs
  • Citalopram
  • Carbamazepine
  • Phenobarbitone
  • Phenytoin
 
  • Levodopa
  • Amantadine
  • Ritonavir
  • Alcohol
  • Drugs affecting CYP2B6 (e.g. orphenadrine, cyclophosphamide, ifosfamide, ticlopidine, clopidogrel)

  • Drugs affecting CYP2D6 substrates (e.g. antidepressants, antipsychotics, metoprolol, flecainide)
 

 

Adverse effects:
Dry mouth, insomnia, headache, rash. Seizure has been rarely reported. The risk of seizure is similar to other antidepressants.2 Refer to the New Zealand data sheet for Zyban for a complete list of known adverse effects.


Frequently asked questions:

  • How does the efficacy of bupropion compare to other medications for smoking cessation?

Bupropion is equally effective as nicotine replacement therapy and nortriptyline in helping people to stop smoking. Varenicline has been shown to be more effective than bupropion.

  • Can bupropion be used in people that are taking other anti-depressants?

The datasheet recommends that bupropion should not be used in patients with predisposing risk factors for seizures unless there is a compelling clinical justification for which the potential medical benefit of smoking cessation outweighs the potential increased risk of seizure. The concurrent use of anti-depressants is a predisposing risk factor for seizures.

  • Is bupropion that best choice of smoking cessation treatment for people with a history of depression?

There is no evidence to suggest that the use of bupropion will protect against depression following smoking cessation. Choice of smoking cessation product should be guided by patient preference and any contraindications or cautions. People with a history of depression should be monitored for depressed mood following smoking cessation.


Additional information:

References:

1. Hughes JR, Stead LF, Lancaster T. Antidepressants for smoking cessation. Cochrane Database of Systematic Reviews 2007(1):CD000031.
2. Oke A, Adhiyaman V, Aziz K, Ross A. Dose-dependent seizure activity associated with fluoxetine therapy. QJM 2001;94(2):113-4.



Last updated : Friday, July 29, 2016
Next review date : Saturday, July 29,2017


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