Walden – NURS 3325 Module 4 Medications
Walden – NURS 3325 Module 4 Medications
NURS 3325 Module 4 Medications
Another potentially detrimental health effect related to smoking that has implications for care of older adults is the potential for altering the effects of medications. Interactions can occur in people who smoke or use nicotine products (including smokeless tobacco) and in people who have recently quit smoking. Interactions can be due directly to the physiologic effects of nicotine or they may be caused by the hydrocarbons in tobacco smoke, which can affect hepatic metabolism of some medications. Additional information and examples of drug–nicotine interactions are discussed in Chapter 8.
Identify 2 medications affected by nicotine. What changes can it cause? How would you address this with your clients?
Despite anti-smoking campaigns, there are about 1.3 billion cigarette smokers worldwide and this number is still increasing.1 Both smoking prevalence and daily tobacco consumption are very high in patients with psychiatric disorders. Over two-thirds of Australians with psychosis smoke cigarettes, compared with one quarter of the general population.
Smoking restriction or cessation is now commonly imposed on patients by ‘no smoking’ policies in Australian hospitals. Stopping smoking is particularly important in patients with mental health problems as they often have an adverse cardiovascular risk profile (from factors including obesity, dyslipidaemia, insulin resistance and hypertension). This is associated with high rates of premature mortality from cardiovascular disease.
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Even with nicotine replacement therapy as a cessation aid, patients with psychiatric illness appear to have more difficulty maintaining long-term abstinence than other smokers. Most resume smoking within five weeks of hospital discharge. These patients should be regularly asked about their smoking status, as an additional risk of resuming or abruptly ceasing cigarette smoking has the potential for drug interactions.
Drug interactions
The chemicals in smoke may interact with antipsychotics, antidepressants, benzodiazepines, oral contraceptives, inhaled corticosteroids and beta blockers via pharmacokinetic and pharmacodynamic (often nicotine-mediated) mechanisms.
Pharmacokinetic interactions
Cigarette smoking induces the activity of cytochrome P450 (CYP) 1A2 (via chemicals in cigarette smoke such as polycyclic aromatic hydrocarbons) and also CYP2B6. These enzymes metabolise several clinically important drugs (such as antidepressants and antipsychotics) (Box) and a number of procarcinogens (such as those in cigarettes).
The effect of smoking on hepatic enzymes is not related to the nicotine component of tobacco. Nicotine replacement therapy does not influence CYP1A2 activity.
Genetic polymorphisms of the CYP1A2 gene contribute to extensive inter-individual variability in drug metabolism and are associated with altered inducibility of gene expression in smokers. There are also marked ethnic differences in the distribution of CYP1A2 mutations, meaning that different ethnic groups respond differently when the patient stops smoking.
CYP1A2 activity is significantly higher in heavy smokers (more than 20 cigarettes/day) than in nonsmokers.This is likely to be clinically relevant for some drugs which have a narrow therapeutic index and are metabolised by CYP1A2, such as clozapine. The induction varies depending on the bioavailability of the components of cigarette smoke and the extent of inhalation. It is not known how the number of cigarettes smoked daily or inter-individual variation affects CYP1A2 induction, but heavier smokers appear to have a greater increase in the clearance of drugs.
This enzyme induction is rapidly reversed when patients abruptly stop smoking, with a new steady state of CYP1A2 activity reached after approximately one week. This reduction in enzyme activity reduces clearance and increases the risk of adverse drug reactions for patients taking drugs metabolised by CYP1A2. These patients should be regularly asked about their smoking and the extent of their cigarette consumption.