Therapeutic AreaFormulary ChoicesCost for 28
(unless otherwise stated)
Rationale for decision / comments
Related information: NICE Tobacco Harm Reduction PH45 June 2013Somerset offers patients free advice planning and medications to help them to quit smoking. Click Smokefreelife
Smoking CessationNicotine Replacement Therapy (NRT)Patches - various
Gum - various
Lozenges - various
Nasal spray
Inhalator®
Quickmist®
Prescribing for the management of nicotine addiction should be in line with NICE guidance.
Evidence for all aids to smoking cessation indicates that motivational support increases likelihood of successful quit attempt.
Decisions around appropriate aids to smoking cessation should be made in agreement with the patient.
Combinations of NRT, bupropion and varenicline for smoking cessation should not be used.
Decisions around route of administration for NRT should be made in agreement with the patient. Combinations of NRT products should be considered for those with a high level of nicotine dependency or where previous attempts to stop smoking have been unsuccessful.
Prescriptions should normally be sufficient to last until 2 weeks after the target stop date, subsequent prescriptions should only be given to people who demonstrate that their quit attempt is continuing.
Bupropion
(Amfebutamone)
Bupropion should not be prescribed to patients with other risk factors for seizures unless the potential benefits of smoking cessation clearly outweigh the risk. Factors increasing seizure risk include:
 Concomitant administration of drugs that lower seizure threshold eg. antidepressants, antimalarials, antipsychotics, quinolones, sedating antihistamines, systemic corticosteroids, theophylline and tramadol, stimulants and anorectics
 Alcohol abuse
 History of head trauma
 Diabetes
150mg tablets: £41.76 (60)Prescribers should consider prescribing Bupropion a month at a time to minimise waste and link with patients receiving ongoing behavioural support. Bupropion should not be prescribed in pregnancy, lactation or to patients aged <18 years
Bupropion is contra-indicated in patients with history of seizure, eating disorders, CNS tumour, or those experiencing acute symptoms of benzodiazepine or alcohol withdrawal
VareniclineVarenicline (Champix®) is a Black Triangle▼drug, consequently all adverse effects should be reported to the MHRA via the Yellow Card scheme. Following reports of depression and suicidal ideation the MHRA advise:
 Smoking cessation with or without pharmacotherapy may be associated with an exacerbation of underlying psychiatric illness, including depression. Care should be taken in such patients, who should be advised of the risk
 Patients should be made aware of the possibility that trying to stop smoking might cause symptoms of depression
 Patients who are taking varenicline who develop suicidal thoughts should stop their treatment and contact their doctor immediately.

There are some concerns about cardiovascular risk with a warning from FDA issued in June 2011. Patients should be instructed to notify their doctor of new or worsening cardiovascular symptoms. The risk appears to be similar with bupropion
Starter pack: £27.30
0.5mg tablets (11)
1mg tablets (14)
0.5mg tablets: £54.60 (56)
1mg tablets: £27.30 (28),
£54.60 (56)
Varenicline is approved for prescribing in Primary Care with the following advice. Varenicline should:
 only be prescribed within its licensed indications for smokers who have expressed a desire to quit smoking
 normally only be prescribed as part of a programme of behavioural support
 not be prescribed in pregnancy, lactation or to patients aged <18 years
Prescribers should consider prescribing the 12 week course of Varenicline a month at a time to minimise waste in patients and link in with patients receiving ongoing behavioural support.
Special advice for certain patientsOffer people with psychosis or schizophrenia who smoke help to stop smoking,even if previous attempts have been unsuccessful. Be aware of the potential significant impact of reducing cigarette smoking on the metabolism of other drugs, particularly clozapine and olanzapine. NICE guidance issued 2014.
Opioid dependenceOral methadone and buprenorphine are recommended by NICE for maintenance therapy in the management of opioid dependence. Patients should be committed to a supportive care programme including a flexible dosing regimen administered under supervision for at least three months, until compliance is assured. In Somerset substance misuse services are provided by Turning Point Somerset which offers a comprehensive program of supportive care through the central team and key workers. Selection of methadone or buprenorphine should be made on a case by case basis, but methadone should be prescribed (as Physeptone®) if both drugs are equally suitable.
Primary care prescribing of methadone 1mg/ml mixture or buprenorphine sublingual tablets for the treatment or maintenance of opioid dependence is only recommended by GPs who undertaken the necessary RCGP training and in practices that have the relevant shared-care arrangements in place with Turning Point Somerset. Prescribing for the treatment or maintenance of drug addiction outside of shared-care arrangements is NOT recommended and could lead to medico-legal implications for the prescriber in some circumstances.
Methadone 1mg/1ml mixture
as Physeptone®
1mg/ml: £5.46 (500ml)
1mg/ml sugar-free: £5.46 (500ml)
Prescribing by brand is recommended as the most cost-effective option.
NB: Sugar-free methadone liquid is thought to have more abuse potential, as it causes fewer complications if injected intra-venously by abusers. SF methadone mixture should be considered second-line. There is no evidence of SF preparations being beneficial in the prevention of dental problems in opioid dependence – dental decay is more likely to be attributed to lifestyle factors that effect dental hygiene and the depressant effect of opioids on salivary secretion.
Buprenorphine sugar-free sublingual tablets0.4mg: £1.60 (7)
2mg: £1.24 (7)
8mg: £1.83 (7)
Prescribing generically is recommended as the most cost-effective option
Alcohol dependenceNaltrexone50mg tablets: £22.34 (28)For alcohol dependence, oral naltrexone is an AMBER drug, to be initiated at Turning Point and continued by general practice.
Somerset Prescribing Forum approved use of generic naltrexone for this indication.