Nicotine Transdermal Patch: learn about side effects, dosage, special precautions, and more on MedlinePlus. Do not use more or less of them or use them more often than prescribed by your doctor. Apply the patch to a clean, dry, hairless area of skin on the. Concurrent Nicotine Patch / Denicotinized Cigarette Therapy for Smoking Cessation II Resource. Do other forms of nicotine (e.g. 7 Why are some tests less expensive than the iScreen OFD?. 5 to 21 mg per day, depending on the patch (); nicotine nasal spray, 0.7 mg per 1-mg dose of one spray in each nostril (Johansson et al., 1991; Gourlay and Benowitz, 1997). Replacement Therapy Transdermal patches 24-hour mg patches are available Three strengths are available 7, 14 and 21 mg in the 24 hr patch. Remove patch after 16 hours for pregnant women where the use of a patch is judged appropriate. Combination therapy of varenicline with nicotine replacement therapy is better than varenicline alone: a systematic review and meta- analysis of randomized controlled trials . No other types of nicotine product were combined with varenicline in these trials. We found no trials comparing combination therapy with NRT alone that met our inclusion and exclusion criteria. One RCT that compared combination therapy and NRT was not included because it combined varenicline and counseling to get long- term NRT users to quit NRT . After meta- analysis, our results demonstrated favorable effects of combination therapy in both early and late outcomes. To our knowledge, this is the first systematic review and meta- analysis on this issue. In our main analysis, the early outcomes in varenicline combined with placebo patch group were consistent with previous studies using varenicline mono- therapy (abstinence rate 4. The late outcomes were also similar (abstinence rate 3. In sensitivity analysis, we identified the largest RCT . After eliminating this RCT, the favorable effects of both early and late outcomes became insignificant. We identified two distinguishing factors that might have caused this difference. First, there were more female subjects in this RCT. Previous studies have revealed that the effect of varenicline did not differ among genders . On the other hand, some studies yielded inconsistent reports on whether male subjects using NRT had higher abstinence rates than females . If nicotine patch use had been less effective in females, the higher percentage of females in this RCT would bring about less effective outcomes, which was not the case. Therefore, gender difference did not seem to contribute to the treatment effect of this RCT. Second, this RCT . A meta- analysis conducted by Shiffman S et al. However, this positive effect was not consistent in the following meta- analyses . These meta- analyses showed that pre- cessation nicotine patch and gum had a moderate but insignificant increase in abstinence rates. Pre- cessation nicotine patch appeared to be more effective than pre- cessation nicotine gum . Therefore, we favored that the effect of pre- cessation nicotine patch contributed to the better outcomes in this RCT. The rationale of combination therapy of varenicline with NRT resides in the hypotheses that 1) varenicline does not fully saturate . A standard- dose of varenicline (1. Further saturation of the receptors seemed to explain the additive effect of NRT. However, a neuropharmacological study utilizing positron emission tomography revealed that a single dose of 0. It deserves a debate whether the combination to . Nicotine addiction develops from complex pathways, and individual genotypes influence both smoking behavior and treatment effects . More studies are required to explore the mechanism of combining varenicline with NRT. The event rates of adverse effects were similar in the two groups. The only significant increase in adverse events was skin reactions in one RCT . The event rate of skin reactions was comparable to those in nicotine patch mono- therapy . Other adverse events of combination therapy were not higher than findings from previous studies of varenicline mono- therapy . The birth of an infant with Down syndrome (trisomy 2. Varenicline combined with nicotine patch appeared to be safe and tolerable in smoking cessation. The question of small study number. Critics might argue that it was too early to perform a meta- analysis when there were only three RCTs available. However, the estimate of the pooled effects would have poor precision. Three solutions are suggested under such circumstance . One option is to report the separate effects and not report a summary effect. Readers are expected to understand that authors cannot draw conclusions about the effect size. The problem is that some readers may revert to . Another option is to perform a fixed effect analysis. This approach yields a descriptive analysis of the included studies, but does not allow us to make inferences about a wider population. A third option is to take a Bayesian approach, where the estimate of variance is based on data from outside of the current studies. We selected the second approach and used fixed effect model in our analysis. Strengths and limitations. In our study, we searched the major databases with rigorous strategies. There were duplicated authors who selected the articles independently, allowing for a low probability that an important study was missed. The included studies had high quality and the Jadad score ranged from 4 to 5. The heterogeneity between the selected studies was low, and there were no significant publication biases. We evaluated both early and late outcomes which was more comprehensive than short- term evaluations. However, there were some limitations. We did not search grey literature or un- published data. Trials that were less known might have been missed. The strength of our research was compromised by the small number of trials. The largest RCT which had the greatest influence to our results was different from the other RCTs in demographic characteristics and treatment design. The impact was that our conclusions could not be generalized to other populations. Also, the funnel plot and tests of publication bias had low power to detect a potential bias. In our review, the adverse events of depression and skin reactions were only reported in one study. There was no report of cardiovascular or suicidal events. The safety of combination therapy requires further investigations.
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