BACKGROUND:Evidence-based smoking cessation guidelines recommend nicotine replacement therapy (NRT), bupropion SR and varenicline as first-line therapy in combination with behavioural interventions. However, there are limited data to guide clinicians in recommending one form over another, using combinations, or matching individual smokers to particular forms. OBJECTIVE:To develop decision rules for clinicians to guide differential prescribing practices and tailoring of pharmacotherapy for smoking cessation. METHODS:A Delphi approach was used to build consensus among a panel of 37 international experts from various health disciplines. Through an iterative process, panellists responded to three rounds of questionnaires. Participants identified and ranked "best practices" used by them to tailor pharmacotherapy to aid smoking cessation. An independent panel of 10 experts provided cross-validation of findings. RESULTS:There was a 100% response rate to all three rounds. A high level of consensus was achieved in determining the most important priorities: (1) factors to consider in prescribing pharmacotherapy: evidence, patient preference, patient experience; (2) combinations based on: failed attempt with monotherapy, patients with breakthrough cravings, level of tobacco dependence; (3) specific combinations, main categories: (a) two or more forms of NRT, (b) bupropion + form of NRT; (4) specific combinations, subcategories: (1a) patch + gum, (1b) patch + inhaler, (1c) patch + lozenge; (2a) bupropion + patch, (2b) bupropion + gum; (5) impact of comorbidities on selection of pharmacotherapy: contraindications, specific pharmacotherapy useful for certain comorbidities, dual purpose medications; (6) frequency of monitoring determined by patient needs and type of pharmacotherapy. CONCLUSION:An algorithm and guide were developed to assist clinicians in prescribing pharmacotherapy for smoking cessation. There appears to be good justification for "off-label" use such as higher doses of NRT or combination therapy in certain circumstances. This practical tool reflects best evidence to date of experts in tobacco cessation.

译文

背景:基于证据的戒烟指南建议将尼古丁替代疗法(NRT),安非他酮SR和伐尼克兰作为一线疗法并结合行为干预。但是,只有有限的数据可以指导临床医生推荐一种形式而不是另一种形式,使用组合或将单个吸烟者与特定形式相匹配。
目的:为临床医生制定决策规则,以指导不同的处方实践和戒烟药物治疗的量身定制。
方法:采用Delphi方法在由37名来自各个健康学科的国际专家组成的小组之间建立共识。通过反复的过程,小组成员回答了三轮问卷。参与者确定并排序了他们用来定制药物疗法以帮助戒烟的“最佳实践”。由10位专家组成的独立小组对结果进行了交叉验证。
结果:对所有三回合的回应率均为100%。在确定最重要的优先事项上达成了高度共识:(1)处方药物治疗时要考虑的因素:证据,患者喜好,患者经验; (2)组合的依据是:单一疗法的尝试失败,渴望突破的患者,对烟草的依赖程度; (3)具体组合,主要类别:(a)两种或更多种形式的NRT,(b)安非他酮形式的NRT; (4)特定组合,子类别:(1a)贴片胶,(1b)贴片吸入器,(1c)贴片锭剂; (2a)安非他酮贴剂,(2b)安非他酮胶; (5)合并症对药物治疗选择的影响:禁忌症,对某些合并症有用的特定药物治疗,双重用途药物; (6)监测频率由患者需要和药物治疗类型决定。
结论:开发了一种算法和指南来协助临床医生开处方戒烟药物。在某些情况下,使用“非标签”用途(例如更高剂量的NRT或联合疗法)似乎有充分的理由。该实用工具反映了迄今为止戒烟专家的最佳证据。

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