Table 3.7Clinical use of the nicotine nasal spray (See FDA package insert for more complete information.)

Clinical use of nicotine nasal spray (FDA approved)
Patient selectionAppropriate as a first-line medication for treating tobacco use
Precautions, warnings, contraindications, and side effects (see FDA package insert for complete list)Pregnancy - Pregnant smokers should be encouraged to quit without medication. Nicotine nasal spray has not been shown to be effective for treating tobacco dependence in pregnant smokers. (Nicotine nasal spray is an FDA pregnancy Class D agent.) Nicotine nasal spray has not been evaluated in breastfeeding patients.

Cardiovascular diseases - NRT is not an independent risk factor for acute myocardial events. NRT should be used with caution among particular cardiovascular patient groups: those in the immediate (within 2 weeks) postmyocardial infarction period, those with serious arrhythmias, and those with unstable angina pectoris.

Nasal/airway reactions - Some 94% of users report moderate to severe nasal irritation in the first 2 days of use; 81% still reported nasal irritation after 3 weeks, although rated severity typically was mild to moderate. Nasal congestion and transient changes in sense of smell and taste also were reported. Nicotine nasal spray should not be used in persons with severe reactive airway disease.

Dependency - Nicotine nasal spray produces higher peak nicotine levels than other NRTs and has the highest dependence potential. Approximately 15–20% of patients report using the active spray for longer periods than recommended (6–12 months); 5% used the spray at a higher dose than recommended.
DosageA dose of nicotine nasal spray consists of one 0.5-mg dose delivered to each nostril (1 mg total). Initial dosing should be 1–2 doses per hour, increasing as needed for symptom relief. Minimum recommended treatment is 8 doses/day, with a maximum limit of 40 doses/day (5 doses/hour). Each bottle contains approximately 100 doses. Recommended duration of therapy is 3–6 months.
AvailabilityPrescription only
Prescribing instructionsDosing information - Patients should not sniff, swallow, or inhale through the nose while administering doses, as this increases irritating effects. The spray is best delivered with the head tilted slightly back.
Costa$49 per bottle (quantity used determines how long supply lasts)

Cost data were established by averaging the retail price of the medication at national chain pharmacies in Atlanta, GA, Los Angeles, CA, Milwaukee, WI, Sunnyside, NY, and listed online during January 2008 and may not reflect discounts available to health plans and others.

From: 6, Evidence and Recommendations

Cover of Treating Tobacco Use and Dependence: 2008 Update
Treating Tobacco Use and Dependence: 2008 Update.
Tobacco Use and Dependence Guideline Panel.

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