A Preliminary Benefit-Risk Assessment of Varenicline in Smoking Cessation

Cochrane Tobacco Addiction Group, Department of Primary Health Care, Oxford University, Oxford, UK.
Drug Safety (Impact Factor: 2.82). 02/2009; 32(2):119-35. DOI: 10.2165/00002018-200932020-00005
Source: PubMed


Varenicline is a recently developed medication for smoking cessation, which has been available on prescription since 2006. It is a selective nicotinic acetylcholine receptor partial agonist, and is designed to reduce withdrawal symptoms and to lessen the rewards of continued smoking. Our objective in this article is to assess the efficacy of varenicline as an aid to smoking cessation and to weigh the potential benefits against the possible risks. We identified ten randomized controlled trials and one cohort study with historical controls. In total there were 7999 participants, 5112 of whom received varenicline. Eight of the trials compared varenicline with placebo for cessation, two compared it with nicotine replacement therapy and one tested extended use for relapse prevention. Three of the varenicline/placebo trials also included a bupropion arm. The recommended dosage of varenicline 1 mg twice daily more than doubled the chances of quitting at 6 months or longer, with a relative risk (RR) compared with placebo of 2.38 (95% CI 2.00, 2.84). It also outperformed bupropion (RR 1.52 [95% CI 1.22, 1.88]) and nicotine replacement (RR 1.31 [95% CI 1.01, 1.71]). A reduced dosage regimen of 1 mg daily also increased cessation (RR 1.88 [95% CI 1.35, 2.60]). In the trials, varenicline significantly reduced craving and other withdrawal symptoms. The most frequent adverse event was nausea, occurring in 30-40% of varenicline users. However, this was generally reported at mild to moderate levels, diminished over time and was associated with attributable discontinuation rates of between 0.6% and 7.6%. Other commonly occurring adverse events included insomnia, abnormal dreams and headache. Serious adverse events were rare, with no treatment-related deaths during the treatment or follow-up phases. Postmarketing surveillance has raised new questions about the safety of varenicline. In February 2008, the US FDA issued a public health advisory note, reporting a possible association between varenicline and an increased risk of behaviour change, agitation, depressed mood, and suicidal ideation and behaviour. They have required the manufacturers to revise the labelling of varenicline and the Summary of Product Characteristics, and to issue a medication guide. It is arguable that much of the reported behavioural and mood changes may be associated with nicotine withdrawal, although some effects occurred in people who continued to smoke while taking the medication. In view of the potential, if unproven, risk that varenicline may be associated with serious neuropsychiatric adverse outcomes, patients attempting to quit smoking with varenicline, and their families and caregivers, should be alerted about the need to monitor for neuropsychiatric symptoms, including changes in behaviour, agitation, depressed mood, suicidal ideation and suicidal behaviour, and to report such symptoms immediately to the patient's healthcare provider.

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    • "Further, Rollema et al. (2010) reported that varenicline has higher efficacy (22±2.5 %) than cytisine (6.5±0.2 %) relative to the effect of 100 μM acetylcholine. Comparisons between both drugs indicated that varenicline resulted in higher rates of abstinence from smoking than cytisine (Cahill et al. 2009; Etter 2006). The greater effectiveness of varenicline than cytisine was suggested not only to be associated with their respective pharmacodynamic properties (Rollema et al. 2010) but also to their different pharmacokinetics . "
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    ABSTRACT: Rationale: Neuronal nicotinic acetylcholine receptors (nAChRs) are pharmacological targets that have recently been implicated in the reinforcing effects of many drugs of abuse, including ethanol. Varenicline and cytisine are nAChR partial agonists in clinical use as smoking cessation aids. However, their efficacies to reduce alcohol consumption have not been fully studied. Objectives: This study aims to compare the effects of varenicline and cytisine on ethanol consumption by rats bred for many generations as high ethanol drinkers (UChB). Results: Repeated dosing (0.5 or 1.0 mg/kg/day i.p.) of varenicline or cytisine, for three consecutive days, to male UChB rats pre-exposed to 10 % (v/v) ethanol and water 24 h/day for 4 weeks, significantly reduced alcohol intake and preference of ethanol over water during 1- and 24-h ethanol access periods. This effect was specific for ethanol intake and was not observed for 0.2 % saccharin or water consumption. Varenicline appears to be more effective than cytisine, probably due to its more favorable pharmacokinetic and pharmacodynamic properties. Long-term use of both nAChRs ligands for more than 8-10 days induced tolerance to their effects on ethanol consumption. Conclusions: This preclinical study in UChB rats demonstrated that both varenicline and cytisine reduce alcohol intake, with varenicline producing a greater and longer-lasting reduction than cytisine. However, dose adjustment will have to be considered as a possible way to counter tolerance arising after continued use.
    Psychopharmacology 01/2013; 227(2). DOI:10.1007/s00213-013-2974-3 · 3.88 Impact Factor
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    • "The presence of a tongue bite, although not specific, may be indicative of seizures. Interestingly, varenicline therapy has been associated with the induction of seizures in some patients [4] [22]. "
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    ABSTRACT: The smoking cessation agent varenicline acts as a partial agonist on α(4)β(2) nicotinic acetylcholine receptors. Although debated, several reports have linked varenicline therapy to an increased risk of suicidal thoughts and/or suicide. In addition, several non-fatal overdose cases have been reported. In this report, we utilised a sample preparation procedure suitable for postmortem samples and gas chromatography coupled to mass spectrometry to analyse samples obtained from a suicidal case in which ingestion of an overdose of varenicline had occurred. Extremely high concentrations of varenicline (>250 ng/ml) were detected in the blood of the deceased, in addition to high concentrations in urine and vitreous humour. To the best of our knowledge, similar high concentrations have not been reported yet. Although, with respect to the mechanism of death in this case, confounding factors were concomitant ethanol consumption and, importantly, potentially fatal hypothermia, this is the first report of a fatality associated with the ingestion of an overdose of varenicline.
    Deutsche Zeitschrift für die Gesamte Gerichtliche Medizin 06/2012; 127(1). DOI:10.1007/s00414-012-0695-5 · 2.71 Impact Factor
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    • "Finally, the effects of the combination of metyrapone and oxazepam were comparable to those of the α4β2 nicotinic acetylcholine receptor partial agonist varenicline in this specific model of intravenous nicotine self-administration (George et al. 2011; Keating and Lyseng-Williamson 2010; O'Connor et al. 2010). Since varenicline is effective in reducing cigarette smoking in humans (Keating and Lyseng-Williamson 2010) and appears to be more beneficial than either bupropion (Cahill et al. 2009; Gonzales et al. 2006; Jorenby et al. 2006) or nicotine replacement therapy (Aubin et al. 2008; Cahill et al. 2009), these data suggest that the combination of metyrapone and oxazepam may also be effective in reducing smoking (O'Dell and Khroyan 2009). "
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    ABSTRACT: Despite increased education regarding its dangers, cigarette smoking remains a significant public health concern due to serious associated health consequences such as cancer and respiratory and cardiovascular diseases. Most smokers fail in their attempts to quit smoking, and current pharmacological interventions have relatively low levels of efficacy and are associated with significant adverse events. We have previously reported that combinations of metyrapone and oxazepam, administered at doses that were ineffective when delivered singly, resulted in dose-related decreases in cocaine self-administration in rats while not affecting food-maintained responding during the same sessions. The current study was designed to test the effects of the administration of a metyrapone:oxazepam combination on nicotine self-administration in rats. Several dose combinations of metyrapone (12.5, 25 or 50 mg/kg) and oxazepam (5 or 10 mg/kg) were tested in rats trained to intravenously (IV) self-administer nicotine (0.03 mg/kg/infusion) during 1-h self-administration sessions using both fixed-ratio and progressive-ratio (PR) schedules of reinforcement. The administration of low doses of metyrapone and oxazepam in combination significantly decreased IV nicotine self-administration in rats. At the lowest doses of 12.5 mg/kg of metyrapone and 5 mg/kg of oxazepam, the drugs alone did not decrease IV nicotine self-administration, but the combination was effective. Varenicline was also tested using the fixed-ratio schedule, and reductions in nicotine intake were similar to those seen with the moderate dose of the combination. The results of this study suggest a potential utility of the combination of metyrapone and oxazepam for smoking cessation in humans.
    Psychopharmacology 03/2012; 223(1):17-25. DOI:10.1007/s00213-012-2682-4 · 3.88 Impact Factor
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