july 2020 • ATS journals

Initiating Pharmacologic Treatment in Tobacco-Dependent Adults. An Official American Thoracic Society Clinical Practice Guideline

Frank T. Leone, Yuqing Zhang, Sarah Evers-Casey, A. Eden Evins, et al.

DOI: 10.1164/rccm.202005-1982ST

Content curated by:David Rodrigues

Key message

Qual o melhor tratamento farmacológico inicial em adultos fumadores? Guideline GRADE da American Thoracic Society que elabora sete recomendações (5 fortes e 2 condicionais, fundamentadas maioritariamente por RCT com boas classificações nas várias dimensões metodológicas) que são relativamente simples e de fácil implementação.

Analysis

Population

Adultos com dependência de tabaco

Method

Guideline da American Thoracic Society que usou metodologia GRADE (Grading of Recommendations, Assessment, Development, and Evaluation) para classificar a certeza nos efeitos estimados e a força das recomendações.

Results

O painel formulou cinco recomendações fortes e duas recomendações condicionais; Recomendações fortes incluem o uso de vareniclina em vez de sistemas transdérmico de nicotina; uso de vareniclina em vez de bupropion; uso de vareniclina em vez de sistema transdérmico de nicotina em adultos com comorbilidade psiquiátrica, iniciação de vareniclina em adultos mesmo que não estejam motivados para a cessação e uso de terapia com duração superior a 12 semanas. As recomendações condicionais incluem a combinação de um sistema transdérmico de nicotina com a vareniclina em vez de vareniclina isoladamente e o uso da vareniclina em vez de cigarros eletrónicos.

Abstract

Background: Current tobacco treatment guidelines have established the efficacy of available interventions, but they do not provide detailed guidance for common implementation questions frequently faced in the clinic. An evidence-based guideline was created that addresses several pharmacotherapy-initiation questions that routinely confront treatment teams. Methods: Individuals with diverse expertise related to smoking cessation were empaneled to prioritize questions and outcomes important to clinicians. An evidence-synthesis team conducted systematic reviews, which informed recommendations to answer the questions. The GRADE (Grading of Recommendations, Assessment, Development, and Evaluation) approach was used to rate the certainty in the estimated effects and the strength of recommendations. Results: The guideline panel formulated five strong recommendations and two conditional recommendations regarding pharmacotherapy choices. Strong recommendations include using varenicline rather than a nicotine patch, using varenicline rather than bupropion, using varenicline rather than a nicotine patch in adults with a comorbid psychiatric condition, initiating varenicline in adults even if they are unready to quit, and using controller therapy for an extended treatment duration greater than 12 weeks. Conditional recommendations include combining a nicotine patch with varenicline rather than using varenicline alone and using varenicline rather than electronic cigarettes. Conclusions: Seven recommendations are provided, which represent simple practice changes that are likely to increase the effectiveness of tobacco-dependence pharmacotherapy.