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Tobacco use disorder in a patient with end-stage kidney disease and stable schizophrenia — ABIM Board MCQ

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HardSmoking CessationTobacco use disorder in a patient with end-stage kidney disease and stable schizophreniaABIM Board

A 59-year-old woman receiving maintenance hemodialysis is evaluated for smoking cessation. She smokes 25 cigarettes daily and is ready to set a quit date. Her medical history includes schizophrenia, which has been stable for 4 years on aripiprazole, and bulimia nervosa during early adulthood, which has been in remission for 25 years. She has no current depression, psychosis, suicidal ideation, or recent psychiatric hospitalization. A previous nicotine patch caused intolerable dermatitis, and she declines all nicotine-containing medications but requests an oral cessation agent. Which of the following is the most appropriate initial smoking-cessation plan?

Educational content. Not a substitute for clinical judgement or local policy.

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Correct answer: E — Begin intensive behavioral counseling with varenicline 0.5 mg once daily

Explanation lettering: E = shown as A · C = shown as B · B = shown as C · A = shown as D · D = shown as E

This nonpregnant adult should receive behavioral counseling plus pharmacotherapy. Varenicline is appropriate despite her stable schizophrenia; evidence does not support withholding it solely because of a stable psychiatric disorder, although neuropsychiatric symptoms should be monitored. Her end-stage kidney disease is the key dosing discriminator: varenicline is predominantly renally eliminated, and the FDA-labeled maximum for patients undergoing hemodialysis is 0.5 mg once daily if tolerated. A is less effective than combined counseling and pharmacotherapy and is unnecessary because an acceptable medication is available. Bupropion (B) is contraindicated in patients with a current or prior diagnosis of bulimia nervosa because of increased seizure risk, even when the eating disorder has been in prolonged remission. Standard varenicline titration to 1 mg twice daily (C) would produce excessive exposure in a patient receiving hemodialysis. Combination nicotine-replacement therapy (E) is effective and ordinarily more effective than single-form nicotine replacement, but it conflicts with this patient's informed refusal of nicotine-containing therapy and includes the patch that previously caused intolerable dermatitis. Therefore, renal-adjusted varenicline combined with counseling is the best plan.

Reference: Tobacco Smoking Cessation in Adults, Including Pregnant Persons: Interventions (January 19, 2021) — https://www.uspreventiveservicestaskforce.org/uspstf/recommendation/tobacco-use-in-adults-and-pregnant-women-counseling-and-interventions CHANTIX (varenicline) Prescribing Information (2016) — https://www.accessdata.fda.gov/drugsatfda_docs/label/2016/021928s040lbl.pdf WELLBUTRIN SR (bupropion hydrochloride) Prescribing Information (2024) — https://www.accessdata.fda.gov/drugsatfda_docs/label/2024/020358s068lbl.pdf