Varenicline treatment for smokers with schizophrenia: a case series.

Sir: Schizophrenia is associated with increased prevalence of smoking, heavy smoking, and smoking-related morbidity and mortality. Standard nicotine dependence treatments have been associated with modest efficacy in patients with schizophrenia and high rates of relapse to smoking upon their discontinu- ation. 1-3 These reports prompted the authors to review clinical nico- tine dependence treatment with varenicline in smokers with schizophrenia at an urban community mental health clinic with attention to clinical efficacy for nicotine dependence and to signs of clinical worsening that may have occurred secondary to varenicline treatment. Method. From October 2006 to October 2007, 19 patients with schizophrenia, most of whom had quit smoking in the past but had relapsed to smoking after discontinuation of nicotine dependence treatment with bupropion or nicotine replacement therapy, requested nicotine dependence treatment with the newly available medication, varenicline. These 19 outpatients with schizophrenia were on stable antipsychotic medication regimens and received a standard titration of varenicline as fol- lows: 0.5 mg/day for 3 days, 0.5 mg b.i.d. for 4 days, then 1 mg b.i.d. Each received brief individual counseling at medication visits. Visits were weekly for 2 weeks, then approximately monthly. Results. All 19 patients reported reduced craving to smoke after initiating varenicline treatment. Four patients discontinued varenicline treatment due to nausea and vomiting. One patient subsequently restarted varenicline and was able to tolerate treat- ment without vomiting on the second exposure. Thirteen pa- tients tolerated the medication, quit smoking within 10 to 21 days of starting varenicline, and maintained self-reported absti- nence for ≥ 12 weeks, verified with periodic expired air carbon monoxide measurements of < 9 ppm at clinical visits. In the pe- riod between 12 and 24 weeks, 4 patients had occasional "slips" in which they smoked < 5 cigarettes per day for a period of < 7 days and then regained abstinence. All 13 patients in this series who quit smoking elected to continue to take varenicline beyond the standard 24-week regi- men to prevent relapse to smoking. Patients in this series have remained clinically stable with no clinical evidence of psy- chotic relapse or significant worsening of psychiatric symptoms or side effects of antipsychotic medications. None of the 19 pa- tients had a psychiatric hospitalization within 24 weeks of start- ing varenicline. No clinical rating scales were performed as part of this treatment. Likewise, no cognitive tests were performed to assess the effect of varenicline on cognitive performance in these patients. Varenicline is a partial α 4β2 and full α 7 nicotinic acetylcho- line receptor (nAChR) agonist.