The ins and outs of prescribing Chantix (varenicline): an illustrated How-To guide

Chantix is pretty popular these days, and with good reason. It works pretty well. In fact, of all of the people I've talked to, there's not one that's not had success with it. Anecdotal, but nifty. I was dead wrong in my guess that insurers would balk at paying for it. Even medicaid is paying for it in my area, which is truly mind-blowing given how tight they are with their formulary. Even when it's not covered, it's still usually cheaper than buying a month's worth of cigarettes.

What's not so nifty about Chantix are the horrific prescriptions we see for it. Directions that make no sense. Or make sense within a certain context, but probably not the context the prescriber was thinking of. This will become clear shortly.

This is a short post, but it's big because of all of the pictures.

Table of Contents:

1. How does Chantix come?
2. Normal Chantix Use: prescribing a course of Chantix
3. Normal Chantix Use: the first month (photos begin)
4. Normal Chantix Use: Month 2 and beyond
5. Abnormal Chantix Use and common missteps

How does Chantix come? (Back to top)

Chantix comes in four different packages, only three of which are of any consequence. The Starting Month Pak, the Continuing Month Pak, and bottles of 0.5mg tablets, which are only used when a patient cannot tolerate the side effects of the normal 1mg strength. The fourth package is a bottle of 56 tablets of the 1mg strength, which is exactly the same as the Continuing Month Pak, minus the fancy packaging. We don't use these.

You can think of Chantix almost like a Medrol Dose Pack: designed for ease-of-use, contained in packaging which explains itself to the patient in very simple terms, with pictures.

Normal Chantix Use: prescribing a course of Chantix (Back to top)

Chantix should ideally be prescribed for most people using two prescriptions:

Chantix starter pack
Sig: Take as directed
#1 package
0 refills

and

Chantix continuing pack
Sig: Take as directed
#X packages
_ refills

The continuing month pack prescription will be used after the patient has finished the starter pack. I have been counseling patients that when the time comes for a refill of their Chantix at the end of the first month to speak with the pharmacy staff to avoid the automated script refill request idiocy that I explained in Footnote #1 of this post.

Normal Chantix Use: the first month (Back to top)

The Starter Pack looks this:

Inside this main pack you'll find the following mini-packs:

The special pack there is the first week. The blue ones are what're inside the Continuing Month Pak, and they are all 1mg tablets (Photo). Inside that yellow first week pack you'll find the following blister tab of 0.5mg tablets:

The end of Week 1 is when the patient is supposed to stop smoking.

Normal Chantix Use: Month 2 and beyond (Back to top)

For the following months, that second prescription with X number of refills is used; inside are four blue packs, as I said before:

Closeup.

Abnormal Chantix Use and common missteps (Back to top)

50% of the time I see a prescription for Chantix, it's not done correctly. It'll be written for a Chantix Starter Pack with a bunch of refills, or a hand-written taper schedule that doesn't make any sense, some variation of these two problems. We smooth this out, but it is imperfect, and each pharmacist does it differently.

Every once in a while, we will come across an instance where a patient was prescribed a Starter Pack, and the followup prescription is for Chantix 0.5mg, 1 tablet twice daily, which makes no sense, given that 3 of the 4 packs in the Starter Pak are for 1mg tablets. Unfortunately, we cannot simply change the prescription to the Continuing Month Pack, even though when we call the prescriber's office 90% of the time we hear something like "Oh yeah, we meant the continuing month thing."

"Thing."

Not especially comforting. I've explained to more than one nurse exactly how Chantix comes, and how it's normally used. In some cases, this information is even relayed back to the prescriber, because I see prescriptions written correctly for someone else later on. It's a nice feeling.

But that 10% is the killer, which is why we have to call. GI upset is the most common side effect of varenicline, and often by reducing the dose to 0.5mg, these side effects are ameliorated, while retaining the efficacy of the drug. That's where that niche bottle of 0.5mg tablets is used. Ever so rarely.

In this RARE case, if you a prescriber, and you actually WANT the 0.5mg, and you are AWARE that this is the "wrong" way to use Chantix, write a brief note acknowledging that you know, and would like the 0.5mg tablets anyway. This will go a long way towards ensuring that your prescription will be filled the same everywhere, exactly the way YOU want it.

Not to mention it will save everybody time. Filling prescriptions is not a passive activity.

[tags]Chantix, pharmacy, medicine, varenicline, smoking, smoking cessation[/tags]