Pre-dosing medications to increase efficacy

Recent studies on pre-dosing suggest it does, in fact, increase quit rates. Most studies of pre-dosing had participants use nicotine gum for about 4 weeks prior to the quit date and most did not ask smokers to try to reduce, but just smoke as usual. The idea is that with extra nicotine in the system, they would be tolerant and find nicotine via cigarettes less rewarding. Sort of like giving someone an IV drip of sugar will decrease food intake. The most recent Cochrane review on nicotine replacement therapy concluded that predosing increases quit rates by about 30%, including a very recent real-world trial (British Med J 2018 361:k2164). Similar results have been achieved in trials with varenicline preloading (Arch Int Med 2011:171:770). Now comes along a study that looks at the feasibility of preloading not with normal doses but supra-normal dosing. This is based on earlier studies that noted NRT only replaces about 30% of nicotine and that if one measured nicotine levels in smokers trying to quit and then titrated nicotine levels up to higher levels this increased quit rates. But this new study took a different track and increased patch doses up to the point that participants began to have some side-effects. This may sound unusual, but is actually commonly done in many areas of medicine (as a psychiatrist this was often done with anti-depressants). During the predosing, even though they did not encourage reduction, cigs/day decreased from 20 to 6 cigs/day Amazingly, they found that 90% tolerated three 21 mg patches when the dose was slowly increased. The most common side-effect was nausea. But, get this, only 6% had to stop the patch. This study did not have a control group but found a quit rate of 82% at 4 weeks (smokers also received in person counseling. Maybe we should get more aggressive in our treatment. Especially given how unbelievably important it is to quit.