• Home
  • Store
    • Newsletter Subscriptions
    • Multimedia Subscriptions
    • Books
    • eBooks
    • ABPN SA Courses
  • CME Center
  • Multimedia
    • Podcast
    • Webinars
    • Blog
  • Newsletters
    • General Psychiatry
    • Child Psychiatry
    • Addiction Treatment
    • Hospital Psychiatry
    • Geriatric Psychiatry
  • Log In
  • Register
  • Welcome
  • Sign Out
  • Subscribe
Home » Varenicline and Bupropion: Soaring Again With EAGLES?

Varenicline and Bupropion: Soaring Again With EAGLES?

November 22, 2019
Nicholas Rosenlicht, MD.
From The Carlat Addiction Treatment Report
Issue Links: Learning Objectives | Editorial Information
Nicholas Rosenlicht, MD. Dr. Rosenlicht has disclosed that he has no relevant financial or other interests in any commercial companies pertaining to this educational activity.
Review of: Anthenelli RM et al, Lancet 2016;387(10037):2507–2520

Varenicline (Chantix) and bupropion (Zyban and others) are effective treatments for tobacco use disorder, but their use (and sales) took a big hit in 2009 when the FDA slapped both with black box warnings linking them to psychiatric complications, including suicidal ideation. Although these concerns did not appear in clinical trials, the FDA responded primarily to numerous post-marketing case reports. Clinicians began to steer clear of these agents, especially after a cottage industry cropped up suing for psychiatric damages purportedly caused by them. To allow removal of the warning, the FDA required the manufacturers of Chantix and Zyban (Pfizer and GlaxoSmithKline, respectively) to perform a sufficiently large randomized trial that adequately assessed these safety issues. The result is the massive and complicated Pfizer- and GSK-sponsored “EAGLES” trial—a somewhat tortured acronym of “Evaluating Adverse Events in a Global Smoking Cessation Study.”

This randomized, double-blind clinical trial recruited 8144 smokers ages 18–75 from 140 centers in 16 countries. Subjects were split into 2 cohorts, one with and the other without psychiatric disorders. Each cohort was then divided into 4 treatment groups in a 1:1:1:1 ratio: varenicline (target dose 1 mg BID), bupropion SR (150 mg BID), transdermal nicotine patch (21 mg/day with taper), or placebo. The treatment phase lasted 12 weeks, followed by a 12-week non-treatment follow-up phase. Subjects were assessed for both tobacco abstinence and for 16 categories of neuropsychiatric symptoms. The main goal was to determine whether the treatments differed in terms of serious psychiatric side effects.

Not surprisingly, there were more reported neuropsychiatric adverse events in the psychiatric cohort (5.8%) than in the non-psychiatric cohort (2.1%). However, the overall incidence of these events was the same in each of the 4 treatment groups. In fact, anxiety and depression symptoms improved about equivalently in all groups. The most common adverse events by treatment group were nausea (varenicline 25%), insomnia (bupropion 12%), abnormal dreams (nicotine patch 12%), and headache (placebo 10%). Rates of suicidal ideation and behavior overall were quite low, but in the psychiatric cohort they were non-significantly higher in the placebo and varenicline groups. The lone completed suicide was in the non-psychiatric placebo group.

All 3 of the active treatments were more effective for tobacco abstinence than placebo, but varenicline was superior to both bupropion and nicotine patch.

CATR’s Take
The EAGLES study has been criticized for its use of an unvalidated scale for adverse events. Further, the FDA raised concerns over inconsistencies in EAGLES’ data collection, but ultimately found that, even when unreliable data were excluded, the results seemed consistent with the study’s conclusions. As a result, the FDA removed the black box warning for varenicline, and it modified the warning for Zyban by removing language about serious psychiatric effects in patients quitting smoking.

These agents, particularly varenicline, can help patients stop smoking, and serious psychiatric adverse effects seem relatively rare. So, we can all breathe somewhat easier in prescribing varenicline and bupropion for smoking cessation. But as with all psychotropic agents, it would be prudent to employ reasonable screening, discussion of risks, and monitoring measures with these agents, particularly in patients who have preexisting psychiatric symptoms.
Addiction Treatment
KEYWORDS addiction addiction-treatment bupropion chantix co-occurring-disorders dual-diagnosis fda-warnings medication pharmacology research research-update side-effects smoking-cessation smoking_cessation_agents substance-use substance-use-disorders suicidality suicide tobacco varenicline wellbutrin
Nicholas Rosenlicht, MD.

Listening to Depression: The Importance of Addressing Hearing Loss

More from this author
www.thecarlatreport.com
Issue Date: November 22, 2019
SUBSCRIBE NOW
Table Of Contents
CME Post-Test - Medical Issues in Addiction Practice, CATR, November/December 2019
Primer: Physical Examination in Addiction Practice
Screening and Prophylaxis of Infectious Diseases in Addiction Practice
PrEP: Introduction to the Basics
Perioperative Management of Patients on Buprenorphine Maintenance
Exposure Therapy Efficacious for PTSD Co-Occurring With Alcohol Use Disorder
Varenicline and Bupropion: Soaring Again With EAGLES?
The COMBINE Study: A Core Paper in the Treatment of AUD
Featured Book
  • AUDFB1e_CoilBound_Graphic2_transparent_sm.png

    (PRE-ORDER) Treating Alcohol Use Disorder—A Fact Book (2023)

    All the tools and information needed to assess and treat your patients who are struggling with...
    READ MORE
Featured Video
  • therapist_canstockphoto9201097.jpg
    General Psychiatry

    Using SAMe In Clinical Practice with Garrett Rossi, MD

    Read More
Featured Podcast
  • Substance_Use_Sites.jpeg
    Addiction Treatment

    Supervised Drug Consumption Sites

    Once controversial, research clearly shows the benefit of these sites, and they have started opening in the United States.

    Listen now
Recommended
  • Approaches to Autism Intervention

    January 31, 2022
    canstockphoto2240982_child-bubbles_thumb.jpg
  • Currently Available Cannabis Products

    September 1, 2022
  • Interpreting Assessment Discrepancies from Multiple Sources

    October 17, 2022
    ChildAssessment.png
  • Approaches to Autism Intervention

    January 31, 2022
    canstockphoto2240982_child-bubbles_thumb.jpg
  • Currently Available Cannabis Products

    September 1, 2022
  • Interpreting Assessment Discrepancies from Multiple Sources

    October 17, 2022
    ChildAssessment.png
  • Approaches to Autism Intervention

    January 31, 2022
    canstockphoto2240982_child-bubbles_thumb.jpg
  • Currently Available Cannabis Products

    September 1, 2022
  • Interpreting Assessment Discrepancies from Multiple Sources

    October 17, 2022
    ChildAssessment.png

About

  • About Us
  • CME Center
  • FAQ
  • Contact Us

Shop Online

  • Newsletters
  • Multimedia Subscriptions
  • Books
  • eBooks
  • ABPN Self-Assessment Courses

Newsletters

  • The Carlat Psychiatry Report
  • The Carlat Child Psychiatry Report
  • The Carlat Addiction Treatment Report
  • The Carlat Hospital Psychiatry Report
  • The Carlat Geriatric Psychiatry Report

Contact

info@thecarlatreport.com

866-348-9279

PO Box 626, Newburyport MA 01950

Follow Us

Please see our Terms and Conditions, Privacy Policy, Subscription Agreement, Use of Cookies, and Hardware/Software Requirements to view our website.

© 2023 Carlat Publishing, LLC and Affiliates, All Rights Reserved.