Nicotine Replacement Therapy After Subarachnoid Hemorrhage Is Not Associated With Increased Vasospasm

Abstract

Background and Purpose-A significant number of patients with aneurysmal subarachnoid hemorrhage are active smokers and at risk for acute nicotine withdrawal. There is conflicting literature regarding the vascular effects of nicotine and theoretical concern that it may worsen vasospasm. The literature on the safety of nicotine replacement therapy and its effects on vasospasm is limited. Methods-A retrospective analysis was conducted of a prospectively collected database of aneurysmal subarachnoid hemorrhage patients admitted to the neurointensive care unit from 1994 to 2008. Paired control subjects matched for age, sex, Fisher score, aneurysm size and number, hypertension, and current medication were analyzed. The primary outcome was clinical and angiographic vasospasm and the secondary outcome was Glasgow Outcome Score on discharge.Conditional logistic models were used to investigate univariate and multivariate relationships between predictors and outcome. Results-Two hundred fifty-eight active smoking patients were included of which 87 were treated with transdermal nicotine replacement therapy.

A systematic review of possible serious adverse health effects of nicotine replacement therapy

“…Of the 12 epidemiological studies, five (Carandang et al 2011; Kimmel et al 2001; Meine et al 2005; Paciullo et al 2009; Panos et al 2010) only considered nicotine patches, while one (Murray et al 2009) only considered nicotine gum. The remainder considered multiple, or any type of NRT, though results by type of NRT (gum, patch, inhaler) were only reported in two publications from the Danish Birth Cohort (birthweight—Lassen et al (2010) and stillbirth rate in Strandberg-Larsen et al (2008)) and in the UK case series analysis (acute myocardial infarction [AMI], stroke and death—(Hubbard et al 2005)).…”

“…The third (Panos et al (2010), study quality “fair”) was a prospective study of patients admitted to an intensive care unit with a neurological insult. Note that one study (Carandang et al 2011) which reported on the relationship between patch use and various adverse health effects in subarachnoid haemorrhage patients is considered in the section below on “Other SAHEs in patients”.…”

“…As summarized in Supplementary File 5, one epidemiological study (Carandang et al 2011) and four clinical trials (Joseph et al 1996; Lee et al 2013; Mohiuddin et al 2007; Thomsen et al 2010) of patients provide information relating NRT and other SAHEs not generally related to cancer or CVD. Further details are presented in CAFs 28C, 30B, 32, 33 and 34.…”

“…Further details are presented in CAFs 28C, 30B, 32, 33 and 34. The epidemiological study (Carandang et al 2011), in patients with subarachnoid haemorrhage, was ascribed study quality “fair”. Three clinical trials (Lee et al 2013; Mohiuddin et al 2007; Thomsen et al 2010) were ascribed a “high” risk of bias for only providing results for an intervention which included use of NRT (not necessarily in all patients), the results possibly reflecting possible effects of intervention rather than of NRT.…”

Inadequacy of Headache Management After Subarachnoid Hemorrhage

“…Transdermal nicotine replacement therapy was provided to smokers of more than 0.5 packs per day. 24,25 Transcranial Doppler imaging was performed daily or every other day at the managing physician's discretion, and a neurological examination was performed every 1 to 2 hours by nurses or physicians. All patients were initially treated in a dedicated neuroscience intensive care unit; a few patients with Hunt and Hess grade I to II SAH deemed at low risk for vasospasm were subsequently managed in a neurological intermediate care unit.…”