Initiating Pharmacologic Treatment in Tobacco-Dependent Adults. An Official American Thoracic Society Clinical Practice Guideline https://www.atsjournals.org/doi/full/10.1164/rccm.202005-1982ST ultimate take home- varenicline is first line!! For Tobacco-Dependent Adults in Whom Treatment Is Being InitiatedShould Treatment Be Started with Varenicline or a Nicotine Patch? 40 more per 1,000 patients; Compared with a nicotine patch, varenicline increased long-term abstinence, measured at 6-month follow-up (RR, 1.20; 95% CI, 1.09 to 1.32; ARR, 40 more per 1,000 patients;) For Tobacco-Dependent Adults in Whom Treatment Is Being Initiated Should Treatment Be Started With Varenicline or Bupropion? 77 more per 1,000 patients taking Varenicline increased tobacco abstinence at 6-month follow-up compared with bupropion (RR, 1.30; 95% CI, 1.19 to 1.42; ARR, 77 more per 1,000 patients;) who andrew so just varenicline by itself?? thats it?? should Treatment Be Started with Varenicline plus Nicotine-Replacement Therapy or Varenicline Alone? 105 more per 1,000 patients; taking Varenicline plus a nicotine patch significantly increased abstinence compared with varenicline alone, (RR, 1.36; 95% CI, 1.07 to 1.72; ARR, 105 more per 1,000 patients; 95% CI, 21 more to 211 more; high certainty in the estimated effects) they mention ecigs vs varenicline and admit we dont have direct evidence but indirect evidence says varenicline is better but they admit because we dont have good evidence and all we have is indirect evidence then base on that go with varenicline but it is given a conditional rec with very low certainty of evidence. In Tobacco-Dependent Adults Who Are Not Ready to Discontinue Tobacco Use, Should Clinicians Begin Treatment with the Optimal Controller or Wait Until They Are Ready to Stop Tobacco Use? to me this was huge maybe one of the biggest recommendation because I always wait till the person is ready to stop but in studies where people could stop or were not interested in stopping those started on varenicline were more like to stop smoking. my mind was blown!! and the evidence on this gives a strong recommendation, with moderate certainty in the estimated effects. infact 173 more per 1,000 smokers were able to stop smoking at 6 months after starting varenicline despite the provider not waiting for affirmation of readiness (RR, 2.00; 95% CI, 1.70 to 2.35; ARR, 173 more per 1,000 patients; 95% CI, 121 more to 234 more; high certainty in the estimated effects). Tobacco-Dependent Adults with Comorbid Psychiatric Conditions, Including Substance-Use Disorder, Depression, Anxiety, Schizophrenia, and/or Bipolar Disorder, for Whom Treatment Is Being Initiated, Should Clinicians Start with the Optimal Controller Identified for Patients without Psychiatric Conditions or Use a Nicotine Patch? “boxed warning regarding possible neuropsychiatric adverse events for both varenicline and bupropion. These concerns stemmed from case reports and postmarketing surveillance, as no RCTs found evidence for these events and early observations suggested no significant increase in neuropsychiatric adverse events with pharmacotherapy compared with placebo, even among patients with preexisting mental illness.” to summarize --with moderate certainty compared with nicotine patches, varenicline 1) may result in a large benefit for nicotine abstinence and 2) compared with nicotine patches, varenicline would likely result in little to no difference in SAEs and last but not least- if you are given the choice to write a script for an Extended-Duration (>12 wk) or Standard-Duration (6–12 wk) then with a strong recommendation and moderate certainty in the estimated effects you should always chose the longer- go with 12 weeks! Guntupalli SR et al. Safety and efficacy of apixaban vs enoxaparin for preventing postoperative venous thromboembolism in women undergoing surgery for gynecologic malignant neoplasm: A randomiz(continued)