Urinary Tobacco Alkaloid Measurement in Patients Having Thromboangiitis Obliterans

Abstract

To the Editor: The recent Residents' Clinic by Geske et al1Geske JB Calvin AD McDonald FS 37-year-old man with painful foot.Mayo Clin Proc. 2008; 83: 821-824Abstract Full Text Full Text PDF PubMed Scopus (1) Google Scholar points out the difficulties of diagnosing thromboangiitis obliterans (TAO or Buerger disease) when the patient admits past smoking but denies current tobacco use.1Geske JB Calvin AD McDonald FS 37-year-old man with painful foot.Mayo Clin Proc. 2008; 83: 821-824Abstract Full Text Full Text PDF PubMed Scopus (1) Google Scholar Denial and rationalization are common features of tobacco dependence, and an objective measure of tobacco use is critical in such circumstances. The tobacco alkaloids nicotine and cotinine can bemeasured in blood and urine and are biomarkers of nicotine exposure. Serum cotinine, with an elimination half-life of 18 to 20 hours, is able to detect nicotine use after 2 to 3 days of abstinence. However, elevated levels of both nicotine and cotinine are also common after use of therapeutic nicotine replacement products and so are not specific markers of tobacco use. In contrast, the urinary tobacco alkaloids anabasine and nornicotine are specific for tobacco use and can be used to distinguish patients who are abstaining from tobacco and using nicotine replacement therapy from those who are smoking.2Moyer TP Charlson JR Enger RJ et al.Simultaneous analysis of nicotine, nicotine metabolites, and tobacco alkaloids in serum or urine by tandem mass spectrometry, with clinically relevant metabolic profiles.Clin Chem. 2002; 48: 1460-1471PubMed Google Scholar Because anabasine and nornicotine are not metabolites of nicotine, they indicate current tobacco use if detected in urine. As mentioned by Geske et al,1Geske JB Calvin AD McDonald FS 37-year-old man with painful foot.Mayo Clin Proc. 2008; 83: 821-824Abstract Full Text Full Text PDF PubMed Scopus (1) Google Scholar the relationship of tobacco to TAO has been known for decades. In an early series from Mayo Clinic, only 5 of 350 men (aged 25-55 years) with TAO were nonsmokers.3Barker N The tobacco factor in thromboangiitis obliterans.Proc Staff Meet Mayo Clin. 1931; 6: 65-68Google Scholar In the discussion, Dr W. J. Mayo quipped: “On the whole, smoking seems a habit which has possibilities for harm, and has little to its credit.” Of course, this report from Mayo Clinic dates to 1931, long before most of the detrimental effects of tobacco use were known. However, as Geske et al1Geske JB Calvin AD McDonald FS 37-year-old man with painful foot.Mayo Clin Proc. 2008; 83: 821-824Abstract Full Text Full Text PDF PubMed Scopus (1) Google Scholar point out, the misconception that tobacco dependence treatment is unsuccessful in patients with TAO is common. Quite the contrary, we found that smokers with TAO were no more tobacco dependent than smokers with coronary artery disease; thus, treatment should be aggressively pursued in these patients.4Cooper LT Henderson SS Ballman KV et al.A prospective, case-control study of tobacco dependence in thromboangiitis obliterans (Buerger's disease).Angiology. 2006; 57: 73-78Crossref PubMed Scopus (19) Google Scholar We also observed that patients with TAO smoked fewer cigarettes per day than patients with coronary artery disease and were more likely to have made a serious attempt to stop in the past. Certainly for smokers with such a severe medical problem as TAO, residential treatment for tobacco dependence offers the best option to stop and remain abstinent from smoking.5Hooten WM Bruns HK Hays JT Inpatient treatment of severe nicotine dependence in a patient with thromboangiitis obliterans (Buerger's disease).Mayo Clin Proc. 1998; 73: 529-532Abstract Full Text Full Text PDF PubMed Scopus (31) Google Scholar An overall 1-year smoking abstinence rate of 45% was reported after an 8-day residential treatment program.6Hays JT Wolter TD Eberman KM Croghan IT Offord KP Hurt RD Residential (inpatient) treatment compared with outpatient treatment for nicotine dependence.Mayo Clin Proc. 2001; 76: 124-133PubMed Google Scholar In patients who continue to smoke, TAO is relentlessly progressive and results in chronic and severe pain, gangrene, and autoamputation. Urinary tobacco alkaloids should be measured in patients with TAO who deny smoking to detect surreptitious smoking. Aggressive tobacco dependence treatment, including residential treatment, should be offered to patients with this disease as soon as possible. Urinary Tobacco Alkaloid Measurement in Patients Having Thromboangiitis Obliterans–Reply–IMayo Clinic ProceedingsVol. 83Issue 10PreviewWe appreciate the insightful points made by Hurt and Hays. We agree that diagnostic studies of tobacco use would augment the evaluation of TAO and could prove particularly helpful in cases such as the one we presented, in which tobacco use was initially denied. In our case, angiography was required for the diagnosis of TAO; when the patient was presented with the angiographic findings while his mother was absent, he admitted to ongoing tobacco use. Urinary tobacco alkaloids might well be of benefit for assessing smoking cessation at subsequent follow-up visits for this patient. Full-Text PDF