Zonisamide Augmentation of Varenicline Treatment for Smoking Cessation

About 20.6 % of the US population smokes cigarettes. This group includes nicotine dependent
smokers who are resistant to current smoking cessation treatments. Varenicline is a smoking
cessation medication found in meta-analytic reviews to be superior to other smoking cessation
treatments, but 56% of patients who take varenicline do not quit. One strategy to increase
quit rates may be to administer a second medication to augment the efficacy of varenicline.
The anti-epileptic medication zonisamide is a good candidate for adjunct treatment as it
increases dopaminergic tone, normalizes glutamate homeostasis, potentiates Gamma-Aminobutyric
Acid (GABA) release. Zonisamide improves sleep and promotes weight loss, two prominent issues
not addressed by varenicline. Finally, the PI of this proposal has documented unpleasant
changes in the taste of cigarettes and reductions in nicotine withdrawal among smokers
receiving zonisamide as part of another clinical trial. The proposed study will explore the
efficacy of varenicline + zonisamide for smoking cessation in a controlled, clinical trial.
Eligible participants (n=60) will be smokers (>10 cig/day for >1 year) seeking treatment.
They will be randomly assigned to receive varenicline + double-blind zonisamide or placebo
for a 10-weeks. Participants will visit the clinic weekly to receive medications and smoking
cessation counseling and to complete self-report questionnaires. Smoking status will be
assessed via weekly urinalysis testing for cotinine (abstinence: <200ng/ml). Cotinine is a
sensitive indicator of smoking status with a longer half-life then carbon monoxide (CO) and
is more likely to detect low or intermittent smoking. The study hypothesis is that
participants who receive the combination zonisamide + varenicline will achieve greater
smoking abstinence compared to varenicline alone. The primary outcome measure will be the
4-week rate of biochemically-confirmed continuous smoking abstinence during weeks 7-10.
Secondary outcomes will include self-reported rates of smoking, subjective effects of
cigarettes, weight change from baseline to week 10, sleep quality, and nicotine withdrawal
severity. This study will advance the science and clinical treatment of smoking cessation,
and will provide the prerequisite data to develop a larger scale clinical trial evaluation of
the combination zonisamide + varenicline for smoking cessation.

Inclusion Criteria:

- Ages 18 - 65 years old; smoking > 10 cigarettes per day for > 1 year

- Desire to quit smoking

- Provide a cotinine positive urine sample

- Commitment to come to the clinic once a week for the 10-week study duration

Exclusion Criteria:

- Allergy to varenicline or sulfonamide drugs (e.g., trimethoprim/sulfamethoxazole,
zonisamide or topiramate);

- Renal insufficiency (eGFR < 60 mL)

- Renal tubular acidosis

- History of nephrolithiasis

- Unexplained hematuria

- Transaminase elevations > 3 times the Upper Limit of Normal (ULN)

- BMI < 19

- Diabetes mellitus

- Respiratory insufficiency

- Asthma requiring medication

- Heart failure

- Chronic diarrhea predisposing to acidosis

- Glaucoma, family history of glaucoma, one-sided blindness

- History of seizures or use of anticonvulsant medications (not including sedatives)

- HIV infection on HAART medication (or CD4 T cell count < 200 /mL)

- History of serious psychiatric disorder: psychosis, dementia, depression requiring
medication in last 6 months, suicidal or homicidal ideation, evidence of violent
behavior in the last 6 months.

- Recent use (last 30 days) of bupropion, nortriptyline, or clonidine

- Recent use (last 30 days) of Nicotine Replacement Products that would interfere with
urine cotinine testing

- Use of tobacco products other than cigarettes

- For female participants, pregnancy, lactation, or refusal to use an effective method
of contraception.