From the Guidelines
Naltrexone should be discontinued in patients who become pregnant, as its safety during pregnancy has not been established, according to the most recent and highest quality study 1. When considering indications to stop naltrexone, several factors come into play, prioritizing morbidity, mortality, and quality of life as outcomes.
Key Considerations
- Pregnancy: The medication's safety during pregnancy hasn't been established, making it a critical indication for discontinuation 1.
- Opioid Pain Management: Naltrexone blocks opioid receptors, preventing pain relief and potentially leading to dangerous attempts to overcome the blockade, thus it should be stopped if a patient requires opioid pain management 1.
- Severe Side Effects: Discontinue naltrexone if patients experience severe persistent side effects like nausea, headache, dizziness, or anxiety that don't improve with time.
- Allergic Reactions: Stop naltrexone if a patient develops a severe allergic reaction.
- Non-adherence: Discontinue the medication if a patient is non-adherent to treatment, as inconsistent use reduces effectiveness in addiction treatment.
Monitoring After Discontinuation
Before stopping naltrexone, consider that it has no withdrawal syndrome, but patients should be monitored for the return of cravings or addictive behaviors when the medication is discontinued 1.
Recent Guidelines
Recent guidelines from the Journal of Hepatology suggest that the decision to continue naltrexone during pregnancy must be taken on an individual basis, weighing its risks against the risks connected to alcohol withdrawal syndrome 1. However, the primary concern remains the lack of established safety during pregnancy, as highlighted in the American Journal of Obstetrics and Gynecology 1.
From the FDA Drug Label
To prevent occurrence of precipitated withdrawal in patients dependent on opioids, or exacerbation of a pre-existing subclinical withdrawal syndrome, opioid-dependent patients, including those being treated for alcohol dependence, should be opioid-free (including tramadol) before starting naltrexone hydrochloride treatment Use of naltrexone hydrochloride should be discontinued in the event of symptoms and/or signs of acute hepatitis.
The indications to stop naltrexone include:
- Precipitated opioid withdrawal in patients dependent on opioids
- Hepatotoxicity, such as symptoms and/or signs of acute hepatitis
- Depression and suicidality, although no causal relationship has been demonstrated, patients should be monitored for the development of depression or suicidal thinking 2 2
From the Research
Indications to Stop Naltrexone
- Naltrexone may need to be stopped in patients who require acute pain management, as it can complicate postoperative pain management and increase the opioid requirement for pain control 3.
- In critically ill patients receiving long-acting naltrexone therapy, stopping naltrexone may be necessary to allow for effective sedation and analgesia 4.
- Patients with opioid use disorder (OUD) who are taking naltrexone may require alternative pain management strategies, such as nonopioid analgesia and nonpharmacologic strategies, to manage acute pain 5.
- There is limited guidance on when to stop naltrexone in patients with OUD, but a multidisciplinary approach to treatment and discharge planning may be beneficial 5.
- The use of multimodal analgesia strategies and anticipating patients' variable sensitivity to opioids may be important considerations when managing pain in patients taking naltrexone 3, 4.
Considerations for Stopping Naltrexone
- The decision to stop naltrexone should be made on a case-by-case basis, taking into account the individual patient's needs and medical history 6, 3.
- Patients who are taking naltrexone for OUD may require ongoing treatment and support to manage their condition, even if naltrexone is stopped 7, 5.
- Alternative treatments, such as low-dose naltrexone, may be effective for managing chronic pain in patients with OUD 7.
- Further research is needed to fully understand the implications of stopping naltrexone in patients with OUD and to develop effective pain management strategies for these patients 6, 3, 5.