What are the guidelines for prescribing Contrave (naltrexone and bupropion) for weight loss?

From the Guidelines

Contrave (naltrexone/bupropion) should be prescribed for adults with a BMI ≥30 kg/m² or ≥27 kg/m² with at least one weight-related comorbidity, as part of a comprehensive weight loss plan that includes lifestyle modifications, as suggested by the American Gastroenterological Association 1. The medication follows a gradual titration schedule: week 1 (one tablet of 8 mg naltrexone/90 mg bupropion in the morning), week 2 (one tablet in the morning and evening), week 3 (two tablets in the morning and one in the evening), and week 4 onwards (two tablets twice daily, for a total daily dose of 32 mg naltrexone/360 mg bupropion) 1.

Key Considerations

• Treatment should be discontinued if patients don't lose at least 5% of their initial body weight after 12 weeks on the full dose.
• Contrave works by affecting both appetite and reward pathways in the brain; naltrexone blocks opioid receptors while bupropion inhibits dopamine and norepinephrine reuptake.
• The medication is contraindicated in patients with uncontrolled hypertension, seizure disorders, eating disorders, during opioid use, in pregnancy, and in those taking MAOIs.
• Common side effects include nausea, constipation, headache, and insomnia.
• Patients should be monitored for depression, suicidal thoughts, and blood pressure increases, especially during the initial titration period, as highlighted in the standards of care in diabetes-2023 1.

Monitoring and Safety

• Blood pressure and heart rate should be monitored periodically while taking naltrexone-bupropion ER, especially in the first 12 weeks of treatment.
• Naltrexone-bupropion ER may be considered for the treatment of overweight or obesity in patients who are attempting smoking cessation, and in patients with depression, as per the AGA recommendations 1.

From the Research

Guidelines for Prescribing Contrave (Naltrexone and Bupropion) for Weight Loss

• The guidelines for prescribing Contrave (naltrexone and bupropion) for weight loss involve considering the patient's body mass index (BMI) and the presence of weight-related comorbidities 2.
• Contrave is approved for use in adults with a BMI of 30 kg/m2 or greater, or a BMI of 27 kg/m2 or greater with at least one weight-related condition 2.
• The medication should be used in conjunction with a reduced-calorie diet and increased physical activity for chronic weight management 2.
• Successful pharmacotherapy for obesity depends on tailoring treatment to patients' behaviors and comorbidities and monitoring of efficacy, safety, and tolerability 2.

Efficacy and Safety of Contrave

• Contrave has been shown to be effective in achieving at least 5% weight loss at 52 weeks, with 55% of participants taking the medication achieving this goal 3.
• The medication has also been associated with significant excess weight loss compared to placebo at 1 year, with a mean weight loss of 5.0 kg 3.
• However, Contrave has been associated with an increased incidence of adverse events, including nausea, headache, and dizziness 3.
• The medication has also been linked to an increase in blood pressure, which may be a concern for patients with hypertension 4.

Comparison with Other Weight Loss Medications

• Contrave has been compared to other weight loss medications, including orlistat, lorcaserin, phentermine/topiramate, and liraglutide 3.
• Phentermine/topiramate and liraglutide have been associated with the highest odds of achieving at least 5% weight loss, while Contrave has been associated with a moderate level of efficacy 3.
• The choice of medication should be based on the individual patient's needs and medical history, as well as the potential benefits and risks of each medication 2.