What are the contraindications to using bupropion, aside from bulimia nervosa and a history of seizure disorder?

Contraindications to Naltrexone/Bupropion ER Beyond Bulimia and Seizure Disorder

Naltrexone/bupropion ER has multiple additional absolute contraindications that must be screened for before prescribing, including uncontrolled hypertension, anorexia nervosa, chronic opioid use, MAOI use within 14 days, and abrupt discontinuation of alcohol/benzodiazepines/barbiturates/antiepileptics. 1, 2

Absolute Contraindications

Beyond the two you mentioned, the following are absolute contraindications where naltrexone/bupropion ER must not be used:

Eating Disorders

• Anorexia nervosa (in addition to bulimia nervosa you already know about) - both conditions show higher seizure incidence with bupropion 3, 2

Cardiovascular

• Uncontrolled hypertension - bupropion can elevate blood pressure and heart rate 1

Substance Use/Withdrawal

• Abrupt discontinuation of alcohol, benzodiazepines, barbiturates, or antiepileptic drugs - dramatically lowers seizure threshold 1, 2
• Chronic opioid use - naltrexone component will precipitate withdrawal or block analgesic efficacy 3, 4, 3

Drug Interactions

• MAOI use within 14 days (or concurrent use) - creates hypertensive crisis risk 3, 1, 2
• Other bupropion-containing products - risk of overdose and seizures 1

Hypersensitivity

• Known allergy to bupropion, naltrexone, or formulation ingredients - anaphylactoid reactions and Stevens-Johnson syndrome reported 1, 2

Pregnancy and Breastfeeding

• All anti-obesity medications are contraindicated in pregnancy and breastfeeding 3

Important Cautions (Use with Extreme Care or Avoid)

Hepatic and Renal Impairment

• End-stage renal disease: not recommended 1
• Severe hepatic impairment: not recommended 1
• Moderate-severe renal or hepatic impairment: maximum dose 1 tablet twice daily 4, 1

Psychiatric Conditions

• Severe depression - monitor closely for worsening depression or suicidal ideation 3
• Bipolar disorder - can precipitate manic episodes 3

Other Medical Conditions

• Narrow-angle glaucoma 3
• Untreated hyperthyroidism (due to phentermine in combination products, but relevant for sympathomimetic effects) 3

Critical Pre-Prescribing Screening

Before prescribing, you must specifically ask about:

1. Current or past seizure history (any type, any cause)
2. Current or past eating disorders (anorexia OR bulimia)
3. Blood pressure control status - measure BP before starting
4. Opioid use - including scheduled procedures requiring opioids (must discontinue before surgery) 4
5. Alcohol consumption patterns - risk if planning to quit abruptly
6. Benzodiazepine, barbiturate, or antiepileptic use - withdrawal risk
7. MAOI use in past 14 days - including linezolid or IV methylene blue 2
8. Other bupropion products - for depression or smoking cessation
9. Pregnancy status/plans - requires reliable contraception
10. Liver and kidney function - baseline labs needed

Common Pitfall

The opioid contraindication is frequently overlooked - patients must discontinue naltrexone/bupropion ER before any procedure requiring opioid analgesia (including routine endoscopy with fentanyl) 4. This requires advance planning and patient education.