How to manage elevated blood pressure in a patient taking Contrave (bupropion and naltrexone) with a blood pressure averaging around stage 1 hypertension?

Management of Elevated Blood Pressure in a Patient Taking Contrave

For a patient taking Contrave (bupropion and naltrexone) with blood pressure averaging around 139/80 mmHg, the medication should be continued while implementing lifestyle modifications and monitoring blood pressure closely, as this represents stage 1 hypertension that does not require immediate discontinuation of Contrave. 1, 2

Understanding the Blood Pressure Classification

The patient's blood pressure of 139/80 mmHg falls into stage 1 hypertension according to the 2017 ACC/AHA guidelines:

• Normal BP: <120/80 mmHg
• Elevated BP: 120-129/<80 mmHg
• Stage 1 hypertension: 130-139/80-89 mmHg
• Stage 2 hypertension: ≥140/90 mmHg 1

Contrave and Blood Pressure Effects

Bupropion, a component of Contrave, can cause elevated blood pressure and hypertension as noted in the FDA label. The medication can lead to:

• Increased blood pressure during treatment
• Higher risk when combined with other drugs that increase dopaminergic or noradrenergic activity
• A transient increase of approximately 1.5 mmHg in systolic and diastolic blood pressure followed by a reduction of about 1 mmHg below baseline 2, 3

Management Algorithm

Step 1: Assess Cardiovascular Risk

• Determine if the patient has existing cardiovascular disease (CVD) or elevated 10-year ASCVD risk (≥10%)
• If high risk: Consider pharmacologic therapy along with lifestyle modifications
• If low risk: Begin with lifestyle modifications alone 1

Step 2: Implement Lifestyle Modifications

• Dietary changes: Increase vegetables, fruits, fish, nuts, and unsaturated fatty acids; reduce red meat and salt intake
• Physical activity: 150 minutes/week of moderate aerobic exercise plus resistance training 2-3 times/week
• Weight management: Target BMI of 20-25 kg/m²
• Alcohol limitation: <14 units/week for men
• Smoking cessation if applicable 4

Step 3: Blood Pressure Monitoring

• Establish home blood pressure monitoring twice daily
• Confirm readings with multiple measurements on separate occasions
• Consider ambulatory blood pressure monitoring to rule out white coat hypertension 1, 4

Step 4: Pharmacologic Intervention (if needed)

• If BP remains elevated after 4-6 weeks of lifestyle modifications and patient has high CVD risk:
  • First-line: ACE inhibitor or calcium channel blocker (preferred for Contrave-induced hypertension)
  • Specifically, isradipine or amlodipine are preferred as they don't alter bupropion levels 1
• Avoid thiazide diuretics as they may increase nephrotoxicity when combined with certain medications 1

Special Considerations

1. Medication interactions: Contrave may reduce the effectiveness of some antihypertensive medications 5

2. Blood pressure monitoring frequency:

   • Initially: Every 2-4 weeks until stable
   • Once controlled: Every 3-6 months 4

3. When to consider discontinuing Contrave:

   • If blood pressure rises to stage 2 hypertension (≥160/100 mmHg) despite treatment
   • If patient experiences other significant cardiovascular symptoms
   • If antihypertensive therapy fails to control blood pressure 2

Potential Pitfalls

1. Underestimating cardiovascular risk: Even stage 1 hypertension increases cardiovascular risk and requires appropriate management

2. Inappropriate antihypertensive selection: Calcium channel blockers are preferred for Contrave-induced hypertension; avoid thiazide diuretics 1

3. Inadequate monitoring: Regular blood pressure monitoring is essential as elevations in blood pressure may precede other complications

4. Abrupt discontinuation: If Contrave must be discontinued due to uncontrolled hypertension, consider gradual tapering rather than abrupt cessation to minimize withdrawal effects

By following this structured approach, clinicians can effectively manage elevated blood pressure in patients taking Contrave while minimizing cardiovascular risk and maintaining the benefits of the medication for weight management when appropriate.