Is Contrave (bupropion and naltrexone) contraindicated in patients over 80 years old?

Contrave (Naltrexone/Bupropion) Use in 80-Year-Old Patients

Contrave (naltrexone/bupropion) is not specifically contraindicated in patients over 80 years old, but requires careful consideration due to increased risks of side effects and reduced clearance in elderly patients.

Age-Related Considerations for Contrave Use

Geriatric Pharmacokinetics

• The FDA label for bupropion notes that while no overall differences in safety or effectiveness were observed between elderly and younger subjects, "greater sensitivity of some older individuals cannot be ruled out" 1
• Bupropion is extensively metabolized in the liver to active metabolites, which are further metabolized and excreted by the kidneys
• Elderly patients are more likely to have decreased renal function, which may necessitate dose adjustments 1

Specific Precautions in Elderly Patients

• The FDA recommends monitoring renal function in elderly patients taking bupropion 1
• Patients aged ≥65 years have increased susceptibility to medication accumulation and a smaller therapeutic window between safe dosages and those associated with respiratory depression 2
• Cognitive impairment in older adults can increase risk for medication errors and make medication-related confusion more dangerous 2

Contraindications and Risk Assessment

Absolute Contraindications (regardless of age)

• Uncontrolled hypertension 2
• Seizure disorders 2, 3
• Concurrent use with monoamine oxidase inhibitors (MAOIs) 2, 3
• Chronic opioid therapy 2, 3
• Pregnancy or active attempts to conceive 2

Risk Factors Requiring Special Attention in Elderly

• Renal impairment: Consider reduced dose and/or frequency in patients with GFR <90 mL/min 1
• Hepatic impairment: For moderate to severe impairment, maximum dose is 150 mg every other day; for mild impairment, consider reducing dose/frequency 1
• Cardiovascular status: Monitor blood pressure and heart rate regularly, especially during the first 8-12 weeks 3, 4
• Polypharmacy: Increased risk of drug interactions in elderly patients 2

Dosing Considerations for Elderly Patients

Recommended Approach

• Start with lower doses than typically used in younger adults
• Consider a more gradual titration schedule to minimize side effects
• For patients with moderate to severe renal impairment, reduce to 1 tablet twice daily 3
• For patients with moderate to severe hepatic impairment, limit to 1 tablet daily 3

Monitoring Requirements

• Regular blood pressure and heart rate monitoring, especially during the first 12 weeks 2, 3
• Periodic assessment of renal and hepatic function 1
• Monitoring for neuropsychiatric adverse effects 3
• Assessment for common side effects: nausea, constipation, headache, dizziness, insomnia, and dry mouth 5, 6

Efficacy and Safety Profile

• Clinical trials have shown 5.0-9.3% weight loss with Contrave, with placebo-subtracted weight loss of 3.2-5.2% during 56 weeks of treatment 5
• Most common side effects include nausea (29.8%), constipation, headache, dizziness, vomiting, and dry mouth 6
• Serious but rare adverse effects include suicidal thoughts and seizures 5
• No studies have reported an increased risk of major adverse cardiovascular events (MACE) with Contrave use 4

Practical Recommendations for 80-Year-Old Patients

1. Comprehensive pre-treatment assessment:

   • Evaluate renal and hepatic function
   • Check blood pressure and cardiovascular risk factors
   • Screen for current opioid use
   • Assess cognitive function and ability to adhere to medication regimen
   • Review all current medications for potential interactions

2. Consider alternative weight management options if:

   • Patient has significant renal or hepatic impairment
   • Patient has uncontrolled hypertension or significant cardiovascular disease
   • Patient is on multiple medications with potential interactions
   • Patient has history of seizures or conditions lowering seizure threshold

3. If proceeding with Contrave in an 80-year-old patient:

   • Start at lower dose and titrate more slowly than in younger adults
   • Monitor blood pressure, heart rate, and mental status frequently
   • Educate patient and caregivers about potential side effects
   • Implement interventions to mitigate common risks (e.g., bowel regimens to prevent constipation)
   • Schedule more frequent follow-up visits than would be typical for younger patients

While not absolutely contraindicated in patients over 80, Contrave should be used with caution in this population, with careful consideration of the risk-benefit ratio and appropriate monitoring.