What are the directions for initiating and adjusting low dose naltrexone (LDN) therapy?

Low Dose Naltrexone (LDN) Initiation and Adjustment Protocol

Low dose naltrexone should be initiated at 1.5 mg taken at bedtime and gradually increased by 1.5 mg every two weeks to a final maximum dose of 4.5 mg taken at bedtime. 1

Initial Assessment Before Starting LDN

• Confirm patient is opioid-free for at least 7-10 days before initiating LDN to prevent precipitated withdrawal 2
• Screen for contraindications:
  • Current opioid use (including tramadol)
  • Recent use of methadone or buprenorphine (may require longer opioid-free period)
  • Severe liver or kidney disease
  • Pregnancy or breastfeeding

Dosing Protocol for LDN

Week 1-2:

• Start with 1.5 mg once daily at bedtime
• Monitor for side effects: headache, vivid dreams, sleep disturbances

Week 3-4:

• If well tolerated, increase to 3.0 mg once daily at bedtime
• Continue monitoring for side effects

Week 5 and beyond:

• If well tolerated, increase to 4.5 mg once daily at bedtime (maximum recommended dose)
• Maintain at this dose for ongoing therapy

Monitoring and Follow-up

• Schedule follow-up at 2-week intervals during dose adjustment period
• Once at stable dose, follow up every 1-3 months to assess:
  • Efficacy for target condition (pain reduction, symptom improvement)
  • Side effects: headache, vivid dreams, insomnia, tachycardia
  • Need for dose adjustment

Common Side Effects and Management

• Sleep disturbances/vivid dreams: Most common side effect, typically improves within 1-2 weeks; if persistent, consider taking dose earlier in the evening
• Headache: Usually transient; can use acetaminophen for management
• Nausea: Usually mild and transient; take with small snack if needed
• Anxiety/jitteriness: May occur in sensitive individuals; consider slowing titration schedule

Special Considerations

• Timing of dose: Bedtime administration is recommended as it may help minimize side effects 1
• Drug interactions: Avoid concurrent use with opioid medications
• Duration of therapy: Long-term use is generally well-tolerated; no standard duration has been established

Discontinuation

If discontinuation is needed:

• For doses ≤4.5 mg: Can typically be stopped without tapering
• For higher doses: Consider gradual reduction by 1.5 mg every 1-2 weeks

Important Precautions

• LDN is an off-label use of naltrexone
• Standard naltrexone doses (50 mg) should NOT be used for LDN indications
• Patients should be informed that they cannot take opioid medications while on LDN
• If emergency pain management is needed, higher doses of opioids may be required to overcome blockade, requiring specialized medical supervision

Practical Tips

• Some pharmacies may need to compound the medication to achieve the low dose
• Patients should be advised to avoid alcohol during initial titration period
• If side effects are problematic, slower titration (e.g., increasing by 0.5 mg every 2 weeks) may improve tolerability

This protocol follows evidence-based guidelines for LDN administration, with the primary goal of maximizing therapeutic benefit while minimizing side effects through careful dose titration.