Protocol for Stopping Contrave (Naltrexone/Bupropion)
When discontinuing Contrave (naltrexone/bupropion), a gradual tapering approach is recommended rather than abrupt discontinuation to minimize potential withdrawal symptoms.
Recommended Discontinuation Protocol
Indications for Discontinuation
- Lack of efficacy: Discontinue if patient has not lost at least 5% of total body weight after 12 weeks at maintenance dose 1
- Development of significant side effects
- Need for opioid therapy (e.g., upcoming surgical procedures)
- Development of contraindications:
- Uncontrolled hypertension
- Seizure disorders
- Pregnancy 2
Tapering Schedule
- Week 1-2: Reduce from full maintenance dose (2 tablets twice daily) to 1 tablet twice daily
- Week 3-4: Reduce to 1 tablet daily in the morning
- Week 5: Complete discontinuation
Special Considerations
For Patients Requiring Opioid Therapy
- Discontinue Contrave at least 7-10 days before scheduled procedures requiring opioid analgesia 1, 2
- This timeframe allows for clearance of naltrexone to prevent:
- Reduced efficacy of opioid analgesics
- Potential precipitation of withdrawal in patients on chronic opioids
For Patients with Hepatic or Renal Impairment
- For moderate to severe hepatic impairment: Use a more gradual tapering schedule (extend each step to 2 weeks) 1
- For moderate to severe renal impairment: Taper from the reduced maintenance dose (1 tablet twice daily) 1
Monitoring During Discontinuation
Vital Signs
- Monitor blood pressure and heart rate weekly during tapering
- Bupropion can affect blood pressure; changes may occur during discontinuation 1, 2
Mood and Mental Health
- Assess for changes in mood, particularly in patients with history of depression
- Bupropion has antidepressant properties; discontinuation may unmask depression 1, 2
- Monitor for emergence of suicidal thoughts, especially during the first 1-2 weeks of tapering 2
Weight Management
- Discuss alternative weight management strategies before discontinuation
- Consider transition to another weight management medication if appropriate
- Emphasize continued lifestyle modifications to maintain weight loss 1
Managing Discontinuation Side Effects
Common Discontinuation Symptoms
- Headaches
- Irritability
- Insomnia or increased sleep
- Fatigue
- Mild anxiety
Management Approaches
- Slow the tapering schedule if significant symptoms occur
- Consider temporary symptomatic treatment for specific symptoms (e.g., sleep aids for insomnia)
- Ensure adequate hydration and regular physical activity to minimize symptoms
Post-Discontinuation Follow-Up
- Schedule follow-up appointment 2-4 weeks after complete discontinuation
- Assess weight maintenance, mood, and overall health status
- Reinforce ongoing lifestyle modifications for weight management
Contraindications to Abrupt Discontinuation
- History of seizure disorders (increased risk with abrupt bupropion discontinuation)
- Current major depressive disorder
- Concurrent use of other medications that affect dopamine, norepinephrine, or serotonin systems 2
Following this structured tapering protocol helps minimize potential withdrawal effects and allows for appropriate monitoring of patients during the discontinuation process.