Can I add Contrave (naltrexone/bupropion) for weight loss while taking Adderall XR 30 mg each morning, Adderall IR 20 mg each evening, propranolol 10 mg daily, lamotrigine 200 mg twice daily, buspirone as needed, cariprazine 4.5 mg daily, and eszopiclone nightly, and which medication should be adjusted?

Adding Contrave to Your Current Medication Regimen: Critical Safety Assessment

You cannot safely add Contrave (naltrexone/bupropion) to your current regimen without first addressing multiple absolute contraindications and making significant medication adjustments. The combination of Contrave with your existing Adderall doses creates unacceptable seizure risk, and several of your medications require careful evaluation before proceeding. 1, 2, 3

Absolute Contraindications That Must Be Resolved First

Seizure Threshold Concerns

Your current medication regimen already includes multiple agents that lower seizure threshold, making Contrave's bupropion component particularly dangerous. 1, 3

• Cariprazine (Vraylar) 4.5 mg can lower seizure threshold, and adding bupropion creates additive risk 1
• Lamotrigine 200 mg twice daily is an antiepileptic drug; if you are taking this for seizure control (rather than mood stabilization), bupropion is absolutely contraindicated 1, 3
• The maximum bupropion dose in Contrave (360 mg daily) must never be exceeded to maintain seizure risk at 0.1%, but your polypharmacy increases baseline risk 2, 3

Stimulant Interaction Risk

Your dual Adderall regimen (30 mg XR morning + 20 mg IR evening = 50 mg total daily amphetamine) combined with bupropion creates potential for serotonin syndrome and severe cardiovascular effects. 1

• Bupropion plus stimulants can precipitate serotonin syndrome despite bupropion's minimal serotonergic activity 1
• Both agents increase norepinephrine, creating additive hypertensive and tachycardic effects 1, 2
• Monitor for altered mental status, tremor, clonus, elevated blood pressure, and tachycardia in the first 24-48 hours after any dose change 1

Cardiovascular Screening Required

You must have controlled blood pressure before starting Contrave, as both naltrexone and bupropion elevate blood pressure and heart rate. 2, 3

• Uncontrolled hypertension is an absolute contraindication 2, 3
• Your propranolol 10 mg daily suggests possible hypertension or tachycardia history—verify current BP control 2, 3
• Baseline and ongoing BP/HR monitoring is mandatory, especially during the first 12 weeks 2, 3

Critical Medication Adjustments Required

If Lamotrigine Is for Seizure Control

Stop here—you cannot use Contrave. Bupropion is absolutely contraindicated in patients with seizure disorders. 1, 3

If Lamotrigine Is for Mood Stabilization (Bipolar Disorder)

Proceed with extreme caution only after:

1. Reduce your total Adderall dose before adding Contrave to minimize additive sympathomimetic effects 1

   • Consider consolidating to once-daily dosing (e.g., 30 mg XR only) rather than 50 mg total daily
   • The evening Adderall 20 mg IR dose is particularly problematic when combined with bupropion's activating properties 1

2. Verify blood pressure control with your current propranolol dose 2, 3

   • If BP is not consistently <140/90 mmHg, Contrave is contraindicated
   • You may need propranolol dose increase to counteract Contrave's hypertensive effects

3. Assess cariprazine necessity for seizure-risk mitigation 1

   • Cariprazine lowers seizure threshold; discuss with prescriber whether dose reduction is feasible
   • If cariprazine is essential for psychosis/mania control, the cumulative seizure risk may be prohibitive

Contrave Titration Protocol (If Cleared to Proceed)

Follow this exact schedule to minimize adverse effects: 2

• Week 1: 8 mg naltrexone/90 mg bupropion once daily in the morning (1 tablet AM)
• Week 2: 8/90 mg twice daily (1 tablet AM, 1 tablet PM—take second dose before 3 PM to avoid insomnia)
• Week 3: 16 mg naltrexone/180 mg bupropion in the morning + 8/90 mg in the evening (2 tablets AM, 1 tablet PM)
• Week 4 onward: 16/180 mg twice daily (2 tablets AM, 2 tablets PM—maintenance dose of 32 mg naltrexone/360 mg bupropion daily)

Take the second dose before 3 PM to minimize insomnia risk, especially given your eszopiclone use for sleep. 1, 2

Mandatory Monitoring Parameters

First 1-2 Weeks (Highest Risk Period)

Assess for suicidal ideation, agitation, irritability, or unusual behavioral changes because antidepressants carry highest suicide risk in the first 1-2 months, particularly in patients under 24 years. 1, 3

• Watch for serotonin syndrome signs: confusion, tremor, clonus, hypertension, tachycardia, sweating 1
• Monitor for seizure warning signs: aura, confusion, muscle twitching 3

Ongoing Monitoring

• Blood pressure and heart rate: Especially during first 12 weeks, as Contrave can cause elevations 2, 3
• Neuropsychiatric symptoms: Aggressiveness, depression, suicidal ideation, anxiety, sleep disorders, psychotic symptoms 3, 4
• Efficacy assessment at 12 weeks: Discontinue if <5% weight loss achieved 2, 3

Medications That Do NOT Require Adjustment

• Buspirone 10 mg twice daily PRN: No significant interaction with Contrave 1
• Eszopiclone 3 mg nightly: No contraindication, though bupropion's activating properties may improve sleep quality and reduce need 1
• Propranolol 10 mg daily: May actually be beneficial to counteract Contrave's cardiovascular effects, but verify adequate BP control first 2, 3

Critical Pitfalls to Avoid

• Do not exceed 32 mg naltrexone/360 mg bupropion daily—seizure risk increases dramatically above this dose 2, 3
• Do not skip the intensive monitoring window in weeks 1-2—this period carries highest risk for suicidal ideation and serotonin syndrome 1, 3
• Do not continue Contrave beyond 12 weeks without adequate response—discontinue if <5% weight loss 2, 3
• Do not confuse early behavioral activation with worsening depression—this often resolves with dose adjustment 1
• Do not take the second Contrave dose after 3 PM—insomnia risk is significant 1, 2

Alternative Weight-Loss Strategies to Consider

Given your complex medication regimen, alternative FDA-approved weight-loss medications may be safer: 5

• Liraglutide (Saxenda) 3.0 mg daily: GLP-1 agonist with no seizure risk or stimulant interactions 5
• Phentermine/topiramate ER (Qsymia): Avoid due to topiramate's interaction with lamotrigine and additive stimulant effects with Adderall 5
• Orlistat (Xenical): No drug interactions with your regimen, though GI side effects limit tolerability 5

Your Adderall regimen itself may contribute to weight management through appetite suppression, making additional pharmacotherapy less necessary. 5