Do Not Prescribe Contrave to This Patient
Contrave (naltrexone-bupropion) is contraindicated in this 78-year-old man because he does not meet the FDA-approved indication for weight-loss pharmacotherapy and has significant cardiovascular contraindications. 1, 2
Why This Patient Does Not Qualify for Contrave
BMI Does Not Meet Threshold for Anti-Obesity Medication
- At 172 lbs and 5'10", this patient has a BMI of approximately 24.6 kg/m², which falls within the normal weight range (18.5–24.9 kg/m²). 2
- Naltrexone-bupropion is FDA-approved only for patients with BMI ≥30 kg/m² (obesity) or BMI ≥27 kg/m² with at least one weight-related comorbidity (e.g., type 2 diabetes, hypertension, dyslipidemia). 2, 3, 4
- Although this patient has hypertension and coronary artery disease, his BMI of 24.6 kg/m² does not meet the minimum threshold of 27 kg/m² required for prescribing anti-obesity medications, even in the presence of comorbidities. 2
Cardiovascular Risk Profile Makes Contrave Inappropriate
- Uncontrolled or poorly controlled hypertension is an absolute contraindication to naltrexone-bupropion because bupropion can elevate blood pressure and heart rate. 1, 2
- Even if this patient's blood pressure is currently controlled on ramipril, bupropion may destabilize control and require intensification of antihypertensive therapy or discontinuation of Contrave. 1, 2
- Patients with established coronary artery disease and multiple stents represent a high-risk cardiovascular population. Although a 2022 systematic review found no increased risk of major adverse cardiovascular events (MACE) with naltrexone-bupropion, bupropion, or naltrexone individually 5, the cardiovascular safety data are limited in patients with advanced coronary disease, and the drug's blood-pressure-raising effects pose unnecessary risk in this context. 1, 2
Monitoring Requirements That Would Be Necessary (But Still Do Not Justify Use)
If this patient somehow met BMI criteria, the following monitoring would be mandatory:
- Baseline and periodic blood pressure and heart rate measurements, especially during the first 12 weeks, because bupropion commonly raises both parameters. 1, 2
- Discontinuation of Contrave if blood pressure becomes uncontrolled (≥130/80 mm Hg in high-risk patients or ≥140/90 mm Hg in standard-risk patients) despite antihypertensive therapy. 1
- Assessment for neuropsychiatric adverse effects (agitation, suicidal ideation) during the first 1–2 months, particularly in adults younger than 24 years, though this patient is 78 years old. 1, 2
Alternative Approach: Lifestyle Modification Without Pharmacotherapy
- A 15-pound weight loss in a patient with BMI 24.6 kg/m² is not medically indicated and would result in a BMI of approximately 22.5 kg/m², which is at the lower end of the normal range and offers no cardiovascular benefit. 2
- For patients with coronary artery disease, the focus should be on optimizing cardiovascular risk factors—maintaining current weight, adhering to a Mediterranean or DASH diet, engaging in moderate-intensity aerobic exercise (as tolerated), and ensuring optimal medical management of hypertension and lipids—rather than pursuing weight loss below a normal BMI. 1
Clinical Pitfalls to Avoid
- Do not prescribe anti-obesity medications to patients with normal BMI (18.5–24.9 kg/m²), even if they request weight loss, because there is no evidence of benefit and potential for harm. 2
- Do not overlook the absolute contraindication of uncontrolled hypertension when considering naltrexone-bupropion; even controlled hypertension in a patient with coronary artery disease warrants extreme caution. 1, 2
- Do not assume that a patient's desire to lose weight justifies pharmacotherapy; weight-loss drugs are indicated only when obesity or overweight with comorbidities poses a health risk, not for cosmetic goals in normal-weight individuals. 2, 3, 4