Praxis Medical Insights

Medication Effects and Approvals

Guanfacine can cause sedation and is FDA-approved as adjunctive therapy with stimulants for ADHD treatment, along with extended-release clonidine, as noted by the American Academy of Pediatrics 1
Bupropion may be associated with cardiovascular malformations in pregnancy, requiring risk-benefit assessment before use, according to the American College of Obstetricians and Gynecologists 2

There is limited data on combining bupropion with stimulants or non-stimulants like guanfacine for ADHD treatment, emphasizing the need for close monitoring, as noted by the American Academy of Child and Adolescent Psychiatry 3
Contrave (naltrexone-bupropion) should be discontinued if a patient has not lost at least 5% of total body weight after 12 weeks at maintenance dose or if significant side effects develop, as recommended by the American Gastroenterological Association 4, 5

A gradual tapering approach is recommended when discontinuing Contrave to minimize potential withdrawal symptoms, with a suggested tapering schedule:
For moderate to severe hepatic or renal impairment, a more gradual tapering schedule should be used, as recommended by the American Gastroenterological Association 5
Monitor blood pressure and heart rate weekly during tapering, and assess for changes in mood, particularly in patients with a history of depression, as suggested by the American Medical Association 6 and the American Gastroenterological Association 5

Absolute contraindications for Contrave use include concurrent opioid use, seizure disorders, uncontrolled hypertension, use of MAOIs within 14 days, and pregnancy, with a strength of evidence level of high 7, 8
Relative contraindications or use with caution include hepatic impairment, history of seizures, and planned surgical procedures requiring opioid analgesia, with a strength of evidence level of moderate 7, 5
Combining citalopram with bupropion can increase the risk of serotonin syndrome, as noted by the American Academy of Child and Adolescent Psychiatry 9

The recommended starting doses are duloxetine 30-60 mg daily and bupropion 100-150 mg daily, with maintenance doses of duloxetine 60-120 mg daily and bupropion 150-450 mg daily 10
The recommended dosing schedule for naltrexone-bupropion (Contrave) involves a gradual titration over 4 weeks to minimize gastrointestinal side effects, with a maintenance dose of bupropion SR 360 mg daily, as recommended by the American Gastroenterological Association, with a strength of evidence level of high 5

Schedule a follow-up appointment 2-4 weeks after complete discontinuation to assess weight maintenance, mood, and overall health status, and reinforce ongoing lifestyle modifications for weight management, based on evidence from Clinical Gastroenterology and Hepatology 4 and JAMA 6
Ensure adequate hydration and regular physical activity to minimize symptoms, and monitor for signs of serotonin syndrome, especially during the initial phase (first 1-2 weeks) 5, 11
Weekly monitoring for suicidal ideation during the first month of treatment, regular assessment of mood and behavior, and emergence of suicidal thoughts are necessary when implementing medication changes, as emphasized by the need for careful monitoring in high-risk patients 9

Common side effects of Contrave include nausea, constipation, headache, dizziness, insomnia, and dry mouth, which may be managed with dose adjustments or supportive care, with a strength of evidence level of high 7, 12, 5
Contrave is contraindicated with monoamine oxidase inhibitors (MAOIs) and may have reduced efficacy with opioids, while CYP2B6 inhibitors/inducers may affect bupropion levels, and antihypertensive medications may have reduced efficacy, with a strength of evidence level of high 12, 5
The American Heart Association recommends that Contrave can be used with Viagra (sildenafil) as there are no significant drug interactions between these medications that would increase risk of adverse cardiovascular events, with a strength of evidence level of moderate 6
The American College of Cardiology advises that neither medication should be used with organic nitrates (e.g., nitroglycerin, isosorbide dinitrate) due to potentially life-threatening hypotension, with a strength of evidence level of high 13