Naltrexone-Bupropion ER for Chronic Pain and Weight Loss in Depression

Naltrexone-Bupropion ER Dosing Protocol

The recommended dosing of naltrexone is 8 mg twice daily as part of the naltrexone-bupropion ER combination, titrated gradually from a starting dose of 8 mg/90 mg once daily to a maintenance dose of two tablets twice daily (32 mg naltrexone/360 mg bupropion daily total), for a patient with poorly controlled depression, chronic pain from fibromyalgia, and severe obesity 1, 2
Start with one tablet (8 mg naltrexone/90 mg bupropion) once daily in the morning, and increase weekly following a specific schedule, for patients with depression and obesity 1
The second dose should not be taken late in the day to minimize insomnia risk, as part of the naltrexone-bupropion ER dosing protocol 1
After 12 weeks on the maintenance dose, discontinue if the patient has not lost at least 5% of total body weight, as they are likely a poor responder, according to the dosing protocol 1

The bupropion component (at doses close to 300 mg daily) has been shown effective for long-term treatment of recurrent major depression, in patients with depression and obesity 1, 3
A small open-label study in women with major depressive disorder showed significant improvement in depressive symptoms that were sustained at 24 weeks of therapy with naltrexone-bupropion ER at FDA-approved doses, for patients with depression and obesity 1, 4
The combination targets both weight management and mood improvement, making it particularly suitable for patients with depression and obesity, according to the American College of Cardiology 5, 3

Monitor vital signs regularly, as naltrexone-bupropion ER should be avoided in patients with uncontrolled hypertension, due to the increased risk of cardiovascular events 1, 4
Avoid in patients requiring opioid therapy as naltrexone can reduce analgesic efficacy or precipitate withdrawal, according to the American College of Cardiology 1, 2
Use with caution in patients with history of seizures or factors that increase seizure risk, as bupropion may lower the seizure threshold, in patients with depression and obesity 1
In patients with moderate to severe renal impairment, reduce the total daily dose by half (one tablet twice daily), to minimize the risk of adverse effects 1
In patients with moderate to severe hepatic impairment, do not exceed one tablet daily, to minimize the risk of adverse effects 1
Monitor for neuropsychiatric adverse effects, particularly in younger patients, as part of the naltrexone-bupropion ER monitoring protocol 4