Perioperative Pain Management of a Patient Taking Naltrexone HCl/Bupropion HCl (Contrave)

Abstract

A 42-year-old obese woman (body mass index = 30.2 kg/m) presented for urgent anterior cervical diskectomy and fusion. She had been taking oral naltrexone-bupropion extended-release (Contrave, Orexigen Therapeutics Inc, La Jolla, CA) for the past 6 months and continued using it until 12 hours preoperatively. Despite discontinuation of this medication, and employing an intraoperative and postoperative multimodal analgesia strategy, immediate pain control was inadequately achieved. Patients taking opioid antagonists who present for surgery pose unique challenges to the anesthesiologist and require extensive preoperative interdisciplinary discussions and planning for pain control throughout the perioperative period.

Update on drug safety evaluation of naltrexone/bupropion for the treatment of obesity

“…In the large-scale randomized noninferiority cardiovascular outcomes trial that was prematurely discontinued, naltrexone/ bupropion ER resulted in 2.5% (placebo-subtracted) weight loss at 104 weeks (n = 2408 naltrexone/bupropion-treated subjects, n = 2264 placebo-treated subjects) [19]. Interestingly, the reported efficacy in this longer-term study is about half of the reported mean efficacy weight loss reported in the phase III clinical trials of naltrexone/bupropion ER for FDA approval [21]. In the 104 week study, however, MACE was the primary study endpoint, not weight loss [19].…”

“…Since FDA approval, only two case reports have reported adverse effects associated with Contrave® [21,22]. The first case was of a 55 year-old obese (BMI 47.75 kg/m 2 ) woman presenting with a body-wide rash with an onset 3 week after initiating Contrave®.…”

“…A single episode of oxygen desaturation (82% oxygen) was observed while managing the patient's pain in a step-down unit. The hydromorphone PCA was discontinued on postoperative day 1, and pain was managed by oral hydromorphone on postoperative day 2 before discharge [21]. Opioid antagonist reversal regimens for pain management are recommended for patients receiving naltrexone for the management of alcoholism [14].…”

The Effect of Ultrasound Guided Superficial Cervical Plexus Block on Postoperative Opioid Consumption in Patients Undergoing Anterior Cervical Discectomy and Fusion Surgery: A Prospective, Randomized Controlled Study

“…Literatür değerlendirildiğinde, ASDF cerrahisi sonrasında analjezi amacıyla kısıtlı sayıda çalışmanın olduğu görülmektedir. Genellikle postoperatif disfaji, yutkunma ağrısı ve insizyon ağrısını azaltmak amacıyla lokal veya sistemik steroidler, lokal anestezik infiltrasyonu, non-steroid antienflamatuvar ilaç kullanımı veya opioid içeren hasta kontrollü analjezi cihazları veya oral opioid kullanımı ile ilgili çalışmalar bulunmaktadır (16,19) . Analjezik etkinliğe ulaşmak için oranla yüksek dozlarda kullanılan bu medikasyonların iyileşme safhasında akut-subakut dönemde füzyonun yapısına zarar verebileceği veya iyileşmesini uzatabileceği ya da bulantı-kusma gibi olumsuz yan etkileri arttırabileceği, analjezi isterken tam tersine hasta memnuniyetini azaltıcı yan etkilerle karşılaşılabileceği konusunda literatürde farklı çalışmalar bulunmaktadır (16,20) .…”

Naltrekson og opioider – en smertefull interaksjon

“…Dosebehovet kan vaere økt mens pasienten fortsatt har sirkulerende naltrekson i blodet, for deretter å bli kraftig redusert ved opphør av antagonisme. En kasuistikk fra 2017 beskriver problematisk postoperativ smertelindring i over ett døgn etter siste inntak av naltrekson/bupropion (5).…”