Contave for Weight Loss in 2021Posted: Dec 16 in Weight Loss Medication by Dr. Lazarus
Contrave is one of our new anti-obesity medications, or “AOMs” approved for chronic weight management in 2014. As the years have gone by, we have accumulated a lot of clinical experience with Contrave for weight loss. This article will review some of the pros and cons of Contrave use, particularly in comparison to the older weight loss medications, like Phentermine and Tenaute (diethylpropion).
What is Contrave
Contrave is a combination of two ingredients. The first is bupropion ER (also sold as Wellbutrin). Bupropion has been in wide-spread clinical use since 1985 as both an anti-depressant, and then later was also approved for smoking cessation (marketed as Zyban). It functions as a mild reuptake inhibitor for the neurotransmitters dopamine and serotonin. Alone, it is associated with a very small weight loss, but the area in the brain responsible for that (the arcuate nucleus of the hypothalamus) quickly adapts to these effects and the weight loss seems short-lived.
The second ingredient in the Contrave is called naltrexone. This has been on the market since 1984, and was originally approved for narcotics overdose. It is an opiate receptor antagonist. It was later also approved for alcoholism in 1994 (marketed as Revia). Naltrexone has activity in the part of the brain referred to as the mesolimbic reward system. By blocking receptors in this system, naltrexone has at least two effects. It significantly reduces food cravings, and it seems to block the adaptation of the hypothalamus to the bupropion, amplifying the appetite control effect.
Why controlling hunger and cravings is important for sustaining weight loss
After losing weight, the body takes action to defend itself. It defends its fat mass both by lowering the metabolic rate and by increasing hunger. The hunger piece of the equation is regulated by a series of hormones released by the stomach, small intestine, and also from the pancreas and fat tissue itself.
These hormonal changes are referred to as metabolic adaptation. Our body responds to weight loss by making us hungrier, and also making it harder to feel satisfied when we eat. Again, this is a hormonal response – it has nothing to do with personality, character, or willpower. It happens to everybody that loses weight.
Most of our patients report feeling hungrier at night. The diet feels boring. After dinner, we want more and more food. We feel like we are running out of steam. These are the biological effects of weight loss, not a persons’ willpower evaporating.
Contrave is very helpful to sustain weight loss over the long-haul because it helps a person overcome these biological effects.
Contrave vs. Phentermine
Although Contrave and Phentermine both affect the appetite control center and both are associated with a similar amount of weight loss, there are several differences between Contrave and Phentermine (and Tenuate / diethylpropion).
First, Contrave was approved for chronic weight management. Although we do tend to use phentermine and tenuate long-term, this was not how their original studies were done, and the use in this fashion is considered “off-label.” Contrave on the other hand was designed from the ground up to be a long-term treatment. The label “chronic weight management” suggests that this drug be taken chronically, similar to a blood pressure medication or a diabetes medication. There is no evidence that the metabolic adaptations to weight loss fade over time, and current medical recommendations are to NOT STOP an anti-obesity medication for a person in whom it was indicated and who experienced a reasonable amount of weight loss.
We would stop the Contrave in several situations. First, if a person is not a responder, and doesn’t lose at least 4% of their body weight in 16 weeks. Second, if a person develops a contraindication (discussed below).
Contrave is far less stimulating than phentermine and tenuate, so for people with difficult to control high blood pressure or sensitivity to the older medications, Contrave can be a better option. Further, Contrave really works for a full 24 hours – it doesn’t hit and wear off like the phentermine / diethylpropion.
However, Contrave can cause more side effects than the older agents. Most often, these are nausea, sometimes vomiting, and constipation. Less commonly, we see headaches and insomnia. The majority of the time, these side effects are transient and go away within a few days. Also, while phentermine and Tenuate are usually dosed once a day in the morning, Contrave is dosed 2 pills in the morning and 2 pills in the evening (after a slow dose escalation that is done during the first month of use).
Who is NOT a candidate for Contrave?
Like the other weight loss medications, Contrave is indicated for individuals with a body mass index (BMI) of 30 or more, or 27 or more with a comorbidity like high cholesterol or diabetes. It has not been studied in kids (< 18 years old). It should be stopped if a person becomes pregnant or is breastfeeding. It should NOT be used if a person has a seizure disorder, anorexia, bulemia, or if a person takes any sort of narcotic medication (codeine-based medications).
Rarely, people can have neuropsychiatric reactions to the Contrave. If this happens the medication should be stopped immediately and the individual should seek immediate medical attention.
For full prescribing information, please click here to view the package insert.
Is Contrave Expensive?
Because it is a brand name medication, Contrave is more expensive than the older medications like Phentermine and Tenuate. It typically is not covered by insurance either. However, we do stock it at CNC where at the time of this article the cost is $119 per month, and there is a mail-order option that is slightly less expensive.
For individuals where this is too expensive, sometimes we will prescribe generic bupropion and generic naltrexone together at dosages similar to the Contrave. While the use of these medications in this fashion is considered “off-label” we have seen some good success using this combination.
Learn more about Contrave
If you have struggled to lose weight and keep it off, consider setting up a consultation with a provider at CNC to discuss the different safe and effective FDA approved prescription anti-obesity medications like Contrave and see if one would be a good fit for you.