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Sposito AC, Bonilha I, Luchiari B, Benchimol A, Hohl A, Moura F, Cercato C, Geloneze B, Nadruz W, Aguilar-Salinas C, Carvalho LSF. Cardiovascular safety of naltrexone and bupropion therapy: Systematic review and meta-analyses. Obes Rev 2021; 22:e13224. [PMID: 33847068 DOI: 10.1111/obr.13224] [Citation(s) in RCA: 9] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/29/2020] [Revised: 01/27/2021] [Accepted: 02/01/2021] [Indexed: 12/30/2022]
Abstract
Despite being approved for clinical use, evidence of cardiovascular safety (CV) is lacking for treatment with bupropion, naltrexone, or their combination (B-N). The purpose of the study is to determine the relationship between these treatments and the risk of major cardiovascular adverse events (MACE). Phase 3 randomized clinical trials (RCT) evaluating bupropion, naltrexone, or B-N versus control with reported incidence of MACE. The meta-analysis included 12 RCTs, 69% for weight loss and 29% for smoking cessation, with 19,176 patients and 7354 patient-years who were randomized to an active treatment (bupropion [n = 2965] or B-N [n = 6980] or naltrexone [n = 249]) versus control (placebo [n = 6968] or nicotine patch [n = 2014]). The mean age was 54 ± 8 years (55% female), and the baseline BMI was 32 ± 5 kg/m2 . The additive network meta-analysis model for random effects showed no association between bupropion, B-N, or naltrexone and MACE (odds ratio [OR] = 0.90 [95%CI 0.65-1.25], p = 0.52; OR = 0.97 [95%CI 0.75-1.24], p = 0.79; OR = 1.08 [95%CI 0.71-1.63], p = 0.73, respectively; I2 = 0%, p = 0.86). Meta-regression analyses showed no significant association between MACE and potential confounders from RCT demographic disparities (p = 0.58). The statistical power (post hoc two-tailed) for non-inferiority was 91%, giving a strong probability of validity. Naltrexone, bupropion, or B-N is not associated with the incidence of MACE as compared with placebo.
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Affiliation(s)
- Andrei C Sposito
- Department of Cardiology, State University of Campinas, Campinas, Brazil.,Obesity and Comorbidities Research Center, State University of Campinas, Campinas, Brazil
| | - Isabella Bonilha
- Department of Cardiology, State University of Campinas, Campinas, Brazil
| | - Beatriz Luchiari
- Department of Cardiology, State University of Campinas, Campinas, Brazil
| | - Alexander Benchimol
- Obesity and Eating Disorders Group, State Institute of Diabetes and Endocrinology, Rio de Janeiro, Brazil
| | - Alexandre Hohl
- Department of Clinical Medicine, Federal University of Santa Catarina, Florianópolis, Brazil
| | - Fabio Moura
- Endocrinology and Metabolism Department, University of Pernambuco, Recife, Brazil
| | - Cíntia Cercato
- Obesity and Metabolic Syndrome Group, Division of Endocrinology and Metabolism, Clinical Hospital, School of Medicine, University of São Paulo, São Paulo, Brazil
| | - Bruno Geloneze
- Obesity and Comorbidities Research Center, State University of Campinas, Campinas, Brazil
| | - Wilson Nadruz
- Department of Cardiology, State University of Campinas, Campinas, Brazil
| | - Carlos Aguilar-Salinas
- Department of Endocrinology and Metabolism, National Institute of Medical Sciences and Nutrition, Mexico City, Mexico
| | - Luiz Sergio F Carvalho
- Department of Cardiology, State University of Campinas, Campinas, Brazil.,Directory of Clinical Research and Innovation, Institute for Strategic Management in Healthcare, Brasília, Brazil
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Onakpoya IJ, Lee JJ, Mahtani KR, Aronson JK, Heneghan CJ. Naltrexone-bupropion (Mysimba) in management of obesity: A systematic review and meta-analysis of unpublished clinical study reports. Br J Clin Pharmacol 2020; 86:646-667. [PMID: 31918448 PMCID: PMC7098870 DOI: 10.1111/bcp.14210] [Citation(s) in RCA: 18] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/14/2019] [Revised: 12/06/2019] [Accepted: 12/18/2019] [Indexed: 11/30/2022] Open
Abstract
AIMS To compare the benefits and harms of naltrexone-bupropion using evidence from clinical study reports. METHODS We searched Food and Drug Administration and European Medicines Agency websites, PubMed, and Clinicaltrials.gov (May 2016) to identify pivotal trials; we then sent a freedom of information request to the European Medicines Agency (July 2016). We included pivotal, phase III placebo-controlled trials. We assessed the risks of bias using the Cochrane criteria, and the quality of the evidence using GRADE. We used a random-effects model for meta-analyses. RESULTS Over a 27-month period (July 2016 to August 2018), we received 31 batches of clinical study report documents containing over 65 000 pages of data from 4 pivotal trials (n = 4536). Significantly more participants who took naltrexone-bupropion achieved ≥5% reduction in body weight: risk ratio (RR) = 2.1 (95% confidence interval 1.35-3.28), P = .001, GRADE = low, number needed to treat (NNT) to benefit = 5 (3-17); this represents a 2.53 kg (1.85-3.21) reduction in baseline body weight compared with placebo. Naltrexone-bupropion had significantly beneficial effects on other cardiovascular risk factors; however, the true effect sizes for these are uncertain because of incomplete outcome data. Naltrexone-bupropion significantly increased the risk of adverse events: RR = 1.11 (1.05-1.18, P = .0004, GRADE = low, NNT to harm = 12 7-27); serious adverse events: RR = 1.70 (1.38-2.1, P < .00001, GRADE = moderate, NNT to harm = 21 13-38); and discontinuation because of adverse events: RR = 1.92 (1.65-2.24, P < .00001, GRADE = moderate, NNT to discontinue treatment = 9 8-13). CONCLUSIONS Naltrexone-bupropion significantly reduces body weight by a small amount but significantly increases the risk of adverse events. A rigorous process of postmarketing surveillance is required.
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Affiliation(s)
- Igho J. Onakpoya
- Centre for Evidence‐Based Medicine, Nuffield Department of Primary Care Health Sciences, Radcliffe Observatory QuarterUniversity of OxfordOxfordUK
| | - Joseph J. Lee
- Centre for Evidence‐Based Medicine, Nuffield Department of Primary Care Health Sciences, Radcliffe Observatory QuarterUniversity of OxfordOxfordUK
| | - Kamal R. Mahtani
- Centre for Evidence‐Based Medicine, Nuffield Department of Primary Care Health Sciences, Radcliffe Observatory QuarterUniversity of OxfordOxfordUK
| | - Jeffrey K. Aronson
- Centre for Evidence‐Based Medicine, Nuffield Department of Primary Care Health Sciences, Radcliffe Observatory QuarterUniversity of OxfordOxfordUK
| | - Carl J. Heneghan
- Centre for Evidence‐Based Medicine, Nuffield Department of Primary Care Health Sciences, Radcliffe Observatory QuarterUniversity of OxfordOxfordUK
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Onakpoya IJ, Aronson JK. Lorcaserin in obesity: minimal benefits and ill-defined harms. BMJ Evid Based Med 2019; 24:145-146. [PMID: 30700436 DOI: 10.1136/bmjebm-2018-111128] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 11/16/2018] [Indexed: 01/20/2023]
Affiliation(s)
- Igho J Onakpoya
- Nuffield Department of Primary Care Health Sciences, University of Oxford, Oxford, UK
| | - Jeffrey K Aronson
- Centre for Evidence Based Medicine, University of Oxford, Oxford, UK
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