Bupropion toxicity
Background
- Bupropion is a norepinephrine/dopamine reuptake inhibitor used for depression, ADHD, and smoking cessation
- Structurally part of the synthetic cathinones
- Toxicity occurs with ingestion of >450mg/d
Clinical Features
- Agitation
- Dizziness
- Tremor
- Nausea/vomiting
- Drowsiness/lethargy
- Tachycardia
- Seizure
- May develop in isolation from other symptoms
- Develops within first 1-4hr for regular-release, up to 8hr for delayed release forms
- Hypotension and cardiogenic Shock
Differential Diagnosis
Seizure
- Epileptic seizure
- First-time seizure
- Seizure with known seizure disorder
- Status epilepticus
- Temporal lobe epilepsy
- Non-compliance with anti-epileptic medications
- Hyponatremia
- INH toxicity
- Non-epileptic seizure
- Meningitis
- Encephalitis
- Brain abscess
- Intracranial hemorrhage
- Alcohol withdrawal
- Benzodiazepine withdrawal
- Barbiturate withdrawal
- Baclofen withdrawal
- Metabolic abnormalities: hyponatremia, hypernatremia, hypocalcemia, hypomagnesemia, hypoglycemia, hyperglycemia, hepatic failure, uremia
- Eclampsia
- Neurocysticercosis
- Posterior reversible encephalopathy syndrome
- Impact seizure (head trauma)
- Acute hydrocephalus
- Arteriovenous malformation
- Seizure with VP shunt
- Toxic ingestion (amphetamines, anticholinergics, cocaine, INH, organophosphates, TCA, salicylates, lithium, phenothiazines, bupropion, camphor, clozapine, cyclosporine, fluoroquinolones, imipenem, lead, lidocaine, metronidazole, synthetic cannabinoids, theophylline, Starfruit)
- Psychogenic nonepileptic seizure (pseudoseizure)
- Intracranial mass
- Syncope
- Hyperventilation syndrome
- Migraine headache
- Movement disorders
- Narcolepsy/cataplexy
- Post-hypoxic myoclonus (Status myoclonicus)
Evaluation
- CBC, CMP
- ECG to eval for QRS and QT prolongation
- Typically does not lead to Torsades de Pointes[1]
Management
- Activated charcoal or gastric emptying are not indicated
- Consider whole-bowel irrigation for sustained-release formulations
- Seizure Treatment
- Benzos are 1st line
- Barbiturates are 2nd line
- Early vasopressor and ionotropic agents for hemodynamic instability (Bupropion depresses myocardial contractility)
- Sodium bicarbonate if QRS prolongation
- Intralipid[4] or ECMO for refractory cases
Disposition
- Consider discharge if asymptomatic after 8hr for regular-release ingestions
See Also
References
- Giroski, L., & Shih, R. (2012). QTC Prolongation and Torsades in Bupropion Overdoses Presenting to United States Emergency Departments. The Journal of Emergency Medicine, 43(5), 934–935. doi:10.1016/j.jemermed.2012.09.104
- Wills BK, Zell-Kanter M, Aks SE. Bupropion-associated QRS prolongation unresponsive to sodium bicarbonate therapy. Am J Ther. 2009;16(2):193-196. doi:10.1097/MJT.0b013e3180a5bd83
- Caillier B, Pilote S, Castonguay A, et al. QRS widening and QT prolongation under bupropion: a unique cardiac electrophysiological profile. Fundam Clin Pharmacol. 2012;26(5):599-608. doi:10.1111/j.1472-8206.2011.00953.x
- Sirianni AJ, Osterhoudt KC, Calello DP, et al. Use of lipid emulsion in the resuscitation of a patient with prolonged cardiovascular collapse after overdose of bupropion and lamotrigine. Ann Emerg Med. 2008;51(4):412-415.e1. doi:10.1016/j.annemergmed.2007.06.004
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