Bupropion contraindications

[throwaway2222]

Hello all,
I am wondering, how strict are you with the FDA contraindications of bupropion and how would you handle the following situation?

I tend to draw the line at not prescribing to people with an active restrictive or purging type eating disorder, as well as known seizure history.

Now, what if you had a patient on bupropion with active anorexia and a history of seizure, whom you inherited from a colleague. You took them off bupropion and they are doing poorly. There are other options but they adamantly refuse to try other things. How would you manage that situation? (I’m sure it’s a common enough scenario, unfortunately.)

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[calvnandhobbs68]

I don't know if I'd restart Wellbutrin in the patient you mentioned just because your liability from a malpractice standpoint would be so high if the patient had a seizure...you're literally violating 2 contraindications on the Wellbutrin packaging.

But this is truly a grey area in terms of seizure risk because from what I know basically all the seizure risk data came from immediate release Wellbutrin or Wellbutrin extended release formulations >450mg daily. So it's not clear the risk of seizures for Wellbutrin XL<450mg is any more than many of the other medications we prescribe (if I remember right, in residency there was a presentation showing relative seizure incidence for Wellbutrin XL at normal dose ranges and it was as much or lower than many of the other meds we use day to day).

 

[TexasPhysician]

I’d have to understand the details better. If the patient had a febrile seizure or has been stable on an anti epileptic for a decade, I’m less worried with XL option.

Active anorexia with struggling to gain weight and below normal BMI - no. If we are talking about a 23 BMI with sporadic difficulty with anorexia but significant mood improvement, Id consider.

Should document well on this case regardless.

 

[nowaysanjose]

I stick hard to the guidelines. Seen more than a few pts seize on bup and was glad I did when it happened.

 

[throwaway2222]

I’d have to understand the details better. If the patient had a febrile seizure or has been stable on an anti epileptic for a decade, I’m less worried with XL option.

Active anorexia with struggling to gain weight and below normal BMI - no. If we are talking about a 23 BMI with sporadic difficulty with anorexia but significant mood improvement, Id consider.

Should document well on this case regardless.

It is definitely the kind of anorexia in the first case.

 

[Taddy Mason]

But this is truly a grey area in terms of seizure risk because from what I know basically all the seizure risk data came from immediate release Wellbutrin or Wellbutrin extended release formulations >450mg daily. So it's not clear the risk of seizures for Wellbutrin XL<450mg is any more than many of the other medications we prescribe (if I remember right, in residency there was a presentation showing relative seizure incidence for Wellbutrin XL at normal dose ranges and it was as much or lower than many of the other meds we use day to day).

This is from Maudsley, UpToDate, and Goldberg and Ernst Managing the Side Effects of Psychotropic Medications and referring to the sources they cited when putting together a psychopharm lecture for med students a while back:

• Risk of seizures with IR bupropion - ~0.4% (I’m assuming this is for standard clinical dosing)
• Risk of seizures with bupropion SR ≤200mg bid or bupropion XL ≤450mg daily - ~0.1%
• Risk of seizures with SSRIs in general - ~0.1%
• Risk of seizures with TCAs in general - 0.4 - 2%

I’ve been told on more than one occasion and by more than one attending (one of whom was involved in some of the clinical trials/research with bupropion in the early 80s), and also recall reading somewhere as well but don’t have any explicit sources off the top of my head, that Lily manipulated the data regarding the risk of seizures with bupropion (e.g., using data from animal studies and at much higher doses of bupropion than are used clinically or in studies with humans, cherry picking data from human studies and taking it out of context, etc.) when fluoxetine was coming out to gain an edge in the market and that this has (and continues to) skew the concern regarding the risk of seizures with bupropion. That said, I would probably be more hesitant about restarting bupropion given the overall clinical picture in OP’s patient, bupropion’s effect on appetite, and the potential risk from a malpractice liability standpoint.

 

[mistafab]

To answer your question, I wouldn't prescribe wellbutrin to this patient, especially when there are other reasonable alternatives.

We had a case where someone was like Texas Physician had mentioned healthy BMI and sporadic ED who started to drop their BMI. Once they crossed the threshold of 19 we refused to prescribe the wellbutrin. I felt that stopping the wellys was appropriate given how people with ED may behaviorally like the anorexigenic effects, and how acute weight loss may provoke other electrolyte abnormalities increasing seizure risk as well - especially in B/P type. Perhaps they have a seizure from the electrolyte problems alone when they are taking the wellbutrin. How could you defend yourself when treatment in this population is contraindicated (x2)? You could point at the absolute low risk of seizure on the med, and could describe how you discussed the risks of this to the patient/ came to mutual agreement/ etc. Would the family care about that if the patient died? Probably not, they would blame you. And the "reasonable person standard" probably wouldn't go in your favor given the double contraindication.

I don't want to hijack your thread, just curious - do people see issues often with falls on people scripted wellbutrin with other 2D6 drugs? I'm thinking lots of people on BBlockers or perhaps fluoxetine/paroxetine would have this happen to them, I just haven't seen it before.

 

[deleted1100659]

I wouldnt prescribe it while they had an active eating disorder, no possible way.

As far as the seizure disorder, that can vary so drastically from pseudoseizures to grand mal. If a neurologist is willing to write them a letter saying that the seizure risk is minimal at most, well controlled/resolved, etc then I would consider it

 

[TexasPhysician]

We had a case where someone was like Texas Physician had mentioned healthy BMI and sporadic ED who started to drop their BMI. Once they crossed the threshold of 19 we refused to prescribe the wellbutrin. I felt that stopping the wellys was appropriate given how people with ED may behaviorally like the anorexigenic effects, and how acute weight loss may provoke other electrolyte abnormalities increasing seizure risk as well - especially in B/P type. Perhaps they have a seizure from the electrolyte problems alone when they are taking the wellbutrin. How could you defend yourself when treatment in this population is contraindicated (x2)? You could point at the absolute low risk of seizure on the med, and could describe how you discussed the risks of this to the patient/ came to mutual agreement/ etc. Would the family care about that if the patient died? Probably not, they would blame you. And the "reasonable person standard" probably wouldn't go in your favor given the double contraindication.

The legal issue is a difficult one because you can be sued either way. Take the same patient and refuse/discontinue Wellbutrin that another physician has documented for months/years about the mood benefit. The patient attempts or completes suicide. Now the family sues you for directly causing harm. After all, the patient has documented benefit with extended use without harm.

This is a case where the documentation is very important regardless of the decision. There are increased legal risks no matter what you do. My decision would be very case dependent, and my follow-ups would be frequent.

 

[calvnandhobbs68]

I don't want to hijack your thread, just curious - do people see issues often with falls on people scripted wellbutrin with other 2D6 drugs? I'm thinking lots of people on BBlockers or perhaps fluoxetine/paroxetine would have this happen to them, I just haven't seen it before.

I do Prozac + Wellbutrin all the time and don't have any problems. Granted, this is all in teenagers/young adults without really any other medical problems generally or many other meds on board.

 

[Mass Effect]

The legal issue is a difficult one because you can be sued either way. Take the same patient and refuse/discontinue Wellbutrin that another physician has documented for months/years about the mood benefit. The patient attempts or completes suicide. Now the family sues you for directly causing harm. After all, the patient has documented benefit with extended use without harm.

This is a case where the documentation is very important regardless of the decision. There are increased legal risks no matter what you do. My decision would be very case dependent, and my follow-ups would be frequent.

Exactly like the above. You can't provide care based on whether or not you can be sued. It's a lose-lose situation. Obvi, don't do anything dangerous. But if a patient has a healthy BMI with AN tendencies and I continued Wellbutrin, I don't think it's hard to justify. If a patient has a BMI of 15, then don't do it. It doesn't make sense even if the end result is the patient commits suicide. Either way, the documentation is what will get you through it, not the fact that you followed or didn't follow guidelines by the letter.

 

[throwaway2222]

Exactly like the above. You can't provide care based on whether or not you can be sued. It's a lose-lose situation. Obvi, don't do anything dangerous. But if a patient has a healthy BMI with AN tendencies and I continued Wellbutrin, I don't think it's hard to justify. If a patient has a BMI of 15, then don't do it. It doesn't make sense even if the end result is the patient commits suicide. Either way, the documentation is what will get you through it, not the fact that you followed or didn't follow guidelines by the letter.

The patient has severe anorexia. I honestly feel like the previous provider was committing malpractice. There are reasonable other options, the patient just won’t take them. I suppose if I document referrals to eating disorder treatment and other options offered, that the patient refused them and why they refused them, that’s all I can do…

 

[throwaway2222]

I guess an additional question I have is, let’s say you have reached a stalemate where you won’t prescribe the bupropion, and patient won’t take anything else. The question naturally comes up of, should they try to find a different psychiatrist. Would it make sense to tell the patient that you think that the vast majority of psychiatrists would not prescribe this med to someone in their situation, or would you not even go there? Again, I think the colleague I got the patient from was being very irresponsible. I would talk to the colleague, but I never got a chance to meet this colleague and I don’t know where they went.

 

[DOBound2019]

If you look closely at the case reports for patients having seizures with bupropion and eating disorders it’s almost always because they are using it inappropriately to suppress their appetite. Taking up and over a gram a day and then usually having other electrolyte abnormalities and so forth. If her eating pathology is as bad as you describe I wouldn’t prescribe as likely she is using it and only takes the medication because of its side effect of suppressing her appetite is my guess. Like most patients if you place a hard boundary make your recommendations and those recs are well documented and within standard of care you have nothing to worry about likely she fires you and goes and tries to find a different psych that will write for it.

 

[Celexa]

I guess an additional question I have is, let’s say you have reached a stalemate where you won’t prescribe the bupropion, and patient won’t take anything else. The question naturally comes up of, should they try to find a different psychiatrist. Would it make sense to tell the patient that you think that the vast majority of psychiatrists would not prescribe this med to someone in their situation, or would you not even go there? Again, I think the colleague I got the patient from was being very irresponsible. I would talk to the colleague, but I never got a chance to meet this colleague and I don’t know where they went.

I would not tell her what I think other doctors would do because, well, sadly there are lots of other doctors who would do the unwise thing. As her previous doc demonstrates.

But yes, I would be firm and clear in my recommendation. If pt is underweight I would not continue to prescribe, and I would tell the patient (as kindly as possibly) that my primary concern is for their safety and well being, and that my recommendation is not going to change. They can then choose to seek a different opinion should they wish.

I appreciate the discussion on this issue. I dealt with it twice in residency so far and in both cases my discomfort was worsened by the fact that it was covid telemedicine and I could not check weights on the patients. The more severe one I arranged a transfer to a colleague with more comfort with eating disorders. In retrospect I agree with others that in someone of normal weight but hx of eating disorder I would be OK prescribing it if I had a way to confirm they are at a healthy weight. In someone underweight or with concern for unsafe weight loss, I would not.

 

[thepoopologist]

I guess an additional question I have is, let’s say you have reached a stalemate where you won’t prescribe the bupropion, and patient won’t take anything else. The question naturally comes up of, should they try to find a different psychiatrist. Would it make sense to tell the patient that you think that the vast majority of psychiatrists would not prescribe this med to someone in their situation, or would you not even go there? Again, I think the colleague I got the patient from was being very irresponsible. I would talk to the colleague, but I never got a chance to meet this colleague and I don’t know where they went.

If you've clearly discussed your rationale with them and documented well, then the only other discussion you can have is where you see their health going should they find another psychiatrist willing to prescribe it again. At some point your concerns for their health are outweighed by their ability to do what they want (assuming this is outpatient)

 

[NickNaylor]

If you've clearly discussed your rationale with them and documented well, then the only other discussion you can have is where you see their health going should they find another psychiatrist willing to prescribe it again. At some point your concerns for their health are outweighed by their ability to do what they want (assuming this is outpatient)

Completely agree. If this patient has active eating disorder symptoms, I wouldn't be prescribing bupropion - the patient's report of improvement only with bupropion may very well be in service of their eating disorder and attempting to suppress their appetite. As long as you discuss with the patient and document your clinical rationale and concerns, I have a hard time believing that you would face any medicolegal liability for refusing to continue to use bupropion in the setting of a poorly controlled eating disorder. And if the patient doesn't like that plan, they're free to find someone else to see.

 

[throwaway2222]

I am so frustrated. Not by the patient, because they probably can’t help what they do, but by the other doctors and “providers” who have been giving them a doubly contraindicated medication for years. Everyone I talked to has told me don’t do it, and yet it has been done, and is often done. The patient is just a victim in this situation because they probably genuinely feel whiplash: like why is this suddenly not ok when it always apparently was ok before? Maybe I’m the misguided one here and if for years nothing went wrong the risk in this patient at least is overrated…

 

[DOBound2019]

I am so frustrated. Not by the patient, because they probably can’t help what they do, but by the other doctors and “providers” who have been giving them a doubly contraindicated medication for years. Everyone I talked to has told me don’t do it, and yet it has been done, and is often done. The patient is just a victim in this situation because they probably genuinely feel whiplash: like why is this suddenly not ok when it always apparently was ok before? Maybe I’m the misguided one here and if for years nothing went wrong the risk in this patient at least is overrated…

I'll say this don't rush to judgement too quickly. Sometimes the reason why a provider arrived at a certain regimen can be quite complicated especially if a patient has been particularly treatment resistant. Also we are getting snap shots of your patient here but our advice may not necessarily be the same after having done our own interviews and review of the records in an extensive fashion for example. That said you are the provider now and you have to do what you think in YOUR clinic judgement is the best way to proceed within the standard of care.

 

[Mass Effect]

I am so frustrated. Not by the patient, because they probably can’t help what they do, but by the other doctors and “providers” who have been giving them a doubly contraindicated medication for years. Everyone I talked to has told me don’t do it, and yet it has been done, and is often done. The patient is just a victim in this situation because they probably genuinely feel whiplash: like why is this suddenly not ok when it always apparently was ok before? Maybe I’m the misguided one here and if for years nothing went wrong the risk in this patient at least is overrated…

Based on nothing except my own experience, here's what likely happened. Patient showed up to first doc, either didn't admit to eating disorder or said it was many years ago. Wellbutrin was started, possibly after other failed trials. Pt then went to another doc, Wellbutrin continued because it worked so well. Somewhere along the way, the ED was discovered, but either no one though to d/c Wellbutrin or the Wellbutrin was the only thing that worked or the patient agreed to ED treatment if she could stay on the Wellbutrin. Doc decided the benefit of her actively engaging in ED treatment was worth the relatively small risk of Wellbutrin (compared to untreated ED), and maybe the patient even improved for a while. Patient then relapsed, either before or after leaving previous provider, and no one d/c'd Wellbutrin and patient ended up on your doorstep. A large part of ED can be personality and instability in treaters can exacerbate the condition. Don't discount this part.

Point is sometimes very competent and well respected doctors can sign off on treatment plans that seem horrible but there might be a reason behind it that we're not getting.

 

[throwaway2222]

Based on nothing except my own experience, here's what likely happened. Patient showed up to first doc, either didn't admit to eating disorder or said it was many years ago. Wellbutrin was started, possibly after other failed trials. Pt then went to another doc, Wellbutrin continued because it worked so well. Somewhere along the way, the ED was discovered, but either no one though to d/c Wellbutrin or the Wellbutrin was the only thing that worked or the patient agreed to ED treatment if she could stay on the Wellbutrin. Doc decided the benefit of her actively engaging in ED treatment was worth the relatively small risk of Wellbutrin (compared to untreated ED), and maybe the patient even improved for a while. Patient then relapsed, either before or after leaving previous provider, and no one d/c'd Wellbutrin and patient ended up on your doorstep. A large part of ED can be personality and instability in treaters can exacerbate the condition. Don't discount this part.

Point is sometimes very competent and well respected doctors can sign off on treatment plans that seem horrible but there might be a reason behind it that we're not getting.

Maybe. In this patient’s case, she has had an easing disorder for a very long time and let’s put it this way… you don’t need a scale to see that they have an eating disorder. I went back to the most recent trial of Wellbutrin in the available medical record and the documentation is incredibly sparse. It mentions easing disorder but no reasoning of any kind.

 

[thepoopologist]

I am so frustrated. Not by the patient, because they probably can’t help what they do, but by the other doctors and “providers” who have been giving them a doubly contraindicated medication for years. Everyone I talked to has told me don’t do it, and yet it has been done, and is often done. The patient is just a victim in this situation because they probably genuinely feel whiplash: like why is this suddenly not ok when it always apparently was ok before? Maybe I’m the misguided one here and if for years nothing went wrong the risk in this patient at least is overrated…

The distance between ideal prescribing behavior and actual prescribing behavior can sometimes be so far apart that hoping for the ideal is as useful as hoping for a chest full of treasure to appear in your living room one day.

 

[futureapppsy2]

Completely agree. If this patient has active eating disorder symptoms, I wouldn't be prescribing bupropion - the patient's report of improvement only with bupropion may very well be in service of their eating disorder and attempting to suppress their appetite. As long as you discuss with the patient and document your clinical rationale and concerns, I have a hard time believing that you would face any medicolegal liability for refusing to continue to use bupropion in the setting of a poorly controlled eating disorder. And if the patient doesn't like that plan, they're free to find someone else to see.

+1. IME, it's common for patients with active EDs especially to ask for bupriopion for the appetite suppression/weight loss effects as much as, if not moreso, than the anti-depressant effects.