What is the cause of worsening symptoms in a patient taking Wellbutrin (bupropion) 150mg and hydroxyzine 25mg?

From the Guidelines

If a patient is experiencing worsening symptoms after starting Wellbutrin 150mg and hydroxyzine 25mg, they should contact their healthcare provider immediately to report these symptoms and consider discontinuing hydroxyzine due to its potential for sedation, dry mouth, and confusion, as well as its interaction with Wellbutrin, which may intensify side effects 1. The provider may recommend temporarily discontinuing one or both medications, reducing the dosage, or switching to alternative treatments depending on the specific symptoms.

• Common adverse effects of Wellbutrin (bupropion) include anxiety, agitation, insomnia, headache, and rarely seizures, as noted in guidelines for managing depression and other conditions 1.
• Hydroxyzine may cause sedation, dry mouth, and confusion, and its use should be approached with caution, especially in older adults, due to the potential for adverse anticholinergic effects and increased risk of falls 1. These medications can sometimes interact, potentially intensifying side effects.
• The worsening symptoms could represent an adverse reaction, an allergic response, or an exacerbation of the underlying condition being treated. It's essential to determine which medication is causing the problem, as discontinuing both simultaneously might make it difficult to identify the culprit.
• The healthcare provider should evaluate whether the symptoms represent a serious adverse effect requiring immediate intervention or if they might resolve with continued treatment as the body adjusts to the medication, considering the potential benefits and risks of each medication, as well as the patient's individual response 1. Patients should never discontinue psychiatric medications abruptly without medical guidance, as this can sometimes lead to withdrawal symptoms or rebound effects.
• A thorough assessment of the patient's symptoms, medical history, and current medications is necessary to make an informed decision about the best course of action, taking into account the potential interactions between Wellbutrin and hydroxyzine, as well as the patient's overall health and well-being 1.

From the FDA Drug Label

Advise the patient to read the FDA-approved patient labeling (Medication Guide) Suicidal Thoughts and Behaviors Instruct patients, their families, and/or their caregivers to be alert to the emergence of anxiety, agitation, panic attacks, insomnia, irritability, hostility, aggressiveness, impulsivity, akathisia (psychomotor restlessness), hypomania, mania, other unusual changes in behavior, worsening of depression, and suicidal ideation, especially early during antidepressant treatment and when the dose is adjusted up or down.

The patient's worsening symptoms after taking Wellbutrin 150mg and hydroxyzine 25mg may be associated with the emergence of anxiety, agitation, panic attacks, insomnia, irritability, hostility, aggressiveness, impulsivity, akathisia, hypomania, mania, or other unusual changes in behavior. These symptoms should be reported to the patient's prescriber or health professional, especially if they are severe, abrupt in onset, or were not part of the patient's presenting symptoms. The patient should be closely monitored, and changes in medication may be necessary 2.

From the Research

Patient Complaints of Worsening Symptoms

• The patient is experiencing worsening symptoms after being given Wellbutrin 150mg and hydroxyzine 25mg.
• According to the studies, bupropion (Wellbutrin) is an effective antidepressant with a relatively safe profile 3, 4.
• However, common side effects of bupropion include nervousness, insomnia, nausea, and seizures 4, 5.
• The patient's worsening symptoms could be related to the side effects of bupropion or an interaction with hydroxyzine.

Potential Side Effects and Interactions

• Bupropion undergoes extensive stereoselective metabolism, and its major active metabolites can reach higher plasma concentrations than bupropion itself 6.
• The combination of bupropion and hydroxyzine may increase the risk of adverse effects, such as seizures, agitation, and insomnia 7.
• The patient's dose of 150mg of Wellbutrin is within the therapeutic range, but the addition of hydroxyzine may be contributing to the worsening symptoms.

Clinical Considerations

• The incidence of seizures with bupropion is less than 1 per 1,000 at usual outpatient doses and less than 1 per 100 at usual inpatient doses 5.
• However, the risk of seizures may be increased with extra doses of bupropion or in combination with other medications 7.
• The patient's symptoms should be closely monitored, and the treatment plan should be adjusted as needed to minimize the risk of adverse effects 3, 4.