What medication can be initiated for a patient experiencing agitation while taking Wellbutrin (bupropion) 300mg?

From the Guidelines

I strongly recommend starting the patient on a small dose of lorazepam, such as 0.5mg, to manage the agitation and hyperactivity ("bouncing") caused by Wellbutrin 300mg, as suggested by the Annals of Emergency Medicine study 1. This approach is based on the study's Level B recommendations, which suggest using a benzodiazepine like lorazepam or a conventional antipsychotic as effective monotherapy for the initial drug treatment of the acutely agitated undifferentiated patient in the ED. Some key points to consider when managing this patient's condition include:

• The patient's symptoms are likely caused by the increase in norepinephrine and dopamine activity due to Wellbutrin (bupropion) 1.
• Reducing the Wellbutrin dose to 150mg daily or switching to a different antidepressant like an SSRI (such as sertraline 50mg daily or escitalopram 10mg daily) may also be effective options, but these changes may take 2-4 weeks to show full effects 1.
• For immediate symptom management, a short-term prescription of propranolol 10-20mg as needed could also be considered, but benzodiazepines like lorazepam are generally more effective for acute agitation 1.
• It's essential to monitor the patient closely during any medication change and ensure they understand the potential risks and benefits of each treatment option, as well as the importance of short-term use of benzodiazepines to avoid dependence and other adverse effects 1.

From the FDA Drug Label

Prior to initiating bupropion hydrochloride extended-release tablets (XL), screen patients for a history of bipolar disorder and the presence of risk factors for bipolar disorder (e.g., family history of bipolar disorder, suicide, or depression). Bupropion hydrochloride extended-release tablets (XL) are not approved for the treatment of bipolar depression. 5. 6 Psychosis and Other Neuropsychiatric Reactions Depressed patients treated with bupropion have had a variety of neuropsychiatric signs and symptoms, including delusions, hallucinations, psychosis, concentration disturbance, paranoia, and confusion. Some of these patients had a diagnosis of bipolar disorder. In some cases, these symptoms abated upon dose reduction and/or withdrawal of treatment. Discontinue bupropion hydrochloride extended-release tablets (XL) if these reactions occur.

The patient is already taking Wellbutrin 300mg, which is another name for bupropion. Given that the patient is experiencing symptoms of "bouncing", it may be related to neuropsychiatric reactions or activation of mania or hypomania. The best course of action would be to discontinue bupropion and consult a healthcare provider for further evaluation and treatment. No new medication can be recommended without further assessment of the patient's condition. 2

From the Research

Medication Options for Patients Taking Wellbutrin 300mg

• The patient is currently taking Wellbutrin 300mg and is experiencing bouncing, which may be a side effect of the medication or an indication that the medication is not effective at the current dose.
• According to the study 3, bupropion (Wellbutrin) is available in three oral formulations: immediate release (IR), sustained release (SR), and extended/modified release (XR).
• The study 4 suggests that the most common cause for discontinuation of bupropion is agitation/excitement, which may be related to the bouncing effect experienced by the patient.
• Another study 5 found that bupropion is generally well tolerated and has a unique pharmacology that inhibits the reuptake of noradrenaline and dopamine, which may be beneficial for patients experiencing bouncing or other side effects.

Alternative Medications or Combination Therapies

• The study 6 suggests that combining bupropion with serotonin reuptake inhibitors (SSRIs) or serotonin-norepinephrine reuptake inhibitors (SNRIs) may be effective in enhancing antidepressant response and reducing sexual side effects.
• However, the study 3 notes that bupropion XR was similar in terms of primary efficacy outcomes to the SSRI escitalopram and the SNRI venlafaxine extended release (XR), but was associated with less sexual dysfunction than escitalopram.
• The study 7 found that a reduction in dosing frequency, such as switching to a once-daily formulation of bupropion, may improve adherence to treatment and reduce side effects.

Considerations for Medication Changes

• When considering medication changes, it is essential to weigh the potential benefits and risks of alternative medications or combination therapies, as noted in the study 5.
• The study 4 highlights the importance of monitoring patients for adverse reactions, such as major motor seizures, which are rare but can occur with bupropion treatment.
• Ultimately, the decision to change medications or add a new medication should be based on a thorough evaluation of the patient's symptoms, medical history, and treatment goals, as well as consultation with a qualified healthcare professional 3, 4, 5, 7, 6.