Is it safe to prescribe Wellbutrin (bupropion) to a patient with a history of epilepsy?

From the Guidelines

No, Wellbutrin (bupropion) is generally not safe for patients with a history of epilepsy and should be avoided in this population. Bupropion lowers the seizure threshold and significantly increases the risk of seizures, particularly in patients with predisposing factors like epilepsy, as noted in a study published in 2022 1. The risk of seizures with bupropion is dose-dependent, occurring in approximately 0.1% of patients at doses up to 300 mg/day, but increasing to 0.4% at higher doses. For patients with epilepsy who need antidepressant treatment, alternative medications such as SSRIs (like sertraline, citalopram, or escitalopram) or SNRIs (like venlafaxine or duloxetine) are generally safer options as they have minimal impact on seizure threshold. These alternatives should be initiated at low doses and titrated slowly while maintaining regular anticonvulsant medication monitoring. The contraindication of bupropion in epilepsy exists because it inhibits the reuptake of dopamine and norepinephrine, which can increase neuronal excitability and potentially trigger seizure activity in susceptible individuals. Key considerations for managing patients with epilepsy include:

• Avoiding medications that lower the seizure threshold
• Monitoring for signs of increased seizure risk
• Adjusting treatment plans as needed to minimize risks and optimize outcomes
• Considering alternative treatments that are safer for patients with epilepsy. Given the potential risks, it is essential to prioritize caution and consider alternative treatment options for patients with a history of epilepsy, as supported by the most recent and highest quality study available 1.

From the FDA Drug Label

The chance of having seizures increases with higher doses of bupropion hydrochloride extended-release tablets (XL). Do not take bupropion hydrochloride extended-release tablets (XL) if you: • have or had a seizure disorder or epilepsy.

The patient has a history of epilepsy, and according to the drug label, bupropion hydrochloride extended-release tablets (XL) are contraindicated in patients with a seizure disorder or epilepsy. It is not safe to prescribe Wellbutrin (bupropion) to a patient with a history of epilepsy. The risk of seizure is a significant concern, and the patient's history of epilepsy increases this risk. Therefore, it is recommended to avoid prescribing bupropion to this patient 2.

From the Research

Patient History and Wellbutrin Prescription

The patient has a history of epilepsy, with the last episode occurring 20 years ago. The question is whether it is safe to prescribe Wellbutrin (bupropion) to this patient.

Seizure Risk Associated with Bupropion

• Bupropion has an epileptogenic potential, which means it may lower the convulsive threshold, making it not recommended for individuals who may be predisposed to seizures 3.
• The risk of seizure appears to be higher with bupropion doses above the recommended maximum, and predisposing factors were noted in over half of the reported cases 4.
• However, when the dosage is maintained at 450 mg/day or less in a divided schedule, the seizure rate is comparable to that of other antidepressant drugs 3.

Considerations for Patients with a History of Epilepsy

• Although the patient's last episode occurred 20 years ago, the risk of seizure associated with bupropion should still be considered.
• There is no clear evidence to suggest that patients with a history of epilepsy are at a higher risk of seizures when taking bupropion, but caution is still advised 5, 4.
• The decision to prescribe bupropion should be made on a case-by-case basis, taking into account the patient's individual risk factors and medical history.

Alternative Treatment Options

• Other antidepressants, such as nortriptyline, may be considered as alternative treatment options for patients with a history of epilepsy 6.
• However, the efficacy and safety of these alternatives should be carefully evaluated and compared to bupropion.

Monitoring and Precautions

• If bupropion is prescribed to a patient with a history of epilepsy, close monitoring for signs of seizures or other adverse effects is recommended 5, 4.
• The patient should be informed of the potential risks and benefits of bupropion and should be advised to seek medical attention immediately if they experience any symptoms of a seizure.