Is a history of purging a contraindication to bupropion (Wellbutrin)?

Yes, a history of purging (bulimia) is an absolute contraindication to bupropion (Wellbutrin).

Bupropion should NOT be used in patients with a current or prior diagnosis of bulimia or anorexia nervosa due to a significantly increased risk of seizures. This is an FDA-mandated contraindication, not merely a precaution 1.

Why This Contraindication Exists

The contraindication stems from historical clinical evidence showing a markedly elevated seizure incidence in bulimic patients:

• Bupropion was temporarily withdrawn from the market in 1986 after clinical trials revealed an unacceptably high rate of grand mal seizures in patients with bulimia 2.

• A multicenter controlled trial found 4 out of 55 bulimic patients (7.3%) experienced grand mal seizures while taking bupropion—a rate far exceeding that seen in other patient populations 3.

• The drug was only reintroduced in 1989 after establishing that seizure risk was dose-dependent in non-bulimic populations, with a 2-year cumulative seizure risk of 0.48% at maximum recommended doses (≤450 mg/day) 2.

Clinical Implications

This contraindication applies regardless of:

• Whether the bulimia is currently active or in remission (history alone is sufficient)
• The formulation of bupropion (IR, SR, XL, or combination products like naltrexone/bupropion ER)
• The intended use (depression, smoking cessation, weight loss, ADHD)

Multiple authoritative guidelines consistently reinforce this contraindication:

• AACE/ACE Obesity Guidelines (2016): State that bupropion-containing weight-loss medications "should not be used in patients with bulimia" 2.
• NCCN Smoking Cessation Guidelines (2016): List bulimia as a contraindication for bupropion 4.
• ATS Adolescent Nicotine Guidelines (2025): Specify that bupropion is contraindicated in patients with current or prior bulimia or anorexia nervosa 5.
• FDA Drug Label: Explicitly lists bulimia and anorexia nervosa as contraindications 1.

Alternative Medications

For patients with a history of purging who need treatment:

For depression/anxiety:

• Consider SSRIs, SNRIs, or other antidepressants without seizure risk

For weight management:

• Orlistat, liraglutide, lorcaserin, or phentermine/topiramate ER are appropriate alternatives 2
• Notably, medications containing topiramate may actually help reduce binge eating disorder symptoms 2

For smoking cessation:

• Varenicline or nicotine replacement therapy are safer options 4, 6

Critical Caveat

One case report documented severe bupropion XR abuse (3,000-4,500 mg/day) in a patient with bulimia who used it to control binge eating and suppress appetite, ultimately resulting in grand mal seizures 7. This underscores both the contraindication's validity and the need for careful screening before prescribing bupropion, as patients may not spontaneously disclose eating disorder histories.

Bottom line: Screen all patients for current or past eating disorders before prescribing bupropion. If any history of bulimia or anorexia nervosa exists, do not prescribe bupropion in any form.