Management of Bupropion-Related Skin Sensation and Emotional Difficulties
The most appropriate approach is to reduce the Wellbutrin (bupropion) dose back to 150 mg daily while adding a low-dose antihistamine to address the prickly skin sensation, as this will likely improve both the dermatologic side effect and emotional regulation difficulties.
Assessment of Current Symptoms
The patient is experiencing:
- Prickly skin sensation (paresthesia) that began after increasing Wellbutrin from 150 mg to 300 mg
- Difficulty managing emotions and workplace interactions
- Some improvement in depressive symptoms (less time in bed, able to engage in writing)
- Slight improvement in concentration
- Diminished effectiveness of propranolol for anxiety
Medication Management Plan
1. Adjust Bupropion Dosing
- Reduce Wellbutrin (bupropion) from 300 mg to 150 mg daily
- This dose reduction is supported by FDA labeling that recommends gradual dose increases to minimize adverse effects 1
- The prickly skin sensation is likely a hypersensitivity reaction to the higher dose of bupropion, similar to the delayed-onset urticaria documented in the literature 2
- The timing of symptom onset (first week after dose increase) strongly suggests a medication-related adverse effect
2. Manage Skin Sensation
- Add a non-sedating antihistamine such as fexofenadine 180 mg daily or loratadine 10 mg daily 3
- Consider continuing hydroxyzine 25 mg as needed for breakthrough symptoms, particularly at bedtime if sleep is affected
- Avoid topical treatments like crotamiton cream or calamine lotion which are not recommended for medication-induced pruritus 3
3. Address Emotional Regulation
- Continue propranolol but adjust the timing to maximize effectiveness
- Consider dividing the propranolol dose to maintain more consistent blood levels throughout the day
- Emotional dysregulation may be directly related to the higher bupropion dose, as bupropion is activating and can worsen anxiety or emotional lability in some patients 3
Rationale for Recommendations
Dose-Response Relationship: Bupropion's side effects are often dose-dependent. The guidelines indicate that bupropion's starting dose is typically 100-150 mg daily with increases to 150-450 mg daily 3, but some patients experience optimal benefit at lower doses with fewer side effects.
Medication-Induced Pruritus: The British Association of Dermatologists' guidelines recommend antihistamines for medication-induced pruritus 3. The prickly skin sensation is consistent with a mild hypersensitivity reaction to bupropion.
Balance of Benefits and Risks: The patient has shown some improvement in depressive symptoms at the higher dose but with significant side effects affecting quality of life. The goal is to maintain antidepressant efficacy while minimizing adverse effects.
Avoiding Polypharmacy: Rather than adding multiple medications to manage side effects, reducing the causative agent (bupropion) is preferable when the patient had partial response at the lower dose.
Monitoring Plan
- Follow up within 1-2 weeks to assess response to dose reduction
- Monitor for:
- Resolution of skin sensations
- Improvement in emotional regulation
- Maintenance of antidepressant effect
- Need for adjustment of propranolol or hydroxyzine dosing
Alternative Approaches if Initial Plan Fails
If reducing the bupropion dose leads to worsening depression:
- Consider augmentation with an SSRI (with caution due to potential serotonin syndrome risk 4)
- Consider switching to mirtazapine which promotes sleep, appetite, and weight gain while treating depression 3
- Consider adding gabapentin for both mood stabilization and potential relief of skin sensations 3
Important Precautions
- Bupropion should not be discontinued abruptly; FDA labeling recommends tapering 1
- Be alert for potential dystonic reactions which have been reported with bupropion, though rare 5
- Avoid combining bupropion with MAOIs or linezolid due to risk of hypertensive crisis 1
- Monitor for seizure risk, which increases at higher doses of bupropion 6