What side effects require cessation of Wellbutrin (bupropion)?

Side Effects Requiring Immediate Cessation of Wellbutrin (Bupropion)

Wellbutrin (bupropion) should be immediately discontinued if patients develop serious neuropsychiatric symptoms, seizures, severe allergic reactions, or significant cardiovascular effects, even before symptom relief from depression or smoking cessation is achieved. 1, 2

Neuropsychiatric Side Effects Requiring Discontinuation

• Development or worsening of suicidal thoughts/behaviors: Despite being uncommon, patients should be monitored for emergence or worsening of suicidal ideation, especially in younger patients 1, 3
• Psychosis or hallucinations: Bupropion can cause or worsen psychotic symptoms (28.6% of overdose cases experience hallucinations) 4, 5
• Severe agitation, hostility, or panic attacks: These may indicate a worsening of the patient's condition or an adverse reaction to the medication 2
• Mania or hypomania activation: Discontinue if signs of mania develop, particularly in patients with bipolar disorder 2

Seizures

• Any seizure activity: Bupropion reduces the seizure threshold with a 0.1% seizure risk at therapeutic doses 1
• Higher risk in specific populations: Patients with history of seizures, brain metastases, structural brain lesions, or alcohol abuse should not use bupropion 3, 6
• Dose-related risk: Seizure risk increases significantly with doses above 450mg/day or in overdose situations (27% of adolescent overdose cases) 4

Severe Allergic Reactions

• Anaphylaxis: Symptoms include difficulty breathing, swelling of face/throat, severe rash 2
• Serum sickness: Characterized by arthralgia, myalgia, fever with rash 2
• Severe skin reactions: Including widespread rash, urticaria, or angioedema 2, 7
• Stevens-Johnson syndrome: Though rare, this life-threatening condition requires immediate discontinuation

Cardiovascular Effects

• Uncontrolled hypertension: Bupropion can increase blood pressure and heart rate 3, 2
• Significant tachycardia or arrhythmias: Particularly in patients with pre-existing cardiovascular disease 2
• Chest pain: May indicate cardiovascular complications requiring immediate attention 2

Other Serious Side Effects

• Angle-closure glaucoma: Symptoms include eye pain, visual changes, and swelling around the eye 1, 2
• Severe liver dysfunction: Though rare, hepatotoxicity has been reported 1
• Serotonin syndrome: When combined with other serotonergic medications 3

Important Considerations

• Bupropion has a significantly higher risk of serious outcomes in overdose compared to SSRIs (58.1% vs 19%) 4
• The risk of neuropsychiatric adverse events is similar between bupropion and placebo in controlled studies, but monitoring is still essential 1
• Common side effects like insomnia, dry mouth, nausea, and headache are typically not reasons for immediate discontinuation unless severe 2, 8

Monitoring Recommendations

• Assess patients weekly during the first month of treatment, with particular attention to neuropsychiatric symptoms
• Educate patients and families about warning signs requiring immediate medical attention
• Consider more frequent monitoring in high-risk patients (history of seizures, suicidality, or cardiovascular disease)
• For patients with rash, discontinue immediately if accompanied by systemic symptoms or if the rash is progressive or severe

Remember that while bupropion is generally well-tolerated, these serious adverse effects require prompt discontinuation to prevent significant morbidity or mortality, even if the patient has not yet experienced therapeutic benefit.