What are the potential interactions between prednisone and Wellbutrin (bupropion)?

Prednisone and Wellbutrin (Bupropion) Interaction

There is no significant direct pharmacokinetic interaction between prednisone and bupropion (Wellbutrin), but caution is warranted due to potential increased seizure risk when these medications are combined, particularly in patients with predisposing factors.

Key Considerations

Seizure Risk

• Bupropion is associated with a dose-dependent seizure risk, with incidence of 0.1% at therapeutic doses (≤450 mg/day) 1, 2
• Higher doses of bupropion (>450 mg/day) significantly increase seizure risk 3, 4, 5
• Prednisone and other corticosteroids can lower seizure threshold in some patients
• The combination may potentially have an additive effect on seizure risk, though this is not explicitly documented in guidelines

Risk Factors for Seizures When Using Bupropion

• History of seizures or seizure disorders
• Brain metastases or structural brain lesions
• Current alcohol/substance abuse
• Abrupt discontinuation of alcohol or sedatives
• Use of medications that lower seizure threshold
• Severe hepatic impairment

Recommendations for Management

Patient Assessment

• Evaluate for seizure risk factors before initiating combination therapy:
  • History of seizures or epilepsy
  • Brain injury, tumor, or structural abnormalities
  • Recent withdrawal from alcohol or sedatives
  • Concurrent medications that lower seizure threshold

Dosing Considerations

• Maintain bupropion at or below recommended maximum doses:
  • SR formulation: 150 mg twice daily (maximum 400 mg/day) 1
  • XL formulation: 150-300 mg once daily (maximum 450 mg/day) 1
• Consider lower initial doses of bupropion when adding to prednisone therapy
• Avoid exceeding maximum recommended doses of bupropion, as seizure risk increases significantly above 450 mg/day 3, 4

Monitoring

• Monitor for neuropsychiatric symptoms, including:
  • Anxiety or agitation
  • Insomnia
  • Mood changes
  • Confusion or cognitive changes
• Be alert for signs of potential hypersensitivity reactions:
  • Skin rashes, urticaria
  • Angioedema 6
  • Anaphylaxis symptoms (rare)

Special Populations

• Patients with brain metastases: Avoid bupropion due to increased seizure risk 1, 2
• Patients with hepatic impairment: Reduce bupropion dose (maximum 1 tablet daily) 2
• Patients with renal impairment: Consider dose reduction (half the normal dose) 2
• Elderly patients: Higher risk of adverse effects; consider lower doses 2

Discontinuation Considerations

If discontinuation of bupropion is necessary while on prednisone:

• Implement gradual tapering to minimize withdrawal symptoms
• For standard doses (300mg XL or 150mg SR twice daily):
  • Reduce to 150mg once daily for 1-2 weeks before complete discontinuation 2
• For patients experiencing significant withdrawal symptoms:
  • Consider slower taper (10% reduction per month)
  • Consider switching to SR formulation for more flexible dosing during taper 2

Conclusion

While there is no documented major direct interaction between prednisone and bupropion, the theoretical risk of lowered seizure threshold warrants caution, particularly in patients with predisposing factors. Careful dosing, monitoring, and awareness of risk factors can help minimize potential adverse effects when these medications are used concurrently.