Bupropion Contraindication in Eating Disorders
Bupropion is contraindicated in patients with eating disorders such as anorexia nervosa or bulimia nervosa due to a significantly increased risk of seizures in this population.
Mechanism of Seizure Risk
The contraindication of bupropion in eating disorders is primarily based on safety concerns:
- Bupropion lowers the seizure threshold, with seizure incidence of approximately 0.1% at therapeutic doses in the general population 1
- In patients with bulimia nervosa, the seizure risk is dramatically higher, as demonstrated in clinical trials 2
- A multicenter controlled trial of bupropion in bulimia reported four grand mal seizures among 55 subjects receiving bupropion, a seizure frequency far higher than observed in other populations 2
Official Contraindication Status
The FDA drug label explicitly states:
- "Bupropion hydrochloride extended-release tablets (XL) are contraindicated in patients with a current or prior diagnosis of bulimia or anorexia nervosa as a higher incidence of seizures was observed in such patients treated with bupropion" 3
Physiological Factors Contributing to Increased Risk
Several factors in eating disorders increase seizure susceptibility with bupropion:
- Electrolyte abnormalities from purging behaviors (vomiting, laxative abuse)
- Nutritional deficiencies affecting neurological function
- Low body weight altering drug metabolism and clearance
- Fluid shifts and dehydration affecting drug concentration
- Compromised blood-brain barrier function
Documented Cases of Abuse and Complications
The literature documents concerning patterns of bupropion misuse in eating disorder patients:
- Case reports describe patients with bulimia nervosa abusing bupropion at doses reaching 3,000-4,500 mg/day to control binge eating and reduce appetite 4
- These high doses led to severe adverse effects including headaches, tachycardia, anxiety, insomnia, and ultimately grand mal seizures 4
- Even at therapeutic doses, bupropion's stimulant, euphoriant, and anorexic effects contribute to its potential for abuse among eating disorder patients 4
Alternative Treatment Options
For patients with eating disorders who require treatment for depression or smoking cessation:
- SSRIs (such as fluoxetine or sertraline) are preferred first-line agents for patients with comorbid eating disorders and depression 1
- SSRIs have demonstrated efficacy for both depression and bulimia nervosa without the seizure risk
- For smoking cessation, nicotine replacement therapy is a safer alternative for patients with eating disorders 1
Clinical Implications
Healthcare providers should:
- Screen for eating disorder history before prescribing bupropion
- Consider bupropion as a potential cause when patients with eating disorders present with seizures
- Be aware that patients may not disclose eating disorder behaviors when seeking bupropion for its appetite-suppressing effects
- Recognize that the contraindication applies even when the eating disorder appears to be in remission
Conclusion
The contraindication of bupropion in eating disorders is well-established and based on substantial evidence of increased seizure risk. This contraindication should be strictly observed to prevent potentially life-threatening complications in this vulnerable population.