Can I add Wellbutrin (bupropion) 150mg to a bipolar patient's regimen of Lamictal (lamotrigine) 100mg?

Adding Wellbutrin to a Bipolar Patient on Lamictal

Adding Wellbutrin (bupropion) 150mg to a bipolar patient on Lamictal (lamotrigine) 100mg is not recommended due to the significant risk of triggering a manic episode, even when the patient is on a mood stabilizer.

Risk Assessment for Adding Bupropion

Risks of Antidepressants in Bipolar Disorder

• Antidepressants, including bupropion, can destabilize mood or precipitate manic episodes in bipolar patients 1
• Even when patients are on mood stabilizers like lamotrigine, the risk of switching to mania remains significant
• In one study, 6 out of 11 bipolar patients experienced manic or hypomanic episodes requiring discontinuation of bupropion, despite being stabilized on mood stabilizers 2

Specific Concerns with Bupropion

• While historically considered to have a lower risk of causing manic switches compared to other antidepressants, evidence shows bupropion can still trigger mania 2
• The risk may be dose-related, with higher doses (>450mg/day) potentially carrying greater risk 3
• FDA labeling specifically warns that bupropion can precipitate a manic, mixed, or hypomanic episode, with increased risk in patients with bipolar disorder 4

Current Treatment Considerations

Lamotrigine's Role in Bipolar Disorder

• Lamotrigine 100mg is likely being used as a mood stabilizer
• Lamotrigine is FDA-approved for maintenance treatment in bipolar disorder 1
• Lamotrigine is particularly effective at preventing depressive episodes but has limited efficacy for preventing manic episodes 5
• The current dose of 100mg may be suboptimal for full mood stabilization (typical target dose is 200mg/day) 5

Alternative Approaches for Bipolar Depression

If the patient is experiencing depressive symptoms:

1. Optimize lamotrigine first:

   • Consider increasing lamotrigine to its target dose of 200mg/day before adding another medication 5
   • Lamotrigine has demonstrated efficacy specifically for bipolar depression 5

2. Consider FDA-approved options for bipolar depression:

   • The combination of olanzapine and fluoxetine is FDA-approved for bipolar depression 1

3. If an antidepressant is deemed necessary:

   • Ensure adequate mood stabilization first
   • Select an SSRI rather than bupropion, as SSRIs are preferred when an antidepressant must be used in bipolar disorder 1
   • Always use antidepressants in combination with a mood stabilizer 1

Monitoring and Safety Considerations

If despite these recommendations, a trial of bupropion is attempted:

• Start at a low dose (150mg/day) and monitor closely for signs of mania or hypomania
• Watch for symptoms such as decreased need for sleep, increased energy, racing thoughts, grandiosity, or impulsive behavior
• Be prepared to discontinue bupropion immediately if signs of mood destabilization occur
• Consider adding a second mood stabilizer (such as lithium or valproate) before adding bupropion, as these may provide stronger antimanic protection 1

Common Pitfalls to Avoid

• Underestimating switch risk: Even with mood stabilizers, antidepressants can trigger mania in bipolar patients
• Inadequate mood stabilization: Ensure the mood stabilizer dose is optimized before adding antidepressants
• Prolonged antidepressant use: If bupropion is used, it should be discontinued after acute depression resolves to minimize switch risk
• Ignoring early warning signs: Subtle changes in sleep, energy, or thinking patterns may indicate an impending mood switch

In conclusion, adding bupropion to lamotrigine in a bipolar patient carries significant risks that likely outweigh potential benefits, especially when safer alternatives exist for managing bipolar depression.