Treatment for Bupropion Toxicity
The treatment for bupropion toxicity requires aggressive supportive care with particular attention to seizure management, cardiac monitoring, and consideration of extracorporeal membrane oxygenation (ECMO) for severe cardiotoxicity that is unresponsive to conventional measures.
Initial Management
- Airway, Breathing, Circulation (ABC): Secure airway early, especially if seizures or altered mental status are present
- Decontamination:
- Activated charcoal if within 1-2 hours of ingestion and patient has intact airway
- Multiple-dose activated charcoal may be beneficial due to bupropion's extended-release formulations
Seizure Management
- First-line: Benzodiazepines (IV lorazepam 2-4 mg or diazepam 5-10 mg)
- Second-line: If seizures persist, consider:
- Propofol
- Phenobarbital
- Intubation and sedation for refractory seizures
- EEG monitoring: Consider for patients with persistent altered mental status to detect non-convulsive seizures 1
Cardiovascular Management
- Continuous cardiac monitoring: QRS widening and QTc prolongation are common
- Sodium bicarbonate: For QRS widening >120 ms (though evidence suggests limited effectiveness in bupropion-specific toxicity) 1
- Magnesium sulfate: For QTc prolongation
- Lidocaine: Consider for ventricular dysrhythmias 2
- Vasopressors: For hypotension unresponsive to fluid resuscitation
- ECMO consideration: For severe cardiotoxicity with cardiogenic shock or refractory dysrhythmias 1, 2
Important Clinical Pearls
- Delayed toxicity: Cardiac decompensation can occur 16-32 hours after ingestion, particularly with extended-release formulations 1
- Atypical presentation: Early resolution of tachycardia may falsely suggest clinical improvement but can actually indicate worsening cardiotoxicity 1
- Prolonged monitoring: Continue cardiac monitoring for at least 24-48 hours after ingestion of extended-release formulations
- Neurological assessment: Fixed and dilated pupils may not indicate poor neurological prognosis; full recovery is possible with appropriate supportive care 2
Special Considerations
- Co-ingestions: Other medications (especially olanzapine) may delay or exacerbate toxicity 1, 3
- Pediatric patients: Lower threshold for aggressive management as seizures and cardiovascular collapse can occur rapidly 4
- Hydroxybupropion levels: If available, can help predict toxicity severity and correlate with ECG changes 2
Monitoring Parameters
- Vital signs: Continuous monitoring with special attention to heart rate and blood pressure
- ECG: Serial ECGs to monitor for QRS widening and QTc prolongation
- Laboratory studies: Electrolytes, renal function, hepatic function, and drug levels if available
- Neurological status: Frequent assessments for seizure activity or altered mental status
Early recognition of severe toxicity and prompt escalation to advanced cardiac life support measures, including ECMO when indicated, are critical for successful management of severe bupropion toxicity.