What are the contraindications for Bupropion (Wellbutrin) XL 450 mg?

Contraindications for Bupropion XL 450 mg

Bupropion XL 450 mg is absolutely contraindicated in patients with seizure disorders, bulimia or anorexia nervosa, patients undergoing abrupt discontinuation of alcohol/benzodiazepines/barbiturates/antiepileptic drugs, patients using MAOIs, and those with hypersensitivity to bupropion. 1

Absolute Contraindications

1. Seizure Disorder

   • Bupropion lowers seizure threshold and is strictly contraindicated in patients with any seizure disorder 1
   • Risk of seizures increases with doses above 450 mg/day 2, 3

2. Eating Disorders

   • Current or prior diagnosis of bulimia or anorexia nervosa
   • Higher incidence of seizures observed in these patients 1

3. Substance Withdrawal

   • Patients undergoing abrupt discontinuation of:
     • Alcohol
     • Benzodiazepines
     • Barbiturates
     • Antiepileptic drugs 1

4. MAOI Use

   • Concomitant use with MAOIs (intended to treat psychiatric disorders)
   • Use within 14 days of discontinuing an MAOI
   • Use of bupropion within 14 days before starting an MAOI
   • Increased risk of hypertensive reactions 4, 1
   • Applies to both irreversible MAOIs (e.g., phenelzine) and reversible MAOIs (e.g., linezolid, methylene blue) 4

5. Hypersensitivity

   • Known hypersensitivity to bupropion or any ingredients in the formulation
   • Risk of anaphylactoid/anaphylactic reactions and Stevens-Johnson syndrome 1

Relative Contraindications/Cautions

1. Hepatic Impairment

   • In moderate to severe hepatic impairment (Child-Pugh score 7-15), maximum dose is 150 mg every other day
   • In mild hepatic impairment (Child-Pugh score 5-6), consider reducing dose/frequency 1

2. Renal Impairment

   • Consider reducing dose/frequency in patients with GFR <90 mL/min 1

3. Risk Factors for Seizures

   • History of head trauma
   • CNS tumors
   • Medications that lower seizure threshold
   • Excessive use of alcohol or sedatives 5, 6

4. Cardiovascular Conditions

   • Uncontrolled hypertension 7
   • Cardiac arrhythmias 7

5. Psychiatric Conditions

   • Severe depression with suicidal ideation (requires close monitoring) 1
   • Bipolar disorder (risk of triggering mania) 7

6. Other Conditions

   • Closed-angle glaucoma 7
   • Patients taking tamoxifen (drug interaction) 7

Special Populations

1. Adolescents and Young Adults

   • Increased risk of suicidal thinking and behavior
   • Close monitoring required during early treatment phase 1

2. Elderly

   • May require lower doses due to decreased clearance
   • Higher risk of adverse effects

Monitoring Recommendations

1. Before Starting Treatment

   • Screen for seizure risk factors
   • Assess for eating disorders
   • Review all medications for potential interactions
   • Evaluate cardiovascular status including blood pressure

2. During Treatment

   • Monitor for emergence of suicidal thoughts, particularly in young adults
   • Watch for signs of seizure activity
   • Monitor blood pressure, especially in patients with hypertension
   • Assess for neuropsychiatric symptoms (anxiety, insomnia, agitation)

Common Pitfalls to Avoid

1. Exceeding Maximum Dose

   • Never exceed 450 mg/day as seizure risk increases significantly 2

2. Inadequate Screening

   • Failing to screen for history of seizures or eating disorders

3. Medication Interactions

   • Not checking for MAOI use within the past 14 days
   • Not considering interactions with other medications metabolized by CYP2D6 8

4. Abrupt Discontinuation

   • Tapering is recommended when discontinuing bupropion XL, especially at higher doses 7

By carefully screening for these contraindications before prescribing bupropion XL 450 mg, clinicians can significantly reduce the risk of serious adverse events and improve patient safety.