Is there a way to reverse a Wellbutrin (bupropion) overdose?

Management of Bupropion (Wellbutrin) Overdose

There is no specific antidote for bupropion overdose. Management consists of supportive care, including close medical supervision and monitoring, while considering the possibility of multiple drug overdose. 1

Clinical Presentation of Bupropion Overdose

• Seizures occur in approximately one-third of all bupropion overdose cases 1
• Other serious reactions include hallucinations, loss of consciousness, mental status changes, sinus tachycardia, ECG changes (conduction disturbances or arrhythmias), clonus, myoclonus, and hyperreflexia 1
• Fever, muscle rigidity, rhabdomyolysis, hypotension, stupor, coma, and respiratory failure can occur, especially when bupropion is part of multiple drug overdoses 1
• Death has been reported in patients ingesting large doses, typically preceded by multiple uncontrolled seizures, bradycardia, cardiac failure, and cardiac arrest 1

Initial Management

• Immediately contact a Certified Poison Control Center for up-to-date guidance (1-800-222-1222 in the US) 1
• Provide supportive care with close medical supervision and monitoring 1
• Focus on airway management, support of breathing, and treatment of hypotension, dysrhythmias, or cardiac arrest 2
• Most cases require ICU admission due to the risk of seizures and cardiac complications 3

Specific Interventions

• Seizure Management: GABA-A agonists (benzodiazepines) are commonly used to manage seizures associated with bupropion overdose 3
• Cardiac Monitoring: Continuous cardiac monitoring is essential due to the risk of arrhythmias and QRS prolongation 3
• Respiratory Support: Approximately one-third of severe cases require intubation and mechanical ventilation 3

Important Considerations

• Bupropion overdose can cause delayed and prolonged symptoms, particularly with sustained-release formulations 4
• Seizures may occur with delayed onset (median 7 hours, range 2-21.5 hours in one study) 5
• Formation of a pharmacobezoar (clumped undigested tablets) in the stomach has been reported in fatal cases, which can lead to prolonged drug release and toxicity 6
• The risk of seizures appears to be dose-related, with moderate outcomes more likely at higher doses (average 1250 mg vs. 694 mg for minor outcomes) 5

Monitoring Duration

• Extended monitoring (at least 24 hours) is recommended due to the risk of delayed seizures, particularly with sustained-release formulations 4
• Patients typically require 1-2 days in the ED or ICU for proper monitoring and management 3

Prognosis

• While most patients recover without sequelae, deaths have been reported with large overdoses 1
• The median reported dose in patients who experienced seizures in one study was 900 mg (range 600-3000 mg) 5

Common Pitfalls to Avoid

• Underestimating the duration of monitoring needed, especially with sustained-release formulations 4
• Failing to recognize early warning signs such as "jittery"/anxious/agitated symptoms, which were present in 83% of patients who later developed seizures 5
• Not considering the possibility of a pharmacobezoar in massive overdoses, which can lead to prolonged toxicity 6

Remember that unlike opioid or benzodiazepine overdoses, there is no specific reversal agent for bupropion toxicity, making supportive care and close monitoring the cornerstone of management 1.