What alternative antiepileptic medication can be used for a patient with seizures who is currently taking Wellbutrin (bupropion) 150mg twice daily (bid) and Celexa (citalopram) 20mg once daily (qd) with no therapeutic effect?

Critical Medication Safety Issue: Discontinue Wellbutrin Immediately

Wellbutrin (bupropion) is absolutely contraindicated in patients with seizure disorders and must be stopped immediately, as it significantly lowers the seizure threshold and can provoke seizures. The patient's current antidepressant regimen needs complete restructuring with seizure-safe alternatives.

Immediate Actions Required

1. Stop Wellbutrin Now

• Bupropion is a known seizure-provoking agent that lowers seizure threshold in a dose-dependent manner
• Continuing this medication while treating seizures is counterproductive and dangerous
• The 150mg BID dosing (300mg total daily) substantially increases seizure risk

2. Initiate Appropriate Antiepileptic Drug (AED) Therapy

For new-onset or uncontrolled seizures, first-line AED options include:

• Levetiracetam: 30-40 mg/kg IV loading dose (maximum 2,500 mg), then maintenance dosing of 15-30 mg/kg every 12 hours - offers favorable safety profile with no significant cardiovascular effects and efficacy of 73% 1, 2

• Valproate: 30 mg/kg IV at 5-6 mg/kg/min shows superior efficacy (88%) with significantly lower risk of hypotension (0% vs 12% with phenytoin) 1, 2

• Lamotrigine or oxcarbazepine: Considered first-line for focal epilepsy in outpatient settings 3

3. Address Depression with Seizure-Safe Alternatives

Celexa (citalopram) can be continued as SSRIs are generally safe in epilepsy, though the dose may need optimization since it's currently ineffective at 20mg daily.

Consider these depression management strategies:

• Increase citalopram to 40mg daily (maximum FDA-approved dose) if tolerated
• Alternative SSRIs (sertraline, escitalopram) have similar safety profiles in epilepsy
• Avoid other antidepressants that lower seizure threshold (tricyclics, other bupropion formulations, maprotiline)

Treatment Algorithm Based on Seizure Presentation

If Patient Presents with Active Seizures or Status Epilepticus:

1. First-line: Benzodiazepines (lorazepam 0.1 mg/kg IV, maximum 2 mg) 2

2. Second-line (if seizures continue after 5-10 minutes):

   • Valproate 30 mg/kg IV at 5-6 mg/kg/min (Level B recommendation) 1, 2
   • OR Levetiracetam 30-40 mg/kg IV (Level C recommendation) 1, 2
   • OR Phenytoin/fosphenytoin 20 mg/kg IV (requires continuous ECG/BP monitoring) 1, 2

3. Refractory cases: Propofol 2 mg/kg bolus followed by 3-7 mg/kg/hour infusion 1, 2

If Patient Has Controlled Seizures but Needs Maintenance Therapy:

• Start levetiracetam 500mg BID, titrate to 1000-1500mg BID as needed 3
• OR lamotrigine (requires slow titration: start 25mg daily, increase gradually over weeks to avoid serious rash) 4
• OR oxcarbazepine 300mg BID, titrate to effect 3

Critical Monitoring Points

After discontinuing Wellbutrin:

• Monitor for withdrawal symptoms (irritability, mood changes) over 1-2 weeks
• Seizure frequency may improve within days of stopping the proconvulsant medication
• Assess depression symptoms and adjust SSRI accordingly

With new AED initiation:

• Levetiracetam: Monitor for behavioral changes, mood disturbances (avoid if psychiatric history) 3
• Valproate: Check baseline liver function, platelets; monitor for thrombocytopenia and hepatotoxicity 4
• Lamotrigine: Watch closely for rash in first 8 weeks (can be life-threatening Stevens-Johnson syndrome) 4

Common Pitfalls to Avoid

• Never continue bupropion in any patient with seizures - this is an absolute contraindication
• Avoid delays in progressing to second-line AEDs if seizures continue after 5-10 minutes 2
• Do not use enzyme-inducing AEDs (carbamazepine, phenytoin) as first-line unless necessary, as they cause multiple drug interactions and metabolic complications 3
• Monitor for respiratory depression with benzodiazepines and barbiturates 2

Expected Outcomes

Approximately 60-70% of patients with newly treated epilepsy achieve seizure freedom with appropriate AED therapy 3, 5. Removing the seizure-provoking agent (Wellbutrin) while simultaneously initiating appropriate AED therapy should significantly improve seizure control in this patient.