Wellbutrin and Tinnitus
Yes, Wellbutrin (bupropion) can cause tinnitus as a documented adverse effect, occurring in 2-6% of patients in clinical trials, with the incidence increasing at higher doses. 1
Evidence from FDA Drug Labeling
The FDA-approved prescribing information for bupropion explicitly lists tinnitus as a known adverse reaction:
- In major depressive disorder trials: Tinnitus occurred in 2% of placebo patients, 6% of patients taking 300 mg/day, and 6% of patients taking 400 mg/day of bupropion sustained-release 1
- In seasonal affective disorder trials: Tinnitus occurred in <1% of placebo patients versus 3% of patients taking bupropion extended-release 1
- Postmarketing reports: Tinnitus has been reported as an adverse reaction during post-approval use of bupropion 1
Clinical Significance and Dose Relationship
The risk of tinnitus appears dose-related, with 300 mg/day and 400 mg/day showing 6% incidence compared to 2% with placebo. 1 This represents a 3-fold increased risk compared to placebo, making it a clinically meaningful adverse effect that should be discussed with patients before initiating treatment.
Mechanism and Context
While the exact mechanism is not fully elucidated, antidepressants including bupropion can affect auditory processing through complex interactions between serotonergic, glutamatergic, and GABAergic neurotransmitter systems in the cochlea and central auditory pathways 2, 3. Bupropion's dopaminergic and noradrenergic effects may similarly influence auditory filtering mechanisms.
Clinical Management Recommendations
If a patient develops tinnitus after starting bupropion:
- Perform otoscopy to exclude cerumen impaction, middle ear infection, or other treatable otologic causes 4, 5
- Determine if the tinnitus is unilateral or bilateral, pulsatile or non-pulsatile 4, 5
- For bilateral, non-pulsatile tinnitus without neurologic deficits: Imaging is not indicated 4
- For unilateral tinnitus: Consider MRI of internal auditory canals to exclude vestibular schwannoma 4
- Consider dose reduction or discontinuation of bupropion if tinnitus is bothersome and no other cause is identified 1
- Monitor for resolution after discontinuation, as drug-induced tinnitus typically resolves when the offending agent is stopped 3
Important Caveats
Do not automatically attribute tinnitus to bupropion without excluding other causes, particularly in patients with:
- Asymmetric hearing loss (requires audiometry and possible MRI) 4, 5
- Pulsatile tinnitus (requires CT or CTA to evaluate vascular abnormalities) 4
- Concomitant use of other ototoxic medications (salicylates, aminoglycosides) 4, 3
- Recent medication changes, including benzodiazepine withdrawal 6
The presence of tinnitus does not automatically require stopping bupropion if the symptom is mild and the medication is providing significant benefit for depression or ADHD. However, patients should be counseled about this potential side effect before starting treatment 1.