Can bupropion be held for a short course of linzolid?

Can Bupropion Be Held for a Short Course of Linezolid?

Yes, bupropion must be stopped promptly before initiating linezolid, and it should remain discontinued until 24 hours after the last dose of linezolid is administered. 1

Critical Drug Interaction

Linezolid is a reversible monoamine oxidase inhibitor (MAOI), and the combination with bupropion creates a significant risk of hypertensive reactions due to increased norepinephrine and dopamine activity. 1

Specific Management Protocol

When Linezolid Treatment is Planned:

• Stop bupropion immediately if linezolid treatment is deemed necessary and the benefits outweigh the risks of hypertensive reactions. 1
• Do not start bupropion in any patient currently being treated with linezolid. 1
• Monitor the patient for 2 weeks OR until 24 hours after the last dose of linezolid, whichever comes first. 1

Resuming Bupropion After Linezolid:

• Wait a minimum of 24 hours after the last dose of linezolid before restarting bupropion. 1
• This 24-hour washout period is sufficient for linezolid (a reversible MAOI) to clear, unlike traditional MAOIs which require 14 days. 1

Clinical Decision-Making Algorithm

If the patient requires urgent linezolid treatment:

1. Assess whether non-pharmacological alternatives exist for the psychiatric condition (including hospitalization if needed). 1
2. If linezolid is judged essential and no acceptable alternatives exist, discontinue bupropion promptly. 1
3. Initiate linezolid treatment with close monitoring for hypertensive reactions. 1
4. Complete the linezolid course (typically 10-14 days for most infections).
5. Wait 24 hours after the final linezolid dose before restarting bupropion. 1

Important Caveats

• The risk profile for non-intravenous methylene blue (another reversible MAOI) with bupropion is less clear, but similar precautions should be considered. 1
• Unlike traditional MAOIs that require 14 days between discontinuation and bupropion initiation, linezolid only requires 24 hours due to its reversible mechanism. 1
• When restarting bupropion after a brief interruption, use the patient's previous maintenance dose rather than re-titrating, unless the interruption was prolonged or the patient experienced adverse effects previously. 2

Monitoring During Transition

• Watch for signs of hypertensive crisis during any overlap period: severe headache, chest pain, tachycardia, visual changes, or altered mental status. 1
• Monitor blood pressure closely if there is any question about timing or adherence. 1
• Be aware that abrupt bupropion discontinuation does not typically cause withdrawal symptoms, making it safe to stop promptly when needed. 2