Does Wellbutrin Increase Fall Risk in Hypertensive Patients?
No, bupropion (Wellbutrin) does not significantly increase fall risk in patients being treated for hypertension and may actually be safer than alternative antidepressants in this population. 1
Cardiovascular Safety Profile of Bupropion
Bupropion has a distinctly favorable cardiovascular profile compared to other antidepressants, particularly regarding orthostatic hypotension—the primary medication-related mechanism for falls in elderly patients:
Bupropion causes minimal orthostatic hypotension, with a low rate observed even in patients with preexisting cardiovascular disease, making it fundamentally different from tricyclic antidepressants which are strongly associated with falls 1
In patients with heart disease, bupropion actually increased supine blood pressure rather than causing hypotension, though this required monitoring in 2 patients who developed exacerbated hypertension 1
Bupropion had no effect on pulse rate and did not cause significant conduction complications or exacerbate ventricular arrhythmias in cardiac patients 1
Fall Risk Context in Hypertensive Patients
Understanding the broader fall risk landscape is critical for your patient population:
Medications That Actually Increase Fall Risk
The medications you should be concerned about for falls in hypertensive patients include:
Benzodiazepines and vestibular suppressants are significant independent risk factors for falls, particularly in elderly patients 2
Tricyclic antidepressants (like amitriptyline) should be avoided due to substantial orthostatic hypotension risk in elderly patients 3
Alpha-1 blockers (doxazosin, prazosin, terazosin) are strongly associated with orthostatic hypotension 4
Antipsychotic agents including quetiapine precipitate syncope and orthostatic hypotension 5, 3
Stroke and CKD Context for Your Patient
Your patient's history of embolic stroke, NSTEMI, and stage 3 CKD creates additional considerations:
CKD itself increases stroke risk, with patients having more than 3 times the standardized mortality ratio for stroke compared to those without CKD 6
Stroke survivors have fall rates as high as 50% in community-dwelling populations, with poor upper extremity function and near-falls in hospital being the best predictors of repeated falls 2
The combination of trunk instability, decreased lower extremity function, and inability to use the hemiparetic upper extremity to prevent falls increases risk substantially 2
Specific Cautions with Bupropion
While bupropion doesn't increase fall risk through orthostatic hypotension, be aware of these rare neurological effects:
One case report documented symptoms mimicking transient ischemic attacks (paresthesia, dizziness, tinnitus, confusion, gait impairment) in a 67-year-old man taking bupropion for smoking cessation, which resolved upon discontinuation 7
This represents an extremely rare idiosyncratic reaction rather than a class effect, but given your patient's embolic stroke history, monitor for any new neurological symptoms 7
Practical Management Algorithm
For your patient with hypertension, stroke history, NSTEMI, and stage 3 CKD:
Bupropion is acceptable from a fall-risk perspective and superior to tricyclic antidepressants 1
Monitor blood pressure closely as bupropion may increase supine BP, which could require adjustment of antihypertensive medications 1
Assess current medication regimen for other fall-risk medications: benzodiazepines, alpha-blockers, antipsychotics, or tricyclics that should be discontinued or dose-reduced 2, 5, 3
Measure orthostatic vital signs before starting therapy: BP after 5 minutes lying/sitting, then at 1 and 3 minutes after standing (orthostatic hypotension defined as ≥20 mmHg systolic or ≥10 mmHg diastolic drop) 5, 3
Screen for other fall risk factors including balance problems, lower extremity weakness from prior stroke, and polypharmacy effects 2
Monitor for rare neurological symptoms (new-onset dizziness, gait impairment, confusion) given stroke history, though this is not a contraindication 7
Key Pitfall to Avoid
Do not assume all antidepressants have equivalent fall risk. The critical error is conflating bupropion with tricyclic antidepressants or other medications that cause orthostatic hypotension. Bupropion's mechanism of action (norepinephrine-dopamine reuptake inhibition) does not produce the alpha-adrenergic blockade responsible for orthostatic hypotension seen with tricyclics 1. This makes it a preferred choice in patients where fall risk from orthostatic hypotension is a concern.