Can a patient with chronic pain and depression, taking hydromorphone (Dilaudid) 1mg three times a day and recently started on Wellbutrin (bupropion) 2 months ago, experience worsening symptoms of sweating and irritability due to the addition of Wellbutrin?

Wellbutrin Can Worsen Sweating and Irritability in This Patient

Yes, Wellbutrin (bupropion) is likely contributing to or worsening the sweating and irritability symptoms in this patient, and these are well-documented adverse effects of the medication that may be dose-related. 1

Direct Adverse Effects of Wellbutrin

• Sweating is a recognized adverse effect of bupropion, particularly at higher doses, and is listed among typical side effects that can include sweating, tremors, nervousness, and insomnia 1
• The patient is taking bupropion 150 mg twice daily (assuming standard dosing), and adverse effects including irritability and sweating can be dose-dependent 1
• Bupropion is classified as an "activating" antidepressant, meaning it tends to increase energy and arousal, which can manifest as irritability, agitation, and nervousness in susceptible patients 1

Hydromorphone's Contribution to Sweating

• Hydromorphone itself commonly causes sweating as a direct adverse effect, listed among the most common reactions including lightheadedness, dizziness, sedation, nausea, vomiting, sweating, and flushing 2
• The FDA label specifically notes that sweating, flushing, and hyperhidrosis are documented adverse reactions to hydromorphone 2
• When hydromorphone and bupropion are combined, the sweating effects may be additive, creating more pronounced symptoms than either medication alone

Irritability: Multiple Contributing Factors

• Irritability can result from bupropion's activating properties, particularly when the dose was increased from 150 mg once daily to twice daily 1
• Hydromorphone can cause mood alterations, agitation, nervousness, and anxiety as documented adverse effects 2
• Depression itself, which is being treated with bupropion, commonly presents with irritability as a core symptom, and inadequate treatment response could manifest as persistent irritability 1

Clinical Management Strategy

• Consider reducing bupropion to 150 mg once daily if the patient was recently increased to twice-daily dosing, as a dose-response relationship exists for adverse effects 1, 3
• Assess whether the irritability represents inadequate depression treatment versus medication side effects by evaluating other depressive symptoms using the PHQ-9 screening tool 1
• If sweating is intolerable and primarily medication-related, switching to a less activating antidepressant such as mirtazapine (which promotes sleep and has a different side effect profile) or an SSRI like sertraline (which has less effect on other medication metabolism) may be appropriate 1

Important Timing Consideration

• The patient started Wellbutrin 2 months ago, which is sufficient time for steady-state levels to be reached and for adverse effects to manifest fully 1
• If symptoms began or worsened around the time of bupropion initiation or dose increase, this temporal relationship strongly suggests medication causality 3

Screening for Underlying Issues

• Screen for depression severity using the two-question screen: "During the past 2 weeks have you often been bothered by feeling down, depressed, or hopeless?" and "During the past 2 weeks have you been bothered by little interest or pleasure in doing things?" 1
• If either answer is affirmative, follow up with PHQ-9 to quantify depression severity, as a score ≥10 warrants psychiatric evaluation and may indicate that irritability reflects undertreated depression rather than medication side effects 1

Pitfalls to Avoid

• Do not assume all symptoms are from the opioid alone—bupropion has a distinct adverse effect profile that includes the exact symptoms this patient is experiencing 1
• Do not abruptly discontinue bupropion without tapering, as withdrawal symptoms can occur; taper over 10-14 days if discontinuation is planned 1
• Do not overlook the possibility that irritability represents worsening depression requiring dose optimization rather than reduction 1