Perioperative Management of Wellbutrin (Bupropion)
Continue Wellbutrin (bupropion) through the perioperative period without interruption. Stopping antidepressants before surgery increases the risk of depression relapse, delirium, and confusion without reducing anesthetic complications 1.
Evidence-Based Recommendation
The strongest evidence comes from a randomized controlled trial demonstrating that patients who discontinued antidepressants 72 hours before surgery experienced significantly worse outcomes 1:
- 20% developed worsening depressive symptoms (vs. 5% who continued therapy, p=0.04) 1
- 30% experienced perioperative delirium or confusion (vs. 13% who continued therapy, p=0.05) 1
- No increase in hypotension or arrhythmias occurred in patients who continued antidepressants 1
Key Clinical Points
Preoperative Management
- Do not discontinue bupropion before elective or emergent surgery 1
- Administer the patient's usual morning dose on the day of surgery with a sip of water 1
- Document continuation in the anesthetic record 2
Intraoperative Considerations
- Bupropion does not increase the risk of hemodynamic instability during anesthesia 1
- Standard anesthetic techniques are appropriate 1
- Monitor for typical cardiovascular responses to anesthesia as you would in any patient 2
Postoperative Management
- Resume bupropion as soon as the patient can tolerate oral medications 1
- If NPO status is prolonged beyond 24 hours, consider alternative routes or temporary substitution after consulting psychiatry 3
- Monitor for mood changes or withdrawal symptoms if medication is inadvertently held 4
Critical Warnings
Abrupt discontinuation of bupropion can precipitate withdrawal symptoms including irritability, anxiety, insomnia, headache, and generalized pain 4. These symptoms complicate postoperative recovery and pain assessment 4.
Withdrawal from antidepressants with short half-lives may cause cardiovascular instability, particularly hypotension requiring vasopressor support 3. While this has been documented primarily with SSRIs and mirtazapine, the principle applies to maintaining all chronic antidepressant therapy 3.
Common Pitfalls to Avoid
- Do not reflexively hold all psychiatric medications based on outdated perioperative protocols 1
- Do not confuse bupropion (Wellbutrin) with buprenorphine (Suboxone/Subutex), which requires entirely different perioperative management 5, 6
- Do not assume withdrawal symptoms are simply postoperative pain if bupropion is inadvertently discontinued 4
Special Consideration: Naltrexone-Bupropion Combination (Contrave)
If the patient is taking naltrexone-bupropion combination therapy for weight management, this presents a unique challenge due to the opioid antagonist component 7:
- The naltrexone component blocks opioid analgesia and requires discontinuation 72 hours before surgery 7
- Plan aggressive multimodal analgesia with regional techniques, NSAIDs, acetaminophen, and ketamine 7
- Expect inadequate pain control with standard opioid doses even after naltrexone discontinuation 7
- Coordinate with pain management and the prescribing physician preoperatively 7