From the FDA Drug Label
Advise the patient to read the FDA-approved patient labeling (Medication Guide) Suicidal Thoughts and Behaviors Instruct patients, their families, and/or their caregivers to be alert to the emergence of anxiety, agitation, panic attacks, insomnia, irritability, hostility, aggressiveness, impulsivity, akathisia (psychomotor restlessness), hypomania, mania, other unusual changes in behavior, worsening of depression, and suicidal ideation, especially early during antidepressant treatment and when the dose is adjusted up or down. The next step when a patient becomes hypomanic after increasing Wellbutrin is to report such symptoms to the patient’s prescriber or health professional, especially if they are severe, abrupt in onset, or were not part of the patient’s presenting symptoms, as they may be associated with an increased risk for suicidal thinking and behavior and indicate a need for very close monitoring and possibly changes in the medication 1.
From the Research
When a patient becomes hypomanic after increasing Wellbutrin (bupropion), the first step is to reduce the dose back to the previous well-tolerated level or discontinue it entirely, depending on symptom severity. Contact the patient promptly to assess the extent of hypomanic symptoms, including sleep disturbance, increased energy, racing thoughts, and impulsivity. If symptoms are mild, reducing the Wellbutrin dose may be sufficient, while monitoring closely over the next few days. For moderate to severe hypomania, consider temporarily adding a mood stabilizer such as valproate (500-1000 mg/day) or an atypical antipsychotic like quetiapine (50-300 mg/day) while decreasing or stopping Wellbutrin, as suggested by studies such as 2. Schedule a follow-up within 1-2 weeks to reassess. This reaction occurs because Wellbutrin enhances dopamine and norepinephrine activity, which can trigger mood elevation in susceptible individuals, particularly those with underlying bipolar disorder, as noted in case reports like 3. Document this reaction in the patient's chart and consider alternative antidepressant options with lower switch risk, such as SSRIs with mood stabilizer coverage, if depression treatment is still needed, taking into account the findings from studies like 4 that compare the risks of different antidepressants in bipolar depression. Key considerations include:
- The risk of switch to hypomania or mania with antidepressant use in bipolar disorder, as discussed in 5 and 4.
- The importance of mood stabilizer coverage when using antidepressants in bipolar depression, highlighted in 5.
- The potential benefits and risks of specific medications like bupropion, as explored in studies such as 6.