Abstract
Bupropion is an atypical antidepressant with a unique aminoketone structure similar to amphetamines. A narrow therapeutic margin is evident from observational studies that show seizure activity with doses of 400-600 mg or higher. A 38-year old woman took an overdose of 6 grams of bupropion with 110 grams of alcohol. She presented to the Emergency Department with agitation, visual hallucinations and myoclonus of the upper limbs; eyes spontaneously open with isochoric and light reactive pupils with horizontal nystagmus; afebrile, normotensive (121/63 mm Hg) and tachycardic (120 beats/minute). The electrocardiogram revealed a sinus tachycardia with prolonged QT interval (QT/QTc: 0.46/ 0.537) and a QRS complex length in the upper limit of normal. Arterial blood gases revealed metabolic acidosis (pH = 7.16) with increased anion-gap (value=18). She developed mal epilepticus needing thiopental induced coma and Intensive Care Unit (ICU) admission. She suffered prolonged symptoms including seizures before fully recovering. The narrow therapeutic range and the increasing use in the treatment of smoking cessation boosted the number of intentional and unintentional poisoning by this drug. Previous reports of Case Report Mendonca et al.; IJMPCR, 3(2): 38-43, 2015; Article no.IJMPCR.2015.033 39 bupropion overdose almost all involve the immediate release formulation. There are some reports of overdose with sustained-release formulation, but there is limited information on its spectrum of toxicity.
Highlights
Intentional drug overdose usually with multiple substances and alcohol is a reality in critically ill intoxicated patients, many of which needing admission to critical care environment
Bupropion is an atypical antidepressant with a unique aminoketone structure similar to amphetamines
Since 1997, bupropion was important as adjunctive therapy in smoking cessation at a dose of 150 mg per day and in higher doses in cocaine addition, not as a substitute but by increasing the concentration of dopamine in the nucleus accumbens, traditionally linked to the sense of well-being and pleasure [5,6]
Summary
Intentional drug overdose usually with multiple substances and alcohol is a reality in critically ill intoxicated patients, many of which needing admission to critical care environment. It is thought that its mechanism of action comprises selective inhibitory effects on transporter and neuronal reuptake on dopamine and serotonin and norepinephrine and a moderated anticholinergic effect [3,4,5,6]. This agent was approved in 1986 as an antidepressant at a dose of 400 to 600 mg per day and promptly removed from the market for higher incidence of seizures, in patients with bulimia, epilepsy or history of head trauma. The authors present a case of intentional overdose by sustained-release bupropion, with review of the literature regarding clinical effects and standards of therapeutic orientation
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