A Case Report of Seizure Induced by Bupropion Nasal Insufflation

A Case Report of Seizure Induced by Bupropion Nasal InsufflationSir: Bupropion hydrochloride (HCl) is an aminoketone antidepressant currently approved by the U.S. Food and Drug Administration (FDA) for depression and smoking cessation.Off-label uses include treatment of attentiondeficit/hyperactivity disorder, chronic fatigue, and cocaine dependence and adjunctive treatment for Parkinson's disease.Bupropion is available in 3 formulations: immediaterelease (IR), sustained-release (SR), and extended-release (XL).Bupropion-induced seizures have been described in safety surveillance studies and case reports.As with other antidepressants and psychotropic medications, bupropion appears to lower the seizure threshold in a dose-dependent fashion.The seizure incidence in patients taking ≤ 450 mg per day of bupropion IR is 0.4%, while the incidence in those taking 600 to 900 mg per day is 2.8%. 1,2 This elevated risk of seizure led to a lowering of the maximum dose and the development of sustained-and extended-release products.The seizure rate for the sustained-release formulation decreased to 0.1% at doses of up to 300 mg per day. 2 An emergency medicine study revealed that bupropion was the third leading cause of new-onset seizures at 1.4%, behind cocaine and benzodiazepine withdrawal. 3 Overdose literature indicates that 68% to 77% of bupropion-induced seizures occur within 4 hours of ingestion. 1,4 While bupropion-induced seizures are well described, data reflecting the consequences of bupropion nasal insufflation are limited.A MEDLINE search using the keywords bupropion and insufflation only revealed 2 letters reporting bupropion nasal insufflation in 2 adolescents, with 1 case resulting in seizure. 5,6 Neither of the 2 letters hypothesized about the mechanism for seizure production.This is the second reported case describing bupropion nasal insufflation-induced seizure.Case report.Mr. A, a 50-year-old homeless white man with a history of multiple emergency department (ED) admissions was brought into the ED in March 2005 by paramedics secondary to seizures from a standing position witnessed by 2 bystanders.Each seizure lasted 30 to 60 seconds with a brief postictal period and no incontinence.Bystander descriptions of the seizures were unavailable.During the intake history, Mr. A admitted to the nasal insufflation of bupropion SR tablets, but was unable to quantify the amount.The patient admitted to a history of bupropion nasal insufflation occasionally resulting in seizures over the past 3 years.He denied a long-standing seizure disorder or treatment with anticonvulsants.He claimed that this route of administration gives him a chemical euphoria, which he described as a "cocaine high."He did not complain of any auditory or visual hallucinations and exhibited no signs of intoxication.Mr. A's medical history was significant for substance abuse, questionable schizoaffective disorder, and prior seizures secondary to bupropion nasal insufflation.He denied a family history of seizure disorder or substance abuse.The patient admitted to smoking, but denied any current alcohol or illicit drug use.The patient reported being incarcerated 3 years ago.He reported no medication allergies and that he was prescribed bupropion SR 150 mg orally twice daily and olanzapine 10 mg orally daily.He stated that he re-