Journal of Medical Toxicology (2020) 16:12–16 https://doi.org/10.1007/s13181-019-00749-4 ORIGINAL ARTICLE Single-Agent Bupropion Exposures: Clinical Characteristics and an Atypical Cause of Serotonin Toxicity Brian Murray1,2 & Joseph Carpenter1,2 & Camille Dunkley1,2 & Tim P. Moran1 & Emily A. Kiernan1,2 & Tony Rianprakaisang3 & Waleed S. Alsukaiti2 & Diane P. Calello4 & Ziad Kazzi1,2 & on behalf of the Toxicology Investigators Consortium (ToxIC) Received: 6 June 2019 /Revised: 8 November 2019 /Accepted: 14 November 2019 /Published online: 10 December 2019 # This is a U.S. government work and its text is not subject to copyright protection in the United States; however, its text may be subject to foreign copyright protection 2019 Abstract Introduction Bupropion is the only Food and Drug Administration–approved synthetic cathinone. It increases the release of norepinephrine in the locus coeruleus and dorsal raphe nucleus, causing an increase in the frequency of serotonergic neuron firing. The diagnosis of serotonin toxicity (ST) from bupropion poisoning is controversial due to the lack of direct serotonergic activity. Nonetheless, there is one documented report of STafter single-agent bupropion overdose and multiple reports describing polypharmacy overdoses where bupropion may have contributed to ST. Methods This is a retrospective analysis of data collected by the Toxicology Investigators Consortium (ToxIC), a prospective multi-center toxico-surveillance and research network registry, from 2014 to 2017. Cases were identified if ST was a clinical effect and bupropion was the single agent listed. Data is presented descriptively. Results Of the 266 recorded single bupropion overdoses, the most common symptoms were seizures (47.1%), tachycardia (greater than 140 bpm) (33.9%), agitation (31.7%), toxic psychosis (20.4%), and myoclonus/tremor/hyperreflexia (19%). Benzodiazepines were the most common therapy (69.2%). Thirteen patients (5.9%) were diagnosed with ST by a medical toxicologist. Conclusion Bupropion overdose is primarily associated with seizures, tachycardia, and agitation; bupropion may be an atypical cause of serotonin toxicity. Keywords Bupropion . Abuse . Single-agent . Characteristics . Serotonin syndrome Introduction from 2000 to 2013 [1], and even though it is considered an effective medication [2], it does have well-documented adverse Bupropion, a monocyclic phenylethylamine antidepressant, is effects such as seizures. The risk of seizure with the maximum the only Food and Drug Administration–approved synthetic daily therapeutic dose of 450 mg is 0.35–0.44% (similar to se- cathinone. It is labeled for use as monotherapy or as an adjunc- lective serotonin reuptake inhibitor (SSRI) antidepressants) [3], tive treatment for major depressive disorder, seasonal affective but increases significantly to 20–33% in overdose. [1, 4]. disorder, and smoking cessation. Bupropion exposures reported Bupropion also causes cardiac toxicity that results in a wid- to the National Poison Data System (NPDS) increased by 75% ened QRS interval, QTc prolongation, and hypotension [5]. The QRS widening is refractory to sodium bicarbonate admin- istration as it is not sodium channel mediated, but rather is due Supervising Editor: Gillian Beauchamp, MD to reduced cardiac intercellular coupling from gap-junction * Brian Murray antagonism [6]. Additionally, tremors, lethargy, agitation, [email protected] dry mouth, hallucinations, nausea and vomiting, confusion, dizziness, tachycardia, and conduction delays have also been reported [1, 4]. Non-epileptic myoclonus was also mentioned 1 Emory University School of Medicine, Atlanta, GA, USA 2 as a side effect in one case report [7]. Georgia Poison Center, Atlanta, GA, USA The exact mechanism of action of bupropion is not 3 Oregon Health and Science University, Portland, OR, USA completely understood. One theory is that bupropion works 4 Rutgers New Jersey Medical School, Newark, NJ, USA through norepinephrine (NE) and dopamine (DA) reuptake J. Med. Toxicol. (2020) 16:12–16 13 inhibition; however, the affinity for these reuptake transporters were imputed using fully conditional specification, an iterative is not in the range of therapeutic use for antidepressants [8, 9]. method that relies on Markov Chain Monte Carlo procedures. Alternatively, bupropion has been shown to increase the re- Analyses were conducted using SPSS v25 (IBM; Armonk, lease of NE, potentially through vesicular monoamine NY). transporter-2 (VMAT-2) activation [2, 10]inthelocus coeruleus and dorsal raphe nucleus [11–14]. This VMAT-2 activation is similar to the mechanism of action of amphet- Results amines [15]. While controversial, concern exists as to whether bupropion has the ability to affect the activity of serotonergic In total, there were 266 single-agent bupropion exposures re- neurons and lead to the development of serotonin toxicity [16, ported to ToxIC during the study period. The number of 17]. single-agent bupropion cases reported per 1000 ToxIC regis- The objective of this study was to identify the clinical char- try cases for each year was 9.9, 9.8, and 13.5 for 2015–2017, acteristics of single-agent bupropion exposures and to deter- respectively [19]. Of these, 45 (17%) were excluded from mine the prevalence of ST among these patients. analysis either because they did not have any signs or symp- toms, or had signs and symptoms determined to be unrelated to their toxic exposure by the evaluating medical toxicologist. Methods (Fig. 1) The remaining 221 cases were included in our analysis. This study was a retrospective analysis of data collected by the The demographic characteristics are described in Table 1. American College of Medical Toxicology (ACMT) Of the included cases, 64% were female, 69% were white, Toxicology Investigators Consortium (ToxIC), a prospective 15% were Hispanic, and the median age was 19 years old multi-center toxico-surveillance and research network registry (IQR = 15–30). The exposure was acute in 68% of the cases, comprised of physicians specifically qualified in the field of acute-on-chronic in 29%, and chronic in 4%. Self-harm medical toxicology from 50 participating sites in the United accounted for 64% of the cases. We were unable to accurately States, Canada, Israel, and Thailand [18, 19]. Cases were in- assess dosage or bupropion formulation as this dosage was not cluded in the registry by a medical toxicologist after a bedside available in 84% cases and only 3% of cases specified the evaluation. This study was approved by the ToxIC Research formulation. One patient insufflated the bupropion, the re- Board and was determined to be exempt from review by our maining 220 exposures were ingestions. One death was Institutional Review Board (IRB). reported. The electronic database was queried for all cases involving The predominant symptoms reported in these patients were a bupropion ingestion from the beginning of 1/1/2015 through seizures (47%), followed by tachycardia greater than 140 bpm 12/31/2017. Only single-agent exposures were included for (34%), agitation (32%), toxic psychosis (20.4%), prolonged analysis. As an internal quality check, particularly important QTc (15.8%), tremor/myoclonus/clonus/hyperreflexia in the absence of definitive toxicologic testing, medical toxi- (15.8%), central nervous system (CNS) depression (15.8%), cologists are asked whether they feel the signs and symptoms and hallucinations (15.4%) (Table 2). Only 3.6% of patients are “TOX Related?”, with answer options: “Most Likely”, developed a QRS longer than 120 ms. In 22.2% of cases, the “Unlikely”,and“Unknown”.Allcaseswhere“Unlikely” medical toxicologist believed that the patient was exhibiting a was selected were excluded from analysis and “Unknown” sympathomimetic toxidrome and in 2.7% of patients, an anti- cases were analyzed as missing data. Clinical outcomes and cholinergic toxidrome was identified. treatment information were recorded for each case. Cases Benzodiazepines were utilized for treatment in 69.2% of were categorized as ST if that clinical outcome was selected the cases. Likewise, sodium bicarbonate and lipid emulsion in the “Toxidrome” category. Participating sites have the op- treatments, which are specifically used in severe bupropion tion to enter “None” under toxidrome or select all toxidromes toxicity, were used infrequently (4.5% and 1.8% respectively). that apply to a specific patient. Intubation was performed in 12.2% of the cases. ST was re- ported in 13 (5.9%) patients. There was one death reported; Statistics however, it was not in patients diagnosed with ST. Categorical variables were described using percentages and 95% confidence intervals (95% CIs). Continuous variables Discussion were described using medians and interquartile ranges. Across the data set, 5.4% of data points were missing and In this investigation of bupropion overdoses reported to the the pattern of these missing values was consistent with miss- ToxIC registry, we observed a 36% increase in single-agent ing completely at random mechanisms (p = 0.6). Missing data bupropion cases per 1000 from 2015 to 2017. The majority of 14 J. Med. Toxicol. (2020) 16:12–16 Fig. 1 Flow chart of bupropion overdoses reported to the Toxicology Investigators Consortium exposures were ingestions with suicidal intent. However, 9% formication [21]. Although the clinical endpoint of “hallucina- of the exposures were for abuse or misuse, likely because tions” is not further defined in the ToxIC registry data collec- bupropion is a