SSRI Discontinuation Vs Bupropion Side Effects?

[nighthawk2551]

Shadowed an interesting patient the other day and wanted to get more perspective on his issue. A few months before I saw him the patient was started on lexapro 10mg for anxiety and depression. A month into it he was started on wellbutrin XR 150 for sexual side effects. A month later the sexual side effects were still present and the patient was noting prominent fatigue. At that visit the resident initiated a 4-day taper of lexapro and increased the wellbutrin to 300. Patient comes in 2 weeks later, before his scheduled appointment, noting severe anxiety, agitation, nightmares, insomnia, bruxism, etc. The resident and the attending were trying to decide if this was SSRI discontinuation syndrome or side effects of wellbutrin. In my mind, the symptoms sounded more like wellbutrin but I'm certainly not an expert. The resident ended up adding Lexapro back and keeping the wellbutrin where it was to see if things get better. I don't think they came to any firm decision but figured the SSRI may help either way.

What do you all think? How do you differentiate SSRI discontinuation vs wellbutrin side effects? SSRI trial followed by wellbutrin seems a very common strategy for starting antidepressants, so I imagine this timeline, maybe even scenario, is somewhat common.

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[WingedOx]

a 4 day taper may as well be a sudden stop.

 

[nighthawk2551]

a 4 day taper may as well be a sudden stop.

That's kind of what I thought. Everything I've looked at has said to taper SSRIs over weeks to months

 

[NickNaylor]

Agreed that 4 days is a bit aggressive, though frankly with 10 mg of escitalopram I wouldn’t even necessarily taper that dose. If I did, I’d just do 5 mg for a week and then stop. Given the changes that were made it could be either/or - I don’t think there’s a way to tell based on the information provided whether this is SSRI discontinuation vs. side effects from bupropion. Might have been helpful to ask what the severity of the symptoms over time was as that might provide some insight (some degree of improvement over time would suggest SSRI discontinuation, unchanged or worsening might be more suggestive of adverse effects from bupropion).

The money will be in the follow-up. If all of that went away after the escitalopram was restarted, then you probably have your answer.

 

[Shikima]

So, a side question, similar context for discontinuation syndrome symptoms. I picked him up in the middle of this movie. Started and stopped on paxil, terrible discontinuation syndrome symptoms of severe tremors, vocal tics and muscle cramping. It's preventing him from working. Began Prozac and escalated it with Wellbutrin, these did not resolve. Started back on Paxil, again no resolution. Added Seroquel per Neurology recommendation with no real benefit. Added Propranolol which initially worked but then stopped, escalated the dosage and it didn't help.

I'm at a loss now what to do. All mood/anxiety symptoms are good and stable. Sleeping very, very well through the night. But the neurological problems persist and now I'm at a loss. Anyone?

 

[whopper]

Four days can be done but it's treading in the area of unneeded risk. Another factor could've been the decreased serotonin, upshift dopamine at the same time.

Although I've never seen this happen to memory I have read in a few texts that some of the side effects of these meds might not be directly related to themselves but the ratio of Serotonon/Dopamine. The problem with this theory is in usual form like Kaplan and Saddock, the texts didn't mention the direct source of information. Just at the end of the chapter there were several sources and I'm not going to sit there and read each one, some of them dozens of pages long.

 

[st2205]

People really tapering SSRIs over weeks on average? That’s surprising. I’ll only really go over the course of a month if they’re on something like Paxil or Effexor, and having been on it for a while or on a high dose, or have demonstrated intolerability of a different taper. Most of the time these patients are missing a good handful of doses throughout the week/month anyway and not having problems. To me at least, the OP sounds much more in line with someone who can’t tolerate an increased dose of Wellbutrin than someome experiencing that symptom cluster as a result of dropping from 10 mg of Lexapro to 5 for 4 days.

Fun fact: 10 mg is often my last stop along the way of a Lexapro taper if they’ve got the 20 mg tablets. However, I always warn people of possible issues coming off and if they experience any of those symptoms to symply resume the dose and call in and we will go slower. It’s very rare that people call back on that and I’d assume half the time it’s because I primed them.

Of course, I’d qualify that 95% of my SSRI/SNRI tapers is a cross taper with another SSRI/SNRI.

 

[Shikima]

I could be beating a dead horse here, or it's a extreme noodle scratcher and there are few answers. Prior to tapering off the meds/lowering them, I'd first like to get a handle on these effects going on.

Any and all suggestions are welcome! Don't be shy!

 

[nighthawk2551]

Of course, I’d qualify that 95% of my SSRI/SNRI tapers is a cross taper with another SSRI/SNRI.

Wouldn't that negate a large part of the problem? The patient in my case was switched to a med with no serotonergic activity.

 

[st2205]

Wouldn't that negate a large part of the problem? The patient in my case was switched to a med with no serotonergic activity.

On paper, yeah, but I’m reality... I honestly perhaps maybe would have told them to go down to 5 mg for a week. If they would have given me any guff about that and wanted to stop, I’d say sure and give them instructions to just go slower if they became symptomatic.

Honestly, the scenario sounds like a pretty clear-cut case of someone sensitive to the effects of Wellbutrin, but hey, whatevs.

 

[WingedOx]

Wouldn't that negate a large part of the problem? The patient in my case was switched to a med with no serotonergic activity.

At least a regular taper you've mostly limited your variables. With a cross-taper you've got at minimum two meds on board, and patients tend to be iffy about describing their own symptoms, so there's guess work to play with.