Wellbutrin and seizure risk in patients with seizure history

[SpongeBob DoctorPants]

How likely is it for Wellbutrin to induce a seizure in someone with a seizure history?

I found an old study and the prescribing information sheet, as well as other sources, which report the risk is less than 0.5% in the general population, but I have not been able to find anything regarding the incidence rate for those who have had prior seizures. Of course it will be higher, but I am wondering how much higher.

In residency I recall being taught by an attending that a history of even one seizure (regardless of etiology) is enough of a contraindication to never prescribe it, which is perhaps a little too strict of a rule to follow, but I have also heard of others being okay with it as long as the seizures are well-controlled, so I'm curious about the actual risk in these individuals.

And does the severity of one's seizure disorder matter when assessing risk? It is logical to avoid using Wellbutrin in a patient who gets frequent seizures, but what about someone who has never been treated for seizures and experiences them rarely?

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[nitemagi]

relative vs. absolute contraindications.

 

[NickNaylor]

The effect is also dose-dependent. I would avoid it and consider it a relative contraindication in someone with a known seizure disorder - even if well-controlled - but I wouldn’t consider it an absolute contraindication. Someone with a poorly controlled seizure disorder is another thing altogether. This is not evidence-based in the sense that they come from specific guidelines, just how I conceptualize the issue.

Even at the highest recommended dose, the risk of seizures is fairly low though much higher than the background rate.

 

[Crayola227]

Am I crazy to think that the best course of action might be to contact the patient's neurologist? Admittedly some very controlled patients are getting their Rx from their PCP and don't regularly see a neurologist, I would still hope there is one on their record somewhere.

Just a curious thought. In fact, maybe this is a good Q for the neuro subforum.

 

[hamstergang]

Am I crazy to think that the best course of action might be to contact the patient's neurologist?

Not crazy, it's exactly what I was thinking. It seems like good care to do such coordination.

Also, if the patient has a seizure after you start Wellbutrin, you're getting blamed. A documented conversation with the neurologist and then the patient seems like the only protection.

 

[st2205]

I’m usually one to put risk in context and not hold back on meaningful treatment because of a small risk, but I’d have a hard time thinking Wellbutrin would be such a game changer to make enough/any difference to compensate for the fact that they likely have another seizure at some point in their life and, as mentioned above, will be blamed on Wellbutrin.

 

[Blitz2006]

I tell patients that up to 450 mg there is 0.04% risk of seizure, above 450 mg is 3% risk. I think this is from uptodate?

 

[SpongeBob DoctorPants]

Thank you for the great comments, everyone! Normally I wouldn't consider using this medication in patients with a seizure disorder, no matter how severe, but what got me wondering about this is that I have recently started Wellbutrin in an adolescent patient, which has been described as a "miracle drug" for her by her parents, and they are now wanting me to prescribe it for her twin sister, whom I have also been treating. The only problem is that she has a history of seizures, perhaps one a year.

 

[ryerica22]

Am I crazy to think that the best course of action might be to contact the patient's neurologist? Admittedly some very controlled patients are getting their Rx from their PCP and don't regularly see a neurologist, I would still hope there is one on their record somewhere.

Just a curious thought. In fact, maybe this is a good Q for the neuro subforum.

In the real world, getting in touch with the Neurologist or PCP is next to impossible, especially if you are in a county setting where the volume of patients is high.

 

[Crayola227]

I'd ask the neuro subforum, lol.

 

[Jules A]

In the real world, getting in touch with the Neurologist or PCP is next to impossible, especially if you are in a county setting where the volume of patients is high.

I have worked urban, suburban and rural. In my experience it is more unusual for a colleague not to return a call.

 

[whopper]

On average most of the time I contact a doctor's office I cannot get any time for them. Yeah I get that they're busy, I 'm busy too but when a doctor calls me I usually stop my meeting with the patient to talk to the other doctor. Also if I fax you a letter at least fax one back or call after hours.

It's as if the system doesn't want doctors to work in collaboration even if the patient's medical problems goes across different specialties.

 

[Crayola227]

How likely is it for Wellbutrin to induce a seizure in someone with a seizure history?

I found an old study and the prescribing information sheet, as well as other sources, which report the risk is less than 0.5% in the general population, but I have not been able to find anything regarding the incidence rate for those who have had prior seizures. Of course it will be higher, but I am wondering how much higher.

In residency I recall being taught by an attending that a history of even one seizure (regardless of etiology) is enough of a contraindication to never prescribe it, which is perhaps a little too strict of a rule to follow, but I have also heard of others being okay with it as long as the seizures are well-controlled, so I'm curious about the actual risk in these individuals.

And does the severity of one's seizure disorder matter when assessing risk? It is logical to avoid using Wellbutrin in a patient who gets frequent seizures, but what about someone who has never been treated for seizures and experiences them rarely?

I discussed this with my very good friend a neurologist.

Basically, up to 10% of the population has a "seizure history," and of whom only 1% is epilepsy.

Not talking seizures with an identified inciting cause (like EtOH w/d), but just a random one, the rule of thumb is "everybody gets one," a freebie. Meaning you don't need meds for it, and you don't need to change your overall prescribing habits in deference to a history of just one seizure.

Especially in adults, once you have a hx of 2 seizures, the push is for seizure prophylaxis. Stronger push for this in adults than for kids, in that kids tend to be supervised, adults less so, and adults tend to be doing things that put themselves and others at greater danger (like driving).

Not to mention that uncontrolled szs even when infrequent tend to worsen over the long haul without tx. Not to mention risk of sudden death from any sz.

My friend the neurologist said that even at 1 seizure per year, that is a significant seizure burden, and that patient should be on meds for sz. If they are not on ppx, they should NOT be given something like Wellbutrin. They need to see a neurologist and get better control of their szs on meds before considering it.

OTOH, the patient that is well controlled on sz meds, you have a risk/benefit discussion like with anything. However, being controlled on sz meds, does buy you more leeway with meds that lower the sz threshold, vs if they are on not on any meds.

Benadryl lowers the sz threshold in pts with sz hx, but they still take it all the time. It's just not a drug that is on the forefront of people's minds.

So the opinion was that there are no absolute contraindications for med Rx'ing in sz pts, but that assumes they are adequately treated and controlled, and that you have a risk/benefit discussion with them, warning them that this may slightly increase the risk of sz.

*disclaimer: this is all my secondhand from an informal discussion with a neurologist

 

[SpongeBob DoctorPants]

Great, thank you for the additional information! This has been a very helpful discussion.