Bupropion Extended-Release Toxicity Resulting in Cardiogenic Shock and Fatatlity

Document Type

Conference Proceeding

Publication Date

10-2025

Publication Title

CHEST

Abstract

INTRODUCTION: Bupropion, an antidepressant, is generally well tolerated at therapeutic doses. However, at supratherapeutic doses, it can cause seizures, dysrhythmias, and cardiovascular collapse. The extended-release formulation is particularly concerning due to prolonged absorption and delayed peak plasma levels, resulting in prolonged toxicity. We present a case of bupropion toxicity leading to cardiogenic shock and fatality.

CASE PRESENTATION: A 57-year-old female with depression presented to the emergency department (ED) one hour after intentionally ingesting approximately 12g of extended-release bupropion. Initially, she was hemodynamically stable, with normal lab work, negative screening for co-ingestions, normal bedside POCUS echocardiogram, and an unremarkable EKG. Activated charcoal was administered prior to admission to the intensive care unit. Three hours post-ingestion, the patient developed multiple seizures, treated with lorazepam and levetiracetam. This progressed rapidly to hypoxia and shock, necessitating intubation and stabilization with vasopressors. At toxicology's recommendation, intravenous lipid emulsion (ILE) was initiated along with a bicarbonate drip for severe metabolic acidosis. Within 12 hours she developed triple-pressor shock. An echocardiogram revealed a newly reduced ejection fraction of 30% with global hypokinesis, consistent with toxic cardiomyopathy. Despite an ongoing bicarbonate drip, repeat EKG demonstrated QTc prolongation at greater than 600 ms, and multiple runs of ventricular tachycardia. At 24-hours post-ingestion, she went into asystolic arrest and was resuscitated with CPR and a transvenous pacer. Given the rapid progression of her cardiovascular and respiratory collapse, venoarterial (VA) extracorporeal membrane oxygenation (ECMO) and continuous renal replacement therapy (CRRT) were initiated. Unfortunately, post-cannulation echocardiogram demonstrated extensive aortic dissection with complete coronary blood flow obstruction. After discussion with family the patient was transitioned to comfort care measures and expired, approximately 48 hours after ingestion.

DISCUSSION: Bupropion acts by inhibiting the reuptake of dopamine and norepinephrine. Its cardiotoxicity likely involves blockade of voltage-gated sodium channels and disruption of myocyte gap junctions. The extended-release formulation has a half-life of 24 hours, with estimated complete clearance requiring about 120 hours. Treatment of bupropion toxicity includes activated charcoal, ILE, ECMO, and CRRT. ILE sequesters lipid-soluble toxins and has been recommended in severe toxicity, although there is insufficient evidence on dosage and administration. ILE does carry risk of hypercoagulability which can lead to thrombosis and filter dysfunction when used in conjunction with ECMO and CRRT. ECMO has shown benefit in patients with bupropion overdose who developed cardiogenic shock, as it provides temporary support to the heart and lungs, and may lead to improved drug clearance. However, ECMO has been associated with rare iatrogenic aortic dissection, as seen here, in approximately 0.5% of cases. CRRT plays an important role in managing severe acidemia, although bupropion itself is poorly dialyzable, limiting its utility in this setting.

CONCLUSIONS: Bupropion has gained favorability due to its side effect profile compared to other antidepressant classes. However, given the potential for toxicity, it is imperative for clinicians to be aware of bupropion's specific toxidrome, promptly recognize overdoses, and take proactive measures including early consideration of ECMO and CRRT. Further research is needed to develop consistent and effective treatment protocols for bupropion overdose.

Volume

168

Issue

4 Suppl

First Page

A3404

Comments

CHEST Annual Meeting, October 19-22, 2025, Chicago, IL

Last Page

A3405

DOI

10.1016/j.chest.2025.07.1915

ISSN

0012-3692

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