Seizures after buproprion overdose

Antidepressant therapy in epilepsy: can treating the comorbidities affect the underlying disorder?

There is a high incidence of psychiatric comorbidity in people with epilepsy (PWE), particularly depression. The manifold adverse consequences of comorbid depression have been more clearly mapped in recent years. Accordingly, considerable efforts have been made to improve detection and diagnosis, with the result that many PWE are treated with antidepressant drugs, medications with the potential to influence both epilepsy and depression. Exposure to older generations of antidepressants (notably tricyclic antidepressants and bupropion) can increase seizure frequency. However, a growing body of evidence suggests that newer ('second generation') antidepressants, such as selective serotonin reuptake inhibitors or serotonin-noradrenaline reuptake inhibitors, have markedly less effect on excitability and may lead to improvements in epilepsy severity. Although a great deal is known about how antidepressants affect excitability on short time scales in experimental models, little is known about the effects of chronic antidepressant exposure on the underlying processes subsumed under the term 'epileptogenesis': the progressive neurobiological processes by which the non-epileptic brain changes so that it generates spontaneous, recurrent seizures. This paper reviews the literature concerning the influences of antidepressants in PWE and in animal models. The second section describes neurobiological mechanisms implicated in both antidepressant actions and in epileptogenesis, highlighting potential substrates that may mediate any effects of antidepressants on the development and progression of epilepsy. Although much indirect evidence suggests the overall clinical effects of antidepressants on epilepsy itself are beneficial, there are reasons for caution and the need for further research, discussed in the concluding section.

Consensus statement: the evaluation and treatment of people with epilepsy and affective disorders

Affective disorders in people with epilepsy (PWE) have become increasingly recognized as a primary factor in the morbidity and mortality of epilepsy. To improve the recognition and treatment of affective disorders in PWE, an expert panel comprising members from the Epilepsy Foundation's Mood Disorders Initiative have composed a Consensus Statement. This document focuses on depressive disorders in particular and reviews the appearance and treatment of the disorder in children, adolescents, and adults. Idiosyncratic aspects of the appearance of depression in this population, along with physiological and cognitive issues and barriers to treatment, are reviewed. Finally, a suggested approach to the diagnosis of affective disorders in PWE is presented in detail. This includes the use of psychometric tools for diagnosis and a stepwise algorithmic approach to treatment. Recommendations are based on the general depression literature as well as epilepsy-specific studies. It is hoped that this document will improve the overall detection and subsequent treatment of affective illnesses in PWE.

Cardiotoxicity associated with intentional ziprasidone and bupropion overdose

BACKGROUND

Ziprasidone and bupropion are medications prescribed for mood and behavior disorders. They have apparently safe cardiac safety profiles in both therapeutic and supratherapeutic doses, but recently the Federal Drug Administration has issued a caution regarding ziprasidone use in combination with other drugs that are known to prolong the QTc interval.

CASE REPORT

A 17-year-old male developed a widened QRS and a prolonged QTc interval following an overdose of ziprasidone and bupropion. He required hospital admission for aggressive cardiac monitoring and antidysrhythmic therapy, stabilizing to baseline by 80 hours postingestion.

CONCLUSIONS

We present a case that underscores the potential cardiotoxicities of these medications. Ziprasidone and bupropion ingestion can be associated with cardiotoxicities that may require several days of aggressive cardiac monitoring and treatment.

Cardiotoxicity associated with intentional ziprasidone and bupropion overdose

BACKGROUND

Ziprasidone (Geodon) and bupropion (Wellbutrin) are medications prescribed for mood and behavior disorders. They have apparently safe cardiac safety profiles in both therapeutic and supra-therapeutic doses.

CASE REPORT

A 17-year-old male developed a widened QRS and a prolonged QTc interval following an overdose of ziprasidone and bupropion. He required hospital admission for aggressive cardiac monitoring and antidysrhythmic therapy, stabilizing to baseline by 80 hours post-ingestion.

CONCLUSIONS

We present a case that underscores the potential cardiotoxicities of these medications. Ziprasidone and bupropion ingestion can be associated with cardiotoxicities that may require several days of aggressive cardiac monitoring and treatment.

Cardiotoxicity following bupropion overdose

OBJECTIVE

To determine whether bupropion overdose has been associated with cardiovascular toxicity.

DATA SOURCES

MEDLINE (1966-January 2002), EMBASE (1980-January 2002), Current Contents (January 2002), and PubMed (January 2002) databases for English-language human reports. Search terms included bupropion, overdose (drug), intoxication, poisoning, and acute ingestion.

DATA SYNTHESIS

Articles describing toxicity following bupropion overdose were evaluated independently by both authors to identify cases of cardiotoxicity.

RESULTS

Thirteen articles describing bupropion overdose in 116 patients were identified. Only 3 patients exhibited cardiotoxicity following acute ingestion; 2 of these patients also ingested other medications. All 3 patients experienced tachycardia and conduction delays (widened QRS complex and/or prolonged QTc interval), but none of these delays progressed to a life-threatening arrhythmia. All patients recovered, with resolution of cardiotoxicity within 2-4 days following ingestion.

CONCLUSIONS

We recommend that all patients with an overdose of bupropion should have an electrocardiogram performed on admission and should be monitored for the development of conduction delays and/or life-threatening arrhythmias.

Causal association in pharmacovigilance and pharmacoepidemiology: thoughts on the application of the Austin Bradford-Hill criteria

The methods used for the evaluation of drug safety signals (including major signals leading to withdrawal of products from the market) are inconsistent and sometimes of poor quality. While the assessment of the safety of medicines needs to consider specific issues such as drug interactions and variation in compliance, the general principles, which are used to study environmental hazards, can be applied for this purpose. The criteria proposed by Sir Austin Bradford-Hill more than 35 years ago for attributing disease causation to environmental factors have been used widely in epidemiology, are applicable to pharmacovigilance and pharmacoepidemiology. The Austin Bradford-Hill criteria include strength, consistency, specificity, temporality, biological gradient, plausibility, coherence, experimental evidence and analogy. The paper reviews each of these criteria with emphasis on pharmacovigilance and pharmacoepidemiology and with some examples. The application of the Austin Bradford-Hill criteria to the evaluation of causal association in pharmacovigilance and pharmacoepidemiology is very useful. However, it requires understanding of the limitations of the data, such as, under-reporting, poor quality of information from third parties and misclassification. Further work is required to develop strategies to handle these limitations.