The Timing of Clinical Effects of Bupropion Misuse Via Insufflation Reported to a Regional Poison Center.

BACKGROUND: Bupropion is an antidepressant medication with expanding indications including smoking cessation, weight loss, attention-deficit/hyperactivity disorder, seasonal affective disorder, and amphetamine dependence. Despite its increasing popularity among providers, it has a well-known narrow therapeutic window that can lead to delayed onset of symptoms with extended-release formulations and devastating consequences in overdose. We have noticed some patients misusing bupropion via insufflation, which added a layer of complexity with regards to the therapeutic application of the drug. This route of use created difficult decisions regarding clinical monitoring in these patients. OBJECTIVES: To determine if prolonged observation is required after insufflation of bupropion and to further describe effects from this route of use. METHODS: This is a retrospective observational study reviewing all the cases of insufflated bupropion use reported to a single poison center without any other coingestants. RESULTS: The majority (85.7%) of patients had mild or moderate effects, and seizures occurred in 19.6% of cases; and the vast majority of patients were symptomatic by the time of the initial call to the poison center. We did not encounter any delayed effects after this route of use. CONCLUSIONS: This report describes the clinical effects reported, and the timing of these effects, after insufflation of bupropion.

Clinical effects of intravenous bupropion misuse reported to a regional poison center.

Bupropion is an antidepressant medication with expanding indications including smoking cessation, weight loss, attention-deficit/hyperactivity disorder, seasonal affective disorder, and amphetamine dependence. Despite its increasing popularity among providers, it has a well-known narrow therapeutic window which can lead to delayed onset of symptoms with extended-release formulations and devastating consequences in overdose. We have noticed some patients misusing bupropion via intravenous use and had difficulty guiding decisions regarding clinical monitoring in these patients. As this route entirely changes the kinetics of bupropion, this has caused concern within our group. We reviewed all the cases of intravenous bupropion use reported to a single poison center without any other coingestants. The majority (66.7%) of patients had moderate effects and one patient had a seizure. No deaths were reported. All patients were symptomatic by the time of initial call to the poison center if they had any reported symptoms due to bupropion. This case series describes the clinical effects reported, and the timing of these effects, after intravenous bupropion use.

Oral Nitroglycerin Solution May Be Effective for Esophageal Food Impaction.

BACKGROUND: Esophageal food impaction is a common illness presenting to emergency departments (ED), and is frequently resistant to pharmacologic therapy. Several medications have been promoted for this indication, but so far have not proven effective. Endoscopic removal is frequently required to resolve the impaction, resulting in risks from anesthesia and the physical procedure, and in prolonged hospital stay for recovery. Oral nitroglycerin solution was recently used in two such cases and may represent a new therapeutic option. CASE REPORTS: A 49-year-old man presented to an ED with dysphagia 30 min after eating steak. He was given 0.4 mg nitroglycerin dissolved in 10 mL tap water orally, and obtained complete relief of symptoms within 2 min. A 43-year-old man with eosinophilic esophagitis and two prior food impaction episodes presented to a community ED with dysphagia and epigastric discomfort 110 min after eating steak. Five hours after symptom onset and after failure of intravenous glucagon, he was given 0.4 mg nitroglycerin sublingually, which resulted in headache but no relief in dysphagia. Twenty-nine minutes later he received 0.4 mg nitroglycerin solution, as above, with symptom resolution within 2 min. WHY SHOULD AN EMERGENCY PHYSICIAN BE AWARE OF THIS?: The cases presented above demonstrate close temporal relationships between administration of oral nitroglycerin solution and symptom relief. Oral nitroglycerin solution for esophageal food impaction seemed effective in these cases, but further research on this therapeutic option is warranted.