Bupropion with Seizure Risk + Eating-Disorder History
Bupropion's eating-disorder contraindication is absolute on the label — but the seizure signal behind it came from actively purging patients with electrolyte disturbance, not from a diagnosis sitting a decade in the past.
A.N., a 32-year-old occupational therapist who recently married and works full-time at an outpatient rehab clinic, restricted food intake to the point of hospitalization twice between ages seventeen and nineteen, meeting criteria for anorexia nervosa, restricting subtype. She has been in full recovery for thirteen years: weight-restored and weight-stable, regular menstrual cycles, no purging behavior of any kind ever documented, and a bone density scan two years ago that came back normal. Nothing in her recent labs — electrolytes, renal function, a CBC drawn last month for an unrelated visit — shows any trace of that history.
She is now six weeks into a moderate depressive episode, her first since her twenties, with a PHQ-9 of 16. Sertraline produced a partial response but caused sexual side effects significant enough that she stopped taking it on her own after two months, and she has been medication-free since. She also smokes about half a pack a day, a habit she picked up in her early twenties and has tried unsuccessfully to quit twice with nicotine replacement alone, and has specifically asked about bupropion — both for its more favorable sexual side-effect profile and because bupropion is also used for smoking cessation.
Bupropion's label carries a contraindication for any current or past diagnosis of anorexia or bulimia nervosa, based on an elevated seizure rate observed in an early bupropion trial conducted in bulimic patients — a trial population that was actively purging, with the kind of electrolyte disturbance that independently lowers seizure threshold on its own. The label doesn't distinguish that context from a fully recovered, medically normalized history a decade removed from any restrictive or purging behavior, and the question in front of the team is whether the contraindication is tracking her actual current risk or a population she no longer resembles.
At the intake consultation
The seizure signal that produced this contraindication came from a 1980s bupropion trial in bulimic patients who were actively purging — a population with real electrolyte disturbance, which independently lowers seizure threshold regardless of what drug is on board. The label folded 'history of anorexia or bulimia' into a blanket contraindication without separating an actively purging patient from someone thirteen years into normalized weight and labs, and those are not the same seizure risk.
I take the mechanism seriously, but a black-box-adjacent contraindication isn't the same category as a relative caution, and prescribing against it isn't just a clinical judgment — it's a decision I'd need to be able to defend if anything ever went wrong, including something unrelated to the eating disorder entirely.
That's a real constraint on this decision even if I agree her actual seizure risk looks low; the label doesn't get to be quietly reinterpreted case by case without her being an active, informed part of that conversation.
Then let's make her an active part of it rather than deciding around her. Her labs are normal, her weight has been stable for over a decade, and she's asking for this drug specifically — a documented informed-consent conversation covering exactly what the pharmacologist described, plus a plan to re-check electrolytes if anything about her eating pattern changes, gives us a real safety net without categorically closing off the option that best fits her actual side-effect priorities. One thing that has to be in that conversation separately from the seizure question: bupropion suppresses appetite and is associated with weight loss, which in someone with her history is worth tracking on its own terms, not just as a seizure-risk proxy.
After a documented informed-consent discussion of the seizure contraindication's origin and her individual risk factors, bupropion XL 150mg was started, with explicit instruction to report any change in eating pattern, weight, or appetite immediately rather than at the next scheduled visit.
The seizure-risk question was specific to an electrolyte-disturbed, actively purging population she hasn't belonged to in over a decade, and the current plan continues unchanged.
Bupropion would be discontinued immediately and electrolytes rechecked — the contraindication's real basis would once again apply to her directly, not just to her history.
The psychiatrist's documentation reflected the disagreement honestly rather than smoothing it over: the decision to prescribe outside a labeled contraindication, the specific evidence the team weighed, and the conditions under which that decision would immediately reverse.