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Regional Officer Netherlands Pharmacovigilance Centre Goudsbloemvallei 7 5237 MH `s-Hertogenbosch, Netherlands FAX 31-73-6426136 E-mail l.degraaf{at}lareb.nl
Neurologist Gemini Hospital Den Helder, Netherlands
Head of Scientific Department Netherlands Pharmacovigilance Centre
Published Online, December 23, 2002. www.theannals.com, DOI
Recently, the Netherlands Pharmacovigilance Centre received a report concerning an extrapyramidal disorder possibly related to the use of bupropion.
Case Report. A 42-year-old white woman used bupropion in the recommended dose of 150 mg once daily, increased to 150 mg twice a day on the fourth day. Eight days after initiation of therapy, she suddenly developed an involuntary urge to move: she made gross flexion movements with her torso (Salaam) and slapping moves with her arms and, in a lesser degree, with her legs. The movements occurred in short attacks of 5-10 seconds, 10–15 times each hour, and were diagnosed as ballism. During these attacks, she was conscious and had no cognitive disturbances. There was no rigidity, no cogwheel phenomenon, and no hypertonia of the extremities. Additional neurologic examination revealed no abnormalities. Additional investigations (hematologic and chemical investigation of blood, computed tomography scan of the brain, electroencephalogram) revealed no abnormalities. Since the movement disorder was thought to be related to the use of bupropion, therapy was discontinued. Treatment with haloperidol 5 mg twice a day and oxazepam 10 mg 3 times a day was initiated, after which the extrapyramidal symptoms diminished.
The patient had no history of neurologic disorders besides migraine without aura, and she used no concomitant medication other than sumatriptan; she took the last sumatriptan tablet 4 days prior to the onset of symptoms. As far as we know, serotonin (5-HT)-receptor agonists are not known to induce extrapyramidal disorders.
Discussion. According to the Naranjo probability scale,2 this adverse reaction can be classified as probable. The fact that the movement disorder diminished after discontinuation of bupropion and no new episodes have occurred since then supports a causal relationship between bupropion and the extrapyramidal symptoms. Moreover, related extrapyramidal disorders such as acute dyskinesia can be explained from the dopaminergic activity of bupropion. So far, 4 cases3-5 of extrapyramidal disorders associated with the use of bupropion have been published: orofacial dyskinesia and tremor in a 70-year-old woman, retropulsion in 2 geriatric patients (aged 85 and 72 y), and rigidity of the trunk and extremities, amimia, and roving eye movements in a 60-year-old man. All patients used bupropion as an antidepressant.
The ability of other dopaminergic drugs such as levodopa and bromocriptine to induce acute dyskinesia is substantiated in the literature.6 Extrapyramidal disorders are described in relation to amphetamines and other central nervous system stimulants,7 but it is unclear whether the structural relationship between bupropion and amphetamines contributes to the occurrence of dyskinesia. This case report shows that acute dyskinesia due to the use of bupropion can manifest itself as ballism, even at low doses.
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