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Clinical Associate Professor, Department of Pharmacy: Clinical and Administrative Sciences, College of Pharmacy, University of Oklahoma, 4502 E 41st St., 2H17, Tulsa, OK 74135-2512, fax 918/660-3009, nancy-brahm{at}ouhsc.edu
Associate Professor, Department of Pharmacy: Clinical and Administrative Sciences, College of Pharmacy, University of Oklahoma
Medical Director, Oklahoma Department of Human Services/DDSD, Adjunct Clinical Associate Professor, Department of Pharmacy: Clinical and Administrative Sciences, College of Pharmacy, University of Oklahoma
Published Online, October 24, 2006. www.theannals.com, DOI 10.1345/aph.1H232
We used bupropion, an aminoketone antidepressant approved for smoking cessation, to successfully treat chronic, persistent, severe nicotine-craving pica in a developmentally disabled adult. A MEDLINE search using the terms bupropion, nicotine craving, developmentally disabled, and pica was performed but yielded no reports of bupropion treatment of pica; therefore, we report the first case, to our knowledge, of successful treatment of pica with bupropion.
Case Report. A nonverbal, profoundly mentally retarded (IQ 14) 50-year-old white male resident of a state-run mental healthcare facility had a long-standing history of nicotine-craving pica. Cigarette butts were the preferred item. The patient was 1.7 meters tall and weighed 71 kg, with a history of partial complex with secondary generalized seizures, as well as a history of aggression capable of escalating to assault.
Behavioral interventions to redirect pica behavior were tried. These included restructuring caregiver behavior and the environment, prompting, response blocking, verbal redirection, and ushering. These were unsuccessful, and the patient's behavior escalated to physical assault. Pharmaceutical interventions were considered following an exacerbation of pica episodes. Options included nicotine replacement therapy, nortriptyline, clonidine, and bupropion.4 Sustained-release bupropion 100 mg twice daily was added in July 2003 to the regimen of lamotrigine 200 mg 3 times daily, gabapentin 600 mg 3 times daily, topiramate 200 mg 3 times daily, zonisamide 300 mg at bedtime, loratadine 10 mg daily, naltrexone 50 mg daily, extended-release propranolol 60 mg twice daily, paroxetine 40 mg daily, risperidone 3 mg twice daily, a multivitamin/mineral supplement daily, and vitamin E 800 IU twice daily.
The pica episodes did not remit or decrease despite the inclusion of paroxetine in the patient's drug regimen. However, during the 11 month period following initiation of bupropion, the frequency of pica episodes decreased markedly. Currently, the patient's antiepileptic medications and bupropion dose remain unchanged.
Discussion. Bupropion blocks the reuptake of norepinephrine and dopamine as well as the nicotinic receptors. These effects are thought to lessen symptoms of nicotine withdrawal and potentially blunt the rewarding effects of smoking.5 For the 12 month period prior to beginning bupropion treatment, the patient experienced an average of 6.25 pica episodes per month, which decreased to an average of 0.9 episodes per month in the 11 month period following initiation of the drug. Although bupropion can lower the seizure threshold, changes in the patient's seizure activity were not reported at this dose. In 2002, 9 seizure episodes were documented; a total of 6 were documented in 2003.
The use of bupropion for smoking cessation has been well documented. Initiation of bupropion in this patient resulted in a significant reduction in behavioral episodes secondary to nicotine-craving pica.
Footnotes
This case report was presented as a poster at the 9th Annual Meeting of the College of Psychiatric and Neurologic Pharmacists, Baltimore, MD, April 25, 2006.
References
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