Gastrointestinal decontamination by gastroscopy in massive bupropion overdoses

INTRODUCTION: Overdoses of the atypical antidepressant bupropion are increasing. Management of very large ingestions is challenging, as severe and treatment-refractory circulatory compromise is not uncommon. In this context, limiting absorption is appealing. Modified-release bupropion tablets maintain their shape during dissolution and are too large for gastric lavage. Although endoscopic evacuation has been described, it remains unclear whether clinically-significant amounts of pharmacologically active substance can be recovered. METHODS: In this case series of six patients with bupropion overdoses exceeding 10 g, gastroscopic evacuation was performed, and the recovered material was analyzed to quantify bupropion content. RESULTS: When gastroscopy was performed within 6 h of ingestion, recovered amounts of bupropion ranged from 3,414 mg to 5,926 mg. When the time to gastroscopy exceeded 24 h, retrieved amounts were much smaller, ranging from 92 mg to 296 mg. DISCUSSION: The patients in this series can be divided into two groups based on intervention timing. In the early intervention group (gastroscopy performed within 6 h of ingestion), the amount of bupropion recovered was, in all cases, sufficient by itself to cause clinically significant intoxication. Gastroscopic removal was therefore likely to have been clinically relevant. CONCLUSIONS: In massive bupropion overdoses, gastroscopy can remove clinically relevant amounts of drug if performed within 6 h of ingestion. After 24 h, tablets may still be recovered, but the pharmacological content was minimal. Computed tomography imaging correlated well with tablet recovery and may be useful in selecting cases suitable for gastroscopic intervention.