Can bupropion cause chest pain, and if so, should the treatment be discontinued?/nA 38-year-old man

Fråga: Can bupropion cause chest pain, and if so, should the treatment be discontinued? A 38-year-old man has been taking bupropion, 150 mg twice daily, for one month, in an effort to stop smoking. He has had two or three episodes of chest pain during this period. He is otherwise healthy, takes no other medicines and has no history of cardiac disease. The patient would like to continue his treatment, if possible.

Sammanfattning: Chest pain has been reported as an isolated side-effect of bupropion treatment and does not nessecarily represent a state of allergy towards the drug. Even though caution is adviced, treatment can probably be continued, possibly with a dose reduction, should the symptoms be mild and passing.

Svar: Bupropion is a norepinephrine and dopamine re-uptake inhibitor, used as an aid in smoking cessation, but with an hitherto unknown mechanism of action in this context. Chest pain is stated as a less common side-effect in the Swedish phycians desk reference (1). The same reference states that bupropion treatment should be discontinued if symptoms of hypersensitivity, such as rash, itching, urticaria or chest pain appear.

A literature search revealed one study concerning chest pain as a side-effect of bupropion. Twenty-two reports of chest pain, among a total of 591 reported adverse reactions to bupropion in the Netherlands, were reviewed retrospectively. The patients were between 21 and 63 years of age, chest pain occurred after 1-27 days of treatment with a median of four days. Treatment recommendations included a dose increase after three days and that smoking should be stopped after seven days. The authors suggest that most cases of chest pain occurred after the dose increase and while the patients were still smoking. Disappearance of symptoms after a dose reduction is reported in one out of three patients. According to patient files and a questionnaire, there was no obvious cardiac origin of the symptoms, which were reversible in 20 cases, while one case was lost to follow-up (2).

The Swedish adverse drug reaction register contains 226 reported reactions with a possible relationship to bupropion, six of which concern chest pain. These patients were between 34 and 56 years of age, had no previous cardiac complaints, and experienced chest pain after 4-21 days of bupropion treatment. One patient, a 34-year-old man, also had rash, dizziness, dyspnea and paresthesia (2).

The above case reports suggest that chest pain can occur as an isolated side-effect of bupropion and that this reaction is reversible upon drug withdrawal or possibly even with dose reduction.

In the present case, treatment can probably continue, as long as the symptoms do not reoccur. An exercise test might be motivated, irrespectively of drug treatment , in a smoker with chestpain.

It is recommended that the case be reported to the regional adverse drug reaction monitoring centre.