Medication Safety and Interactions

Contraindications and Precautions

The American Diabetes Association recommends that bupropion should not be used in combination with monoamine oxidase inhibitors (MAOIs) due to potential drug interactions 1
Bupropion should not be used in patients with seizure disorders or agitation, and caution is needed in patients with liver or kidney dysfunction, advanced age, history of seizures, or cardiovascular disease, as advised by the American Academy of Family Physicians 2, 3, 4, 5
Benzodiazepines like lorazepam can cause respiratory depression and sedation, according to the American Academy of Pediatrics 6
Naltrexone cannot be used with opioids due to reduced efficacy and potential for withdrawal, and must be discontinued before procedures requiring opioid analgesia, as stated in guidelines from the American Gastroenterological Association 7
Clonidine must be tapered to avoid rebound hypertension when discontinuing, as recommended by the American College of Cardiology and the American Heart Association 8, 9, 10

Monitor for common SSRI side effects, including nausea, dry mouth, drowsiness, nervousness, insomnia, dizziness, sexual dysfunction, and for bupropion, monitor for the risk of seizures and common side effects including insomnia, dry mouth, headache, nausea, and sexual dysfunction, as advised by the American Academy of Family Physicians 11, 12, 3, 13, 14
Bupropion is associated with lower rates of sexual dysfunction compared to SSRIs and may be beneficial if sexual side effects are contributing to the patient's dislike of their current medication, as suggested by the American College of Physicians and the American Academy of Family Physicians 14, 14

Alternative medications to SSRIs include sertraline, citalopram, bupropion, mirtazapine, and venlafaxine, with the choice depending on the patient's symptom profile and side effect concerns, as recommended by the American Academy of Family Physicians 13
For patients with negative symptoms, cariprazine, aripiprazole, or low-dose amisulpride may be considered, according to the American Psychiatric Association 15
Cognitive-behavioral therapy (CBT) has similar effectiveness to second-generation antidepressants with fewer adverse effects, and lower relapse rates compared to medication alone, as strongly recommended by the American College of Physicians based on moderate-quality evidence 16, 14

The American Association for the Study of Liver Diseases recommends careful dosing of mirtazapine and consideration of low-dose dexmedetomidine for short-term use in severe cases, as it has a favorable profile in patients with cirrhosis, while avoiding benzodiazepines due to the risk of hepatic encephalopathy 17, 18
The Clinical and Molecular Hepatology society advises against using opioids, medications with high sedative properties, and limiting acetaminophen to 2-3g daily, and contraindicates NSAIDs due to the risk of decompensation in patients with liver disease 17, 19
Regular physical exercise has strong evidence for reducing fatigue, according to the Annals of Oncology 20
The Journal of Clinical Oncology recommends evaluating possible medical causes of fatigue, such as anemia, thyroid dysfunction, and cardiac disease 21

The American College of Physicians recommends combination therapy with two agents for patients who have had an inadequate response to monotherapy, and considering switching to cognitive therapy or augmenting with an atypical antipsychotic if combination therapy fails 16
For patients who have not responded adequately to bupropion treatment, the most evidence-based augmentation strategies include adding an atypical antipsychotic, switching to cognitive therapy, or augmenting with cognitive therapy, as recommended by the American College of Physicians 22
Switching to another antidepressant is a reasonable alternative if augmentation is unsuccessful, according to the American College of Physicians 22