A 21-year-old woman is evaluated in the primary care clinic for a three-month history of p… — USMLE Step 2 CK

A $21$ -year-old woman is evaluated in the primary care clinic for a three-month history of persistent sadness, hypersomnolence, and low energy. She also mentions a strong desire to quit smoking cigarettes but has been unsuccessful with nicotine replacement therapy. Her temperature is $37.0^\circ\text{C}$ ( $98.6^\circ\text{F}$ ), blood pressure is $105/70\text{ mmHg}$ , and pulse is $84/\text{min}$ . Her body mass index is $18.4\text{ kg/m}^2$ . Physical examination is notable for bilateral parotid gland hypertrophy, enamel erosion on her lingual tooth surfaces, and hyperkeratotic calluses on the dorsum of her right hand. Laboratory results show a serum potassium of $3.2\text{ mEq/L}$ . The physician is considering a pharmacologic intervention that can address both her mood disorder and tobacco dependence. Which of the following medications is most strongly contraindicated in this patient?

BupropionCevap
B
Escitalopram
C
Mirtazapine
D
Trazodone
E
Venlafaxine

Cevap

Bupropion

Bupropion is a norepinephrine-dopamine reuptake inhibitor (NDRI) frequently utilized for treating major depressive disorder and for smoking cessation. However, a major adverse effect of bupropion is that it lowers the seizure threshold in a dose-dependent manner. Because of this risk, bupropion is absolutely contraindicated in patients with seizure disorders and those with a history of anorexia nervosa or bulimia nervosa. This patient's presentation features hypokalemia, parotid gland hypertrophy, dental enamel erosion, and calluses on the dorsum of the hand (Russell sign), which are all classic signs of bulimia nervosa with self-induced vomiting. The electrolyte abnormalities (e.g., hypokalemia, hyponatremia) inherent to purging behaviors structurally increase the risk of seizures, making the administration of bupropion exceptionally dangerous.

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Analyze the patient's physical examination and laboratory findings to identify any underlying, undiagnosed conditions.

The patient has parotid gland hypertrophy, dental enamel erosion, calluses on the dorsum of the right hand (Russell sign), and hypokalemia. These findings are classic for bulimia nervosa with recurrent self-induced vomiting.

Identifying the comorbid condition is crucial because eating disorders strongly dictate which psychopharmacologic agents are safe to use.

Determine the clinical indications for the medications being considered.

The physician is seeking a medication that treats both depression and tobacco dependence, which strongly suggests bupropion as the intended agent.

Understanding the primary indication helps evaluate the appropriateness of the chosen therapy.

Evaluate the safety and contraindications of bupropion in the context of the patient's bulimia nervosa.

Bupropion is an absolute contraindication in patients with eating disorders due to an unacceptably high risk of triggering seizures, especially in the presence of electrolyte derangements like hypokalemia.

Medication safety must be prioritized over dual-indication benefits when absolute contraindications exist.

Anahtar Kavram

Bupropion is absolutely contraindicated in patients with eating disorders (such as anorexia nervosa or bulimia nervosa) because it lowers the seizure threshold, and these patients are already at increased risk for seizures due to electrolyte imbalances.

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