J Pediatr Intensive Care 2020; 09(02): 153
DOI: 10.1055/s-0040-1702233
Letter to the Editor
Georg Thieme Verlag KG Stuttgart · New York

Reply to: Treatment of Bupropion Toxicity with Lipid Emulsion

Kasha Bornstein
1   Department of Medical Education, University of Miami Miller School of Medicine, Miami, Florida, United States
Timothy Montrief
2   Department of Emergency Medicine, Jackson Memorial Hospital, Miami, Florida, United States
Mehruba A. Parris
2   Department of Emergency Medicine, Jackson Memorial Hospital, Miami, Florida, United States
› Author Affiliations
Further Information

Publication History

05 January 2020

20 January 2020

Publication Date:
27 February 2020 (online)

We thank the authors for these clinically important observations relating to the management of acute drug-related toxicity with intravenous lipid emulsion (ILE), particularly their discussion of laboratory data to discuss kinetics of the pharmacologic agents in the case presented.[1]

Dr. Lee and Dr. Sohn note astutely that the recurrence of symptomatology following initial treatment of bupropion overdose with ILE in the presented case may have resulted from expected pharmacokinetics of ILE, namely, its short half-life of 13.7 ± 5.2 minutes.[2] Indeed, it is well understood that ILE is rapidly removed from the bloodstream into the hepatobiliary system.[3] Per the medication package insert, the plasma elimination half-life of bupropion extended release is 21 (±9) hours, though this is a referent from chronic dosing and not in the context of overdose.[4] Case report literature notes a slightly shorter (19.8 hours) elimination half-life in patients with significant acute overdose.[5] However, even this shorter half-life does not account for the discrepancy in plasma kinetics considering the bolus (versus continuous infusion) dosing of ILE. Drs. Lee and Sohn present a strong argument for the alternative mechanism of action of ILE that accounts for the discrepancy in plasma kinetics, for example, lipid shuttle.

We agree that further research is needed to confirm this lipid-shuttle mechanism with in vivo studies. However, this remains challenging due to (1) the paucity of overdose cases, particularly cases in which serum drug levels are obtained, reported, and/or published; and (2) extended ethical dilemmas in studying acute overdose, particularly in pediatric populations in extremis.