From the Guidelines
Bupropion dosing should be adjusted based on creatinine clearance (CrCl) rather than eGFR, with a recommended reduction in total daily dose by one-half in patients with moderate to severe renal impairment. When considering the dosing of bupropion based on CrCl or eGFR, it is essential to prioritize the patient's renal function to minimize the risk of adverse effects. According to the study by 1, in patients with moderate to severe renal impairment, the total daily dose of bupropion should be reduced by one-half, and it should be avoided in end-stage renal disease. The following adjustments can be made:
- For patients with moderate to severe renal impairment, the total daily dose should be reduced by one-half (i.e., 1 tablet twice per day for naltrexone-bupropion ER).
- In patients with end-stage renal disease, bupropion should be avoided.
- For patients with mild renal impairment, standard dosing can generally be used with careful monitoring. It is crucial to monitor patients with any degree of renal impairment closely for side effects, such as seizures, agitation, and insomnia, and to proceed with dose titration more slowly than in patients with normal renal function. The study by 1 provides guidance on the dosing of bupropion in patients with renal impairment, emphasizing the importance of adjusting the dose to minimize the risk of adverse effects. Key considerations when dosing bupropion in patients with renal impairment include:
- Reducing the total daily dose by one-half in patients with moderate to severe renal impairment
- Avoiding bupropion in patients with end-stage renal disease
- Monitoring patients closely for side effects and adjusting the dose accordingly.
From the FDA Drug Label
2.7 Dose Adjustment in Patients with Renal Impairment Consider reducing the dose and/or frequency of bupropion hydrochloride extended-release tablets (XL) in patients with renal impairment (glomerular filtration rate less than 90 mL/min)
The dosing of bupropion should be adjusted in patients with renal impairment, considering a reduction in dose and/or frequency.
- Renal Impairment: Consider reducing the dose and/or frequency of bupropion hydrochloride extended-release tablets (XL) in patients with a glomerular filtration rate less than 90 mL/min.
- Dose Adjustment: The label does not provide specific dose adjustment recommendations based on the degree of renal impairment, only that the dose and/or frequency should be considered for reduction. 2
From the Research
Dosing of Bupropion Based on Crcl or Egfr
- The study 3 investigated the effect of kidney disease on bupropion pharmacokinetics and found that bupropion AUC was 126% higher, C(max) 86% higher, CL/F 63% lower, and t(1/2) 140% longer in renally impaired patients.
- However, the study 3 also stated that dosage recommendations for patients with renal impairment cannot be given due to the similar pharmacological activity of the principal metabolites of bupropion.
- Another study 4 found that changes in creatinine clearance estimates are common in hospitalized patients with renal impairment, and programs designed to alert physicians to potentially excessive dosages of renally eliminated drugs need to be sensitive to these changes.
- The study 5 discussed recent recommendations concerning kidney function assessment and their implications for drug dosing in patients with renal impairment, including a recommendation to avoid the use of the Cockcroft-Gault equation for drug dosing.
- The study 6 compared equations to estimate glomerular filtration rate and their impact on frequency of cisplatin-associated acute kidney injury, and found that eGFRCKD-EPI had the highest positive predictive value and area under the curve.
- The study 7 identified drug-related problems in patients with renal impairment, including incorrect dose and inappropriate drug choice, and found that the clinical pharmacist's interventions had a high acceptance rate.
- Overall, the dosing of bupropion based on Crcl or Egfr should take into account the patient's renal function and the potential for drug-related problems, as highlighted in the studies 3, 4, 7, 5, 6.