From the Guidelines
Bupropion dosage should be initiated at 90 mg once daily in the morning, with a weekly escalation to 90 mg twice daily, as part of the naltrexone-bupropion ER combination, to minimize the risk of insomnia and other adverse effects, as recommended by the most recent guideline 1. The recommended titration schedule for naltrexone-bupropion ER, which contains 90 mg of bupropion, begins with 1 tablet daily in the morning, followed by weekly escalation to 1 tablet twice per day, then 2 tablets in the morning and 1 in the afternoon, until the maintenance dose of 2 tablets twice per day is reached, as outlined in the 2022 clinical practice guideline on pharmacological interventions for adults with obesity 1. Some key points to consider when prescribing bupropion include:
- The maximum recommended dose should not exceed 2 tablets twice per day, due to the increased risk of adverse effects, such as insomnia and seizures, as noted in the guideline 1.
- Patients with moderate to severe renal impairment should have their total daily dose reduced by one-half, and those with end-stage renal disease should avoid the medication altogether, as recommended by the guideline 1.
- Patients with moderate to severe hepatic impairment should not exceed 1 tablet daily, to minimize the risk of adverse effects, as outlined in the guideline 1.
- Bupropion may lower the seizure threshold, and naltrexone-bupropion ER should be avoided in patients with epilepsy, and used with caution in patients with a history of seizures or clinical factors that may increase the risk of seizures, as noted in the guideline 1. In contrast to other guidelines, such as the 2019 ACC/AHA guideline on the primary prevention of cardiovascular disease, which recommends a different dosing regimen for bupropion, the 2022 guideline provides more specific and detailed recommendations for the use of naltrexone-bupropion ER, including the titration schedule and dosing regimen, making it a more relevant and reliable source for clinical decision-making 1.
From the FDA Drug Label
In the first study, the bupropion dose range was 300 mg to 600 mg per day administered in 3 divided doses; 78% of patients were treated with doses of 300 mg to 450 mg per day. The second study included 2 fixed doses of bupropion (300 mg and 450 mg per day) and placebo. The third study, outpatients were treated with bupropion 300 mg per day A longer-term, placebo-controlled, randomized withdrawal trial demonstrated the efficacy of bupropion HCl sustained-release in the maintenance treatment of MDD The trial included adult outpatients meeting DSM-IV criteria for MDD, recurrent type, who had responded during an 8-week open-label trial of bupropion 300 mg per day. The initial bupropion dose was 150 mg once daily for 1 week, followed by up-titration to 300 mg once daily.
The recommended dosage of bupropion is:
- 300 mg to 600 mg per day administered in 3 divided doses for the treatment of MDD
- 300 mg per day for the maintenance treatment of MDD
- 150 mg once daily for 1 week, followed by up-titration to 300 mg once daily for the prevention of seasonal major depressive episodes associated with SAD 2
From the Research
Bupropion Dosage
- The recommended dosage of bupropion is maintained at 450 mg/day or less in a divided schedule to minimize the risk of seizures 3.
- Bupropion is available in three oral formulations: immediate release (IR), sustained release (SR), and extended release (XR) 4, 5, 6.
- The IR formulation is administered three times daily, while the SR formulation is administered twice daily, and the XR formulation is administered once daily 4, 5, 6.
- All three formulations are bioequivalent in terms of systemic exposure to bupropion 4, 5, 6.
- In a study on smoking cessation, bupropion SR was initiated at 150 mg/day and increased to 300 mg/day 7.
- The efficacy and tolerability of bupropion have been established in various studies, with the newer formulations offering the advantage of reduced frequency of daily administration 5, 6.