Transitioning from Sertraline 50 mg to Bupropion
When transitioning from sertraline 50 mg to bupropion, gradually taper sertraline over 10-14 days while starting bupropion at 37.5 mg daily, then increasing by 37.5 mg every 3 days to a target dose of 150 mg twice daily.
Rationale for Medication Change
Bupropion offers several advantages over sertraline for certain patients:
- Less sexual dysfunction (only 7-15% with bupropion vs. 41-63% with sertraline) 1, 2
- Activating properties that can improve energy levels 3
- Different mechanism of action (dopamine/norepinephrine reuptake inhibitor vs. SSRI)
Cross-Titration Protocol
Step 1: Initiate Bupropion
- Start bupropion at 37.5 mg every morning 3
- Take in the morning to minimize risk of insomnia
- Can be taken with or without food 4
Step 2: Begin Sertraline Taper
- Reduce sertraline by 12.5 mg every 3-4 days
- Tapering schedule example:
- Days 1-3: Sertraline 50 mg + Bupropion 37.5 mg
- Days 4-7: Sertraline 37.5 mg + Bupropion 75 mg
- Days 8-11: Sertraline 25 mg + Bupropion 112.5 mg
- Days 12-14: Sertraline 12.5 mg + Bupropion 150 mg
- Day 15 onward: Bupropion only
Step 3: Optimize Bupropion Dosage
- Increase bupropion by 37.5 mg every 3 days as tolerated 3
- Target dose: 150 mg twice daily (morning and afternoon)
- Second dose should be taken before 3 pm to minimize insomnia 3
Monitoring During Transition
Watch for Withdrawal Symptoms
- Dizziness, fatigue, headaches, nausea, irritability
- Slow the taper if withdrawal symptoms become problematic
Monitor for Adverse Effects of Bupropion
- Headache, dry mouth, insomnia, agitation
- Seizure risk (contraindicated in patients with seizure disorders) 3
Assess for Serotonin Syndrome
- Although rare, combining sertraline and bupropion during cross-titration can potentially cause serotonin syndrome 5
- Symptoms include confusion, agitation, muscle twitching, sweating, shivering
- If these occur, discontinue both medications and seek immediate medical attention
Important Precautions
Contraindications for Bupropion
- Seizure disorders
- Current or prior diagnosis of bulimia or anorexia
- Concurrent use of MAOIs
- Abrupt discontinuation of alcohol or sedatives
Special Dosing Considerations
- For patients with hepatic impairment: Maximum dose 150 mg every other day 4
- For patients with renal impairment: Consider reduced dose/frequency 4
Follow-up Recommendations
- Schedule follow-up within 1-2 weeks of starting cross-titration
- Assess for therapeutic response and adverse effects
- If inadequate response after 4-8 weeks at target dose, consider dose adjustment or alternative treatment
Common Pitfalls to Avoid
- Stopping sertraline abruptly (can cause withdrawal symptoms)
- Starting bupropion at too high a dose (increases risk of side effects)
- Taking the second bupropion dose too late in the day (can cause insomnia)
- Failing to monitor for potential drug interactions
- Not allowing adequate time (4-8 weeks) to assess full therapeutic effect of bupropion
By following this structured approach, you can effectively transition from sertraline to bupropion while minimizing withdrawal effects and optimizing therapeutic outcomes.