What is the recommended starting dose for bupropion (Wellbutrin) initiation?

Bupropion Initiation Dosing

The recommended starting dose for bupropion is 150 mg once daily, which can be titrated up based on clinical response and tolerability. 1, 2

Formulation-Specific Dosing

Immediate Release (IR)

• Not commonly used for initial therapy due to three-times-daily dosing requirement
• Higher risk of seizures compared to sustained-release formulations

Sustained Release (SR)

• Initial dose: 150 mg once daily in the morning 2
• After 3-4 days, increase to target dose of 150 mg twice daily (300 mg total daily) 2
• Maximum dose: 400 mg per day (200 mg twice daily)
• Second dose should be taken before 3 PM to minimize insomnia risk 2

Extended Release (XL/ER)

• Initial dose: 150 mg once daily in the morning 1
• After 4 days, may increase to target dose of 300 mg once daily 1
• Maximum dose: 450 mg daily 2
• Take in the morning with or without food 1

Special Populations and Dosing Considerations

Hepatic Impairment

• Moderate to severe impairment (Child-Pugh score 7-15): Maximum 150 mg every other day 1
• Mild impairment (Child-Pugh score 5-6): Consider reducing dose/frequency 1

Renal Impairment

• Consider reducing dose and/or frequency with GFR <90 mL/min 1

Indication-Specific Starting Doses

Depression

• Start with 150 mg once daily (SR or XL) 1, 2
• For SR: Increase to 150 mg twice daily after 3-4 days 2
• For XL: Increase to 300 mg once daily after 4 days 1

Smoking Cessation

• Start 1-2 weeks prior to quit date 2
• Initial dose: 150 mg once daily for 3 days 2
• Increase to 150 mg twice daily (300 mg total) 2
• Treatment duration: 7-12 weeks 2

ADHD (Off-label)

• Start with 100-150 mg daily 2
• Gradually increase to 150-450 mg daily 2

Weight Management (as component of Contrave®)

• Contains bupropion SR 90 mg + naltrexone 8 mg per tablet 2
• Week 1: 1 tablet daily 2
• Week 2: 1 tablet twice daily 2
• Week 3: 2 tablets in morning, 1 in afternoon 2
• Week 4 onward: 2 tablets twice daily (maintenance dose) 2

Important Monitoring and Precautions

• Seizure risk: Increases with higher doses; never exceed maximum recommended doses 2
• Dose-related adverse effects: Insomnia, dry mouth, headache, nausea 2
• Psychiatric symptoms: Monitor for worsening depression or emergence of suicidal thoughts 1
• Hypertension: Monitor blood pressure, especially during dose titration 2
• Mania risk: May be dose-related; appears more common at doses >450 mg/day 3

Common Pitfalls to Avoid

1. Too rapid titration: Increases risk of adverse effects and discontinuation
2. Late-day dosing: Taking second dose of SR formulation after 3 PM increases insomnia risk 2
3. Exceeding maximum doses: Significantly increases seizure risk
4. Abrupt discontinuation: When stopping, taper from 300 mg to 150 mg daily before discontinuing 1
5. Combining with MAOIs: Allow 14 days between discontinuing MAOIs and starting bupropion 1

When initiating bupropion, start low and titrate slowly to minimize side effects while achieving therapeutic benefit. The most recent FDA guidance emphasizes gradual dose increases to minimize seizure risk.