What is the recommended dosage and treatment plan for Wellbutrin (bupropion) for smoking cessation?

Bupropion (Wellbutrin) for Smoking Cessation: Dosage and Treatment Plan

The recommended dosage of bupropion for smoking cessation is 150 mg once daily for 3 days, then 150 mg twice daily for 7-12 weeks, with treatment initiated 1-2 weeks before the target quit date. 1

Pharmacotherapy Details

Standard Bupropion Dosing Protocol

• Initial dose: 150 mg orally once daily for 3 days
• Maintenance dose: 150 mg orally twice daily (maximum 300 mg per day)
• Duration: 7-12 weeks (may be extended up to 6 months for continued cessation)
• Timing: Start 1-2 weeks before the target quit date 1

Efficacy

• Bupropion SR significantly increases smoking abstinence rates compared to placebo (19.7% vs. 11.5% at 6+ months) 1
• Clinical trials have shown 23.1% abstinence rates at one year with 300 mg daily dosing 2

Treatment Algorithm

1. Initial Assessment:

   • Confirm patient is ready to quit smoking
   • Screen for contraindications:
     • Seizure disorders
     • Eating disorders
     • Severe hepatic cirrhosis
     • History of bipolar disorder
     • Current use of MAO inhibitors
     • Brain metastases (due to seizure risk)
     • Closed-angle glaucoma 1

2. Prescription and Initiation:

   • Prescribe bupropion SR 150 mg tablets
   • Set a target quit date 1-2 weeks after starting medication
   • Begin with 150 mg once daily for 3 days
   • Increase to 150 mg twice daily if tolerated 1

3. Behavioral Support:

   • Combine pharmacotherapy with behavioral counseling (increases success rates)
   • Schedule follow-up within 2 weeks of the quit date 1, 3
   • Use the 5 A's approach: Ask, Advise, Assess, Assist, Arrange 1, 4

4. Monitoring:

   • Assess for side effects (common: dry mouth, insomnia)
   • Monitor for rare but serious side effects:
     • Neuropsychiatric symptoms (depression, suicidal ideation)
     • Seizures (risk approximately 1 in 1000) 5
   • Evaluate smoking status at each visit

5. Treatment Adjustments:

   • If patient experiences intolerable side effects, consider dose reduction
   • If smoking continues after several weeks, consider:
     • Adding nicotine replacement therapy (NRT) to bupropion
     • Switching to combination NRT or varenicline 1

Comparative Effectiveness

• First-line options (in order of effectiveness):

  1. Varenicline (28.0% abstinence rate at 6+ months)
  2. Combination NRT (patch + short-acting form)
  3. Bupropion SR (19.7% abstinence rate at 6+ months) 1

• Bupropion SR may help limit weight gain during smoking cessation (1.5 kg with 300 mg vs. 2.9 kg with placebo) 2

Important Considerations

• Neuropsychiatric safety: Monitor for mood changes, though recent studies show neuropsychiatric adverse events with bupropion are not significantly increased compared to nicotine patches or placebo 1

• Combination therapy: Consider combining bupropion with NRT for improved efficacy (RR 1.24 compared to bupropion alone) 1

• Extended therapy: For patients with previous relapse, consider extending treatment beyond the standard 7-12 weeks 1

• Common pitfalls:

  • Inadequate treatment duration
  • Failure to provide behavioral support
  • Not addressing breakthrough cravings
  • Premature discontinuation due to minor side effects 4

Bupropion SR represents an effective non-nicotine pharmacotherapy option for smoking cessation, particularly for patients who cannot use or have failed with other first-line therapies, with the added benefit of potentially limiting weight gain during the cessation process.