What is the recommended protocol for tapering Wellbutrin (bupropion) while initiating Lamictal (lamotrigine) and Vraylar (cariprazine)?

Tapering Wellbutrin While Adding Lamictal and Vraylar

A slow, gradual taper of Wellbutrin (bupropion) is recommended when adding Lamictal (lamotrigine) and Vraylar (cariprazine), with a reduction of 10% of the original dose per week as a reasonable starting point, which may need to be slowed to 10% per month for longer-term users. 1

Wellbutrin Tapering Protocol

Initial Considerations

• Assess for any history of seizures, as both discontinuing bupropion and adding lamotrigine can affect seizure threshold
• Determine duration of Wellbutrin use (longer use requires slower taper)
• Consider current Wellbutrin formulation (IR, SR, or XL) as this affects tapering strategy

Recommended Tapering Schedule

1. Standard approach: Reduce by 10% of the original dose per week 1
2. For long-term users: Consider slower taper of 10% per month 1
3. For Wellbutrin XL: Due to its extended-release properties, maintain once-daily dosing but reduce dose gradually
4. For Wellbutrin SR: Maintain twice-daily dosing while reducing total daily dose

Specific Dosing Recommendations

• If on Wellbutrin XL 300mg: Reduce to 150mg for 1-2 weeks, then to 75mg (using SR formulation if needed) before discontinuation
• If on Wellbutrin SR: Reduce each dose by 50mg increments with at least 1-2 weeks between reductions
• Avoid abrupt discontinuation to prevent withdrawal symptoms including increased depression, irritability, anxiety, and insomnia 2

Adding Lamictal and Vraylar

Lamictal Introduction

1. Start at 25mg daily for 2 weeks
2. Increase to 50mg daily for weeks 3-4
3. Increase to 100mg daily for week 5
4. Titrate to target dose (typically 200mg daily) based on response
5. Important: The slow titration is mandatory to reduce risk of serious rash, including Stevens-Johnson syndrome

Vraylar Introduction

1. Start at 1.5mg once daily
2. After 1 week, may increase to 3mg daily if needed
3. Maximum recommended dose is 6mg daily
4. Initiate after Lamictal has reached at least 50mg daily to better assess individual medication effects

Monitoring During Transition

Withdrawal Symptoms to Monitor

• Increased depression, anxiety, or irritability
• Insomnia or sleep disturbances
• Headache or dizziness
• Fatigue or lethargy

Potential Drug Interactions

• Monitor for increased risk of seizures as both discontinuing bupropion and adding lamotrigine affect seizure threshold 2
• Be aware that bupropion inhibits CYP2D6, which may affect metabolism of other medications 3
• Spacing the medications throughout the day can minimize peak concentration overlaps 2

Special Considerations

If Withdrawal Symptoms Emerge

• Slow the taper further (e.g., from 10% per week to 10% every 2 weeks)
• Consider implementing adjunctive treatments for specific symptoms:
  • Trazodone 25-50mg at bedtime for insomnia 2
  • Clonidine for physical withdrawal symptoms if severe 1

If Depressive Symptoms Worsen

• Pause the taper temporarily
• Consider accelerating the titration of Lamictal or Vraylar if clinically appropriate
• Resume taper when symptoms stabilize

Contraindications and Cautions

• Avoid abrupt discontinuation of Wellbutrin as this can increase withdrawal symptoms 1
• Do not convert to methadone for weaning purposes due to complex pharmacokinetics 1
• Schedule follow-up appointments 1-2 weeks after each significant dose reduction to monitor for adverse effects

Patient Education

• Explain that withdrawal symptoms, if they occur, can be safely managed
• Emphasize that the slow taper is designed to minimize discomfort
• Discuss the importance of not missing doses of the new medications (Lamictal and Vraylar)
• Advise reporting any rash immediately, especially during Lamictal initiation

This approach prioritizes patient safety while effectively transitioning between medications to maintain mood stability and minimize withdrawal effects.