What is the recommended dosing for Bupropion (Wellbutrin) in the treatment of Attention Deficit Hyperactivity Disorder (ADHD)?

Bupropion Dosing for ADHD

For ADHD treatment, bupropion should be initiated at 150 mg XL daily and titrated to a maintenance dose of 150-300 mg daily, with a maximum dose of 450 mg per day. 1

Dosing Guidelines

Bupropion (Wellbutrin) is used off-label for ADHD treatment, with the following specific dosing recommendations:

Sustained Release (SR) Formulation:

• Starting dose: 100-150 mg daily
• Maintenance dose: 100-150 mg twice daily

Extended Release (XL) Formulation:

• Starting dose: 150 mg daily
• Maintenance dose: 150-300 mg daily
• Maximum dose: 450 mg per day 1

Efficacy and Evidence

Bupropion has demonstrated efficacy for ADHD in adults, though the evidence quality is considered low 2. A Cochrane review found that bupropion:

• Decreased ADHD symptom severity
• Increased the proportion of patients achieving clinical improvement
• Had similar tolerability to placebo 2

In direct comparison studies with methylphenidate (a first-line treatment), bupropion showed comparable efficacy profiles, though stimulants generally remain the preferred first-line option 3, 1.

Treatment Algorithm

1. First-line treatment: Stimulants (methylphenidate, lisdexamfetamine) are recommended as first-line therapy for ADHD 1
2. Second-line treatment: Non-stimulants (atomoxetine, clonidine, guanfacine)
3. Alternative option: Bupropion when:
   • Stimulants are ineffective or not tolerated
   • Comorbid depression exists
   • Substance use disorders are present (bupropion may be preferred over stimulants) 4

Important Monitoring and Precautions

• Seizure risk: Bupropion carries a 0.1% seizure risk at therapeutic doses, which increases with higher doses 5
• Contraindications: Avoid in patients with:
  • History of seizures
  • Eating disorders
  • Uncontrolled hypertension
  • Severe hepatic impairment 5
• Drug interactions: Do not combine with MAO inhibitors 5
• Monitoring: Regular assessment of:
  • Blood pressure and heart rate
  • Neuropsychiatric symptoms
  • Suicidal ideation (carries black box warning) 5

Special Populations

Pregnancy:

• Bupropion is FDA pregnancy Category C/D, indicating potential fetal risk
• Some studies suggest a small absolute increase in risk for cardiovascular malformations with first-trimester exposure 1, 5
• Consider alternatives with better established safety profiles during pregnancy 5

Comorbid Substance Use Disorders:

• Bupropion may be particularly useful in patients with ADHD and comorbid substance use disorders
• Studies show improvement in ADHD symptoms even in patients with active substance use 4

Titration Strategy

1. Begin with lowest effective dose (150 mg XL daily)
2. Assess response and tolerability after 1-2 weeks
3. Increase by 150 mg increments if needed
4. Allow 6 weeks to determine full efficacy 6

Bupropion represents a valuable alternative for ADHD treatment, particularly in patients who cannot tolerate stimulants or have specific comorbidities like depression or substance use disorders.