What is the recommended initial dosing regimen for bupropion (Wellbutrin) in a male patient?

Bupropion Initiation Protocol for Male Patients

The recommended initial dosing regimen for bupropion in male patients is 150 mg once daily for the first week, followed by up-titration to 300 mg daily (given as 150 mg twice daily) if tolerated. 1

Dosing Schedule and Formulation Options

• Initial dose: 150 mg once daily for 1 week 2, 1
• Target dose: 300 mg daily (usually divided as 150 mg twice daily) 2, 1
• Maximum dose: 450 mg daily (not to exceed this amount) 2, 1

Available formulations:

• Immediate-release (IR): Administered three times daily
• Sustained-release (SR): Administered twice daily
• Extended-release (XL): Administered once daily

All three formulations are bioequivalent in terms of systemic exposure to bupropion 3, but differ in dosing frequency, which may impact adherence.

Dose Adjustment Protocol

1. Week 1: Start with 150 mg once daily
2. Week 2 and beyond: If well-tolerated, increase to 300 mg daily (as 150 mg twice daily for SR formulation or 300 mg once daily for XL formulation)
3. Dose optimization: Adjust based on clinical response and side effects
   • If inadequate response at 300 mg daily, may increase to maximum of 450 mg daily
   • If side effects occur, return to 150 mg daily 1, 4

Special Considerations

Renal Impairment

• Moderate to severe impairment: Reduce dose by 50%
• End-stage renal disease: Avoid bupropion 2

Hepatic Impairment

• Moderate to severe impairment: Do not exceed 150 mg daily 2

Seizure Risk Management

• Bupropion lowers seizure threshold - contraindicated in patients with seizure disorders
• Avoid in patients with conditions that lower seizure threshold 2
• Ensure adequate spacing between doses to minimize peak plasma concentrations

Monitoring Parameters

• Blood pressure and heart rate: Monitor regularly, especially during dose titration
• Neuropsychiatric symptoms: Assess for anxiety, agitation, insomnia, and suicidal ideation
• Treatment response: Evaluate depressive symptoms at each visit

Common Side Effects to Discuss with Patient

• Early side effects: Insomnia, dry mouth, anxiety/jitteriness, headache
• Dose-dependent effects: Decreased appetite, potential for increased blood pressure and heart rate
• Serious concerns: Risk of seizures (dose-related), severe skin reactions, neuropsychiatric symptoms 2, 1

Important Precautions

• Black box warning: Increased risk of suicidal thoughts in young adults 2
• Contraindications: MAO inhibitors (must be separated by at least 14 days), seizure disorders, abrupt discontinuation of alcohol or sedatives, eating disorders 2, 1
• Drug interactions: Avoid combining with MAOIs; use caution with drugs that lower seizure threshold

Clinical Pearls

• Males may require different dosing than females, as pharmacokinetic studies show females have greater AUC, Cmax, and elimination half-life for bupropion 5
• Bupropion has a lower incidence of sexual dysfunction compared to SSRIs, making it potentially advantageous for male patients concerned about sexual side effects 3, 6
• Acute dystonia has been reported with bupropion dose increases, suggesting careful monitoring when titrating doses 4

By following this structured approach to bupropion initiation, clinicians can optimize treatment outcomes while minimizing adverse effects in male patients requiring antidepressant therapy.