What are special considerations when starting someone on Wellbutrin (bupropion)?

Special Considerations When Starting Wellbutrin (Bupropion)

When starting a patient on Wellbutrin (bupropion), it is essential to avoid use in patients with seizure disorders, screen for agitation, and start with a low dose of 37.5 mg every morning, then increase by 37.5 mg every 3 days to a target of 150 mg twice daily, with the second dose given before 3 PM to minimize insomnia risk. 1

Patient Selection and Contraindications

• Absolute contraindications include:

  • Seizure disorder or history of seizures 2
  • Current or prior diagnosis of bulimia or anorexia nervosa 2
  • Abrupt discontinuation of alcohol, benzodiazepines, barbiturates, or antiepileptic drugs 2
  • Concurrent use of MAOIs or within 14 days of discontinuing MAOIs 2
  • Known hypersensitivity to bupropion 2

• Use with caution in patients with:

  • Agitation (should not be used in agitated patients) 1
  • History of head trauma or prior seizures
  • Liver or kidney dysfunction 3
  • Advanced age 3
  • Cardiovascular disease 3

Dosing Strategy

1. Initial dosing: Start with 37.5 mg every morning 1
2. Titration: Increase by 37.5 mg every 3 days 1
3. Target dose: 150 mg twice daily 1
4. Timing: To minimize insomnia risk, administer the second dose before 3 PM 1
5. Duration of trial: A full therapeutic trial requires at least 4-8 weeks 1

Monitoring for Adverse Effects

• Common side effects to monitor for:

  • Insomnia and activation (most common) 4
  • Dry mouth 4
  • Headache 4
  • Nausea 4
  • Constipation 2
  • Dizziness 2

• Serious adverse effects requiring immediate attention:

  • Seizures (discontinue immediately and do not restart) 2
  • Neuropsychiatric symptoms (anxiety, agitation, panic attacks, insomnia, irritability, hostility, aggressiveness) 2
  • Suicidal ideation, especially in young adults (18-24 years) 2
  • Severe allergic reactions 2
  • Angle-closure glaucoma (can cause mild pupillary dilation) 2

Drug Interactions

• Important interactions to consider:
  • Do not combine with other bupropion-containing products (Zyban, Wellbutrin SR, Aplenzin) 2
  • Avoid alcohol (can increase seizure risk and decrease alcohol tolerance) 2
  • Use caution with drugs metabolized by CYP2D6 4
  • Contraindicated with MAOIs 2
  • Caution with opioids (may reduce efficacy) 3

Special Populations

• Elderly patients: May be given full adult doses of bupropion, but monitor closely 5
• Patients with depression and psychosis: Require concomitant antipsychotic medication 1
• Patients with suicidal ideation: Bupropion may be relatively safer in overdose compared to TCAs, but still requires close monitoring 5

Discontinuation

• After 9 months, consider dosage reduction to reassess the need for medication 1
• Discontinue gradually over 10-14 days to limit withdrawal symptoms 1
• Never discontinue abruptly, especially in elderly patients 3

Clinical Pearls

• Bupropion is activating and may provide rapid improvement in energy levels 1
• It has a lower incidence of sexual dysfunction compared to SSRIs 4, 6
• It may cause less weight gain than other antidepressants 7
• In rare cases, bupropion can cause acute dystonia, particularly with dose increases 8
• Patients should refrain from driving or operating complex machinery until they are reasonably certain bupropion does not adversely affect their performance 2

By following these guidelines, clinicians can optimize the safety and efficacy of bupropion treatment while minimizing adverse effects and complications.