How should Wellbutrin (bupropion) be dosed and monitored?

Dosing and Monitoring of Wellbutrin (Bupropion)

Wellbutrin (bupropion) should be started at 150 mg once daily in the morning for the first 4 days, then increased to the target dose of 300 mg once daily, with gradual dose titration to minimize seizure risk. 1

Initial Dosing and Titration

• Starting dose: 150 mg once daily in the morning
• Target dose: After 4 days, increase to 300 mg once daily
• Administration:
  • Take in the morning
  • Swallow tablets whole (do not crush, divide, or chew)
  • May be taken with or without food 1

Dosage Adjustments for Special Populations

• Hepatic impairment:

  • Moderate to severe impairment (Child-Pugh score 7-15): Maximum 150 mg every other day
  • Mild impairment (Child-Pugh score 5-6): Consider reducing dose/frequency 1

• Renal impairment:

  • GFR < 90 mL/min: Consider reducing dose and/or frequency 1

Switching Protocols

• When switching from other bupropion formulations (immediate-release or sustained-release), maintain the same total daily dose when possible 1
• When switching from other antidepressants, allow appropriate washout periods:
  • At least 14 days should elapse between discontinuation of an MAOI and initiation of bupropion 1

Discontinuation

• For patients on 300 mg daily, decrease to 150 mg once daily prior to discontinuation 1
• Avoid abrupt discontinuation to minimize withdrawal symptoms 2

Monitoring Parameters

Initial and Follow-up Monitoring

• Baseline assessment:

  • Vital signs (especially blood pressure)
  • Mental status examination
  • Liver and renal function tests
  • History of seizures or seizure risk factors 2

• Regular monitoring:

  • Blood pressure and heart rate (bupropion can cause elevated blood pressure) 2
  • Mental status (monitor for neuropsychiatric adverse effects, including suicidal thoughts, especially in patients younger than 24 years) 3
  • Seizure risk (bupropion lowers seizure threshold) 3

Side Effects to Monitor

• Common side effects: Insomnia, dry mouth, headache, nausea, and agitation 2
• Serious adverse effects:
  • Seizures (risk increases with higher doses; incidence <1% at usual outpatient doses) 4
  • Cardiovascular effects (increased blood pressure, tachycardia) 5
  • Neuropsychiatric effects (agitation, anxiety, suicidal ideation) 2

Warning Signs Requiring Immediate Attention

• Development of "jittery"/anxious/agitated symptoms (may precede seizures) 6
• Seizure activity (median onset time 7 hours after overdose, range 2-21.5 hours) 6
• Significant increase in blood pressure 5

Contraindications and Precautions

• Absolute contraindications:

  • Seizure disorders
  • Current or prior diagnosis of bulimia or anorexia nervosa
  • Concurrent use of MAOIs or within 14 days of discontinuing MAOIs 1
  • Abrupt discontinuation of alcohol, benzodiazepines, or antiepileptic drugs 2

• Use with caution in:

  • Patients with factors predisposing to seizures
  • Patients with cardiovascular disease (monitor blood pressure) 5
  • Patients with hepatic or renal impairment 1

Clinical Pearls

• Bupropion has a lower risk of sexual dysfunction compared to SSRIs, making it a good option for patients concerned about this side effect 7
• For patients with both depression and need for smoking cessation, bupropion may provide dual benefits 2
• When used as part of combination therapy (e.g., naltrexone-bupropion ER for weight management), additional monitoring may be required 3
• The extended-release formulation (XL) allows for once-daily dosing, potentially improving adherence compared to multiple daily dosing required with immediate-release formulations 7