Bupropion Dosing for Older Adults
For older adults, bupropion should be initiated at a lower dose of 37.5 mg every morning, then increased by 37.5 mg every 3 days to a maximum of 150 mg twice daily. 1, 2
Initial Dosing and Titration
- Start with 37.5 mg every morning for older adults 1
- Gradually increase by 37.5 mg every 3 days as tolerated 1
- Lower starting doses (approximately 50% of standard adult dose) are appropriate for older adults due to increased risk of adverse reactions 2
- To minimize risk of insomnia, administer the second dose before 3 p.m. 1
Maximum Dosing
- Maximum recommended dose for older adults is 150 mg twice daily (300 mg total daily dose) 1, 2
- For patients over 75 years of age, consider further dose reduction 2
- If no response is seen after 6-8 weeks at an adequate dose, consider alternative treatment 2
Formulation Considerations
- Bupropion SR (sustained release): Typically administered twice daily 2
- Bupropion XL (extended release): Typically administered once daily in the morning 2
- Both formulations are bioequivalent in terms of systemic exposure to bupropion 3
Special Considerations for Older Adults
- Elderly patients may be at increased risk for accumulation of bupropion and its metabolites 4
- For patients with moderate to severe renal impairment (common in older adults), reduce the total daily dose by half 2, 4
- For patients with moderate to severe hepatic impairment, the total daily dose should not exceed 150 mg daily 2, 4
Monitoring and Side Effects
- Most common side effects include insomnia, dry mouth, headache, and nausea 5
- Insomnia and dry mouth occur significantly more frequently with bupropion SR than with placebo 5
- Monitor for neuropsychiatric adverse effects and vital signs, particularly blood pressure 2
- Side effects are generally transient and often resolve quickly without therapeutic intervention 5
- If necessary, manage side effects by reducing the bupropion dose 5
Contraindications and Precautions
- Avoid in patients with seizure disorders as bupropion may lower the seizure threshold 2, 6
- Avoid in patients taking monoamine oxidase inhibitors (MAOIs) or within 14 days of discontinuing MAOIs 2
- Use caution in patients with uncontrolled hypertension 2
- To minimize seizure risk, do not exceed 450 mg per day total dose 2, 6
Clinical Efficacy in Older Adults
- In a naturalistic study of elderly patients with major depression, 74% responded to bupropion treatment 7
- The mean maximum daily dose achieved in elderly patients on bupropion SR monotherapy was 240 mg (range 150-400 mg) 7
- Response rates did not differ significantly among older adults with high and low medical comorbidity 7
Remember that careful dose titration is essential in older adults to minimize adverse effects while achieving therapeutic benefit.