Is starting a patient on bupropion (Bupropion) extended release 150mg daily for a week then increasing to 300mg daily an appropriate treatment regimen?

Bupropion Extended Release Dosing Protocol

Starting a patient on bupropion extended release 150mg daily for a week then increasing to 300mg daily is the appropriate standard dosing regimen for major depressive disorder. 1

Initial Dosing and Titration

• The FDA-approved dosing for bupropion extended release (XL) for major depressive disorder recommends starting with 150 mg once daily in the morning for 4 days, then increasing to the target dose of 300 mg once daily in the morning 1
• Starting at 150mg daily for one week before increasing to 300mg daily is an acceptable and common titration schedule that may help minimize the risk of seizures, which is a concern with bupropion 2, 1
• Gradual dose increases are specifically recommended to minimize the risk of seizures 1

Administration Guidelines

• Bupropion extended release tablets should be swallowed whole and not crushed, divided, or chewed 1
• The medication should be administered in the morning and may be taken with or without food 1
• To minimize the risk of insomnia, a common side effect, the medication should be taken earlier in the day 2

Dosage Considerations for Special Populations

• For patients with moderate to severe hepatic impairment, the maximum dose should not exceed 150 mg every other day 1
• For patients with mild hepatic impairment, consider reducing the dose and/or frequency of dosing 1
• For patients with renal impairment (GFR less than 90 mL/min), consider reducing the dose and/or frequency 1
• For older adults, a more conservative approach may be warranted, starting with lower doses (37.5 mg every morning) and gradually increasing by 37.5 mg every 3 days 3

Safety Considerations

• Bupropion should not be used in patients with seizure disorders as it may lower the seizure threshold 2, 1
• Avoid use in patients taking monoamine oxidase inhibitors (MAOIs) or within 14 days of discontinuing MAOIs 1
• Monitor for common side effects including insomnia, dry mouth, and anxiety 4
• The medication is activating and may improve energy levels quickly, but should not be used in agitated patients 3

Efficacy and Maintenance

• Clinical studies have shown that both 150mg and 300mg daily doses of bupropion SR are effective for depression, with 300mg daily showing greater efficacy 5
• Population pharmacokinetic/pharmacodynamic analyses reveal that the efficacy of bupropion SR is directly related to dose, with 300mg daily being optimal for most patients 4
• For long-term treatment, it is generally agreed that episodes of depression require several months or longer of antidepressant treatment beyond the response in the acute episode 1
• Periodically reassess the need for maintenance treatment and the appropriate dose 1

Discontinuation Protocol

• When discontinuing treatment in patients on 300 mg once daily, decrease the dose to 150 mg once daily prior to discontinuation to minimize withdrawal symptoms 1

Formulation Differences

• The three formulations of bupropion (immediate release, sustained release, and extended release) are bioequivalent in terms of systemic exposure but differ in their dosing frequency 6, 7
• Extended release (XL) formulation allows for once-daily dosing, which may improve adherence compared to multiple daily doses required for other formulations 7

Starting with 150mg daily for a week before increasing to 300mg daily is a prudent approach that balances efficacy with safety by allowing the patient to adjust to the medication while minimizing the risk of adverse effects, particularly seizures.