What is the recommended dosage and treatment plan for using Wellbutrin (bupropion) for smoking cessation?

Bupropion (Wellbutrin) Dosage and Treatment Plan for Smoking Cessation

The recommended dosage of bupropion for smoking cessation is 150 mg once daily for 3 days, then 150 mg twice daily for 7-12 weeks, with treatment initiated 1-2 weeks before the quit date. 1

Dosing Protocol

• Initiation phase: Begin bupropion 1-2 weeks prior to the target quit date 1

  • Days 1-3: 150 mg orally, once daily 1
  • Day 4 onward: 150 mg orally, twice daily (if tolerated) 1
  • Maximum dose: 300 mg per day 1

• Duration: 7-12 weeks of treatment 1

  • Prescribe for shorter durations initially (e.g., 4 weeks) and provide additional medication only if the quit attempt is continuing 1
  • Consider extending therapy to promote continued cessation (6 months to 1 year) in successful quitters 1

Monitoring and Follow-up

• Evaluate the patient's response after the first 4 weeks 1
• Provide an additional month of treatment if the quit attempt is continuing 1
• Monitor for development or worsening of neuropsychiatric issues (depression, suicidal ideation) 1
• Track attempts at smoking reduction; if efforts stall, consider switching to a different pharmacotherapy 1

Contraindications and Precautions

• Contraindicated in patients with:

  • Seizure disorders or risks (stroke, brain metastases) 1
  • Those taking MAO inhibitors (increased risk of hypertensive reactions) 1
  • Those taking tamoxifen 1
  • Closed-angle glaucoma 1
  • History of bipolar disorder 2
  • Severe hepatic cirrhosis 2
  • Eating disorders 2

• Common side effects:

  • Dry mouth 1
  • Sleep disturbance 1
  • Headaches 1
  • Nausea 1

• Serious but rare side effects (monitor closely):

  • Seizures (estimated risk: 0.1%) 1
  • Allergic/hypersensitivity reactions 1
  • Neuropsychiatric symptoms 1

Alternative and Combination Approaches

• First-line options for smoking cessation include:

  • Bupropion (as described above) 1
  • Combination NRT (nicotine patch + short-acting NRT) 1
  • Varenicline 1

• Regarding combination therapy:

  • Bupropion can be used with NRT, though evidence for superior efficacy compared to either agent alone is mixed 1, 3
  • A meta-analysis of 12 trials showed a nonsignificant trend toward improved cessation with the addition of NRT to bupropion 1
  • One study found 69% abstinence at 6 months with bupropion plus nicotine patches 4

Special Considerations

• Bupropion may be particularly beneficial for smokers with a history of depression 1
• Longer duration of bupropion treatment may help prevent relapse in those who have successfully quit 1
• Bupropion appears to be as effective as NRT but less effective than varenicline for smoking cessation 3
• When comparing efficacy: varenicline > bupropion ≈ NRT 1, 5

Behavioral Support

• Combine pharmacotherapy with behavioral support to increase cessation rates 1
• Behavioral interventions should include:
  • Social support 1
  • Training in practical problem-solving skills 1
  • Multiple sessions (at least 4 in-person counseling sessions) 1

Common Pitfalls to Avoid

• Prescribing the full course initially: Instead, prescribe for 4 weeks initially and then reassess, as many quit attempts fail early 1
• Inadequate pre-quit preparation: Starting bupropion on the quit date is less effective; ensure it's started 1-2 weeks before quitting 1
• Ignoring psychiatric history: Carefully screen for seizure risk and psychiatric conditions before prescribing 1
• Neglecting behavioral support: Pharmacotherapy works best when combined with counseling 1
• Continuing medication despite relapse: If the patient resumes smoking, reassess the treatment approach 1