Bupropion XL for Sexual Dysfunction in Patients on Cariprazine
For your patient on Vraylar 1.5mg with low sex drive who you've started on Wellbutrin 150mg, prescribe the XL (extended-release) formulation taken once daily in the morning.
Rationale for XL Over SR
Dosing Convenience and Adherence
- Bupropion XL is administered as 300mg once daily in the morning, while SR requires 150mg twice daily dosing 1, 2
- The once-daily XL formulation improves adherence, which is critical when treating sexual dysfunction that may already be affecting quality of life 1
- For sexual desire disorders specifically, maintaining consistent therapeutic levels throughout the day with a single dose is preferable 2
Evidence for Sexual Dysfunction Treatment
- Bupropion SR at 150mg twice daily (300mg total) has demonstrated efficacy in treating hypoactive sexual desire disorder (HSDD) in women, with 29% response rates in nondepressed women and up to 66% improvement in various sexual complaints when used as adjunctive therapy 3, 4
- The total daily dose of 300mg is what matters for efficacy in sexual dysfunction, not the formulation - both SR (150mg BID) and XL (300mg once daily) deliver the same total exposure 1, 2
- Bupropion has significantly lower rates of sexual dysfunction compared to serotonergic antidepressants (7-15% vs 41-63%), making it the primary pharmacologic agent for HSDD 5, 6
Practical Titration Strategy
- Start with 150mg XL once daily in the morning for 4-7 days to assess tolerability 2
- Increase to the target dose of 300mg XL once daily in the morning after the initial titration period 1, 2
- Administer in the morning to minimize insomnia risk, which occurs in 7-12% of patients 7, 2
Critical Safety Considerations
Seizure Risk Management
- The maximum dose should not exceed 450mg per day for XL formulation to minimize seizure risk 1, 2
- Never crush, divide, or chew XL tablets - this destroys the extended-release mechanism and increases seizure risk 2
- Contraindicated in patients with seizure disorders, eating disorders (bulimia/anorexia), or abrupt discontinuation of alcohol/benzodiazepines 1, 2
Monitoring Parameters
- Assess efficacy after 6-8 weeks at the target dose of 300mg daily 1
- Monitor blood pressure, as bupropion should be avoided in uncontrolled hypertension 1
- Screen for neuropsychiatric adverse effects, particularly in younger patients 1
Drug Interaction with Cariprazine
- While not specifically addressed in the evidence, both medications can be activating - monitor for increased anxiety, agitation, or insomnia 7
- The second dose timing concern with SR (must be before 3pm) is eliminated with once-daily XL dosing 1, 7
Common Pitfalls to Avoid
- Do not prescribe SR unless the patient has specific reasons requiring twice-daily dosing (such as dose adjustments for hepatic/renal impairment where flexibility is needed) 1
- Avoid evening administration of any bupropion formulation due to insomnia risk 7
- Do not abruptly discontinue - when stopping 300mg XL, taper to 150mg XL for a period before complete discontinuation 2
- Ensure adequate renal function assessment - if GFR <90 mL/min, consider dose reduction 1, 2