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

Wellbutrin (Bupropion) for Smoking Cessation

Start bupropion SR at 150 mg once daily for 3 days, then increase to 150 mg twice daily (300 mg total daily) for 7-12 weeks, beginning treatment 1-2 weeks before your target quit date. 1, 2

Dosing Protocol

Initiation Phase:

• Begin bupropion 1-2 weeks prior to the target quit date to establish therapeutic drug levels before the cessation attempt 1, 2
• Days 1-3: 150 mg orally once daily 1, 2
• Day 4 onward: 150 mg orally twice daily (if tolerated) 1, 2
• Maximum dose: 300 mg per day for smoking cessation 1, 2

Treatment Duration:

• Standard course: 7-12 weeks 1, 2
• Extended treatment: Can continue for 6 months to 1 year in successful quitters to prevent relapse 1
• The evidence shows 12-month sustained abstinence rates improve by 9-10 percentage points compared to placebo 3

Monitoring and Follow-Up

Assessment Schedule:

• Evaluate response after the first 4 weeks of treatment 1
• Provide an additional month of treatment if the quit attempt is continuing 1
• Formal efficacy assessment after 7-12 weeks 2

Safety Monitoring:

• Monitor for neuropsychiatric symptoms including depression, suicidal ideation, or behavioral changes 1
• Check blood pressure, as bupropion should be avoided in uncontrolled hypertension 2
• Watch for worsening symptoms in patients younger than 24 years 2

Contraindications and Precautions

Absolute Contraindications:

• Seizure disorders or any condition that lowers seizure threshold (risk approximately 1 in 1,000) 4, 1, 3
• Current use of MAO inhibitors or within 14 days of discontinuation 1, 2
• Patients taking tamoxifen 1
• Closed-angle glaucoma 1
• Eating disorders (bulimia or anorexia nervosa) due to increased seizure risk 2
• Severe hepatic cirrhosis 3

Common Side Effects:

• Dry mouth (13% vs 5% placebo) 5
• Insomnia (24% vs 15% placebo) - administer second dose before 3 PM to minimize 2, 5
• Headaches 1
• Nausea 1

Rare but Serious Side Effects:

• Seizures: approximately 1 in 1,000 4, 3
• Allergic/hypersensitivity reactions: 1 in 1,000 to 1 in 10,000 4, 1

Dose Adjustments for Special Populations

Hepatic Impairment:

• Moderate to severe impairment: Maximum 150 mg daily (one tablet total) 2

Renal Impairment:

• Moderate to severe impairment (GFR <90 mL/min): Reduce total daily dose by half 2
• Bupropion and metabolites are cleared renally and may accumulate 2

Older Adults:

• Start with 37.5 mg every morning 2
• Gradually increase by 37.5 mg every 3 days as tolerated 2
• Maximum dose: 150 mg twice daily (300 mg total) 2

Combination Therapy and Behavioral Support

Pharmacotherapy Combinations:

• Bupropion can be combined with nicotine replacement therapy (NRT), though evidence for superior efficacy is mixed 1, 6
• One study showed 69% abstinence at 6 months and 58.6% at one year when combining bupropion with nicotine patches 6

Behavioral Support:

• Combining pharmacotherapy with behavioral support significantly increases cessation rates 1
• Include social support, practical problem-solving skills training, and multiple counseling sessions 1
• Published trials demonstrating efficacy included smokers receiving frequent behavioral counseling sessions 4

Special Clinical Considerations

Depression Comorbidity:

• Bupropion may be particularly beneficial for smokers with a history of depression, addressing both conditions simultaneously 1, 2
• The efficacy in smoking cessation appears independent of its antidepressant effect 4

Weight Gain Mitigation:

• Among continuously abstinent subjects, weight gain was inversely associated with bupropion dose (1.5 kg gain at 300 mg vs 2.9 kg with placebo) 7
• Combining bupropion with naltrexone can help mitigate smoking cessation-associated weight gain 2

Common Pitfalls to Avoid

• Don't start too close to quit date: Beginning only days before quitting doesn't allow therapeutic levels to establish 1, 2
• Don't exceed maximum dose: Never exceed 300 mg/day for smoking cessation to minimize seizure risk 1, 2
• Don't skip the titration: The gradual increase from 150 mg once daily to twice daily is necessary to minimize seizure risk 2
• Don't ignore screening: Always screen for seizure risk factors, eating disorders, and medication interactions before prescribing 1, 2, 3