What is the recommended dosing of Wellbutrin (bupropion) to mitigate sexual side effects in patients taking Lexapro (escitalopram)?

Bupropion Dosing for SSRI-Induced Sexual Dysfunction

Start bupropion sustained-release at 150 mg once daily in the morning, then increase to 150 mg twice daily (300 mg/day total) after 3-7 days if tolerated, which is the most effective dose for reversing sexual side effects from escitalopram. 1, 2

Dosing Strategy

Initial Dosing

• Begin with 150 mg once daily in the morning 1
• Most improvement (>50%) occurs within the first 2 weeks at lower doses (100-200 mg/day) 1
• This starting dose minimizes insomnia risk while assessing tolerability 3

Dose Escalation

• Increase to 150 mg twice daily (300 mg/day total) after 3-7 days if the initial dose is well-tolerated 3, 1
• The second dose should be taken before 3 PM to minimize insomnia risk 3
• Maximum dose is 150 mg twice daily (300 mg/day total) for sexual dysfunction management 3

Expected Response

Efficacy Data

• Overall response rates: 75% in men and 46% in women 1
• Bupropion improves all categories of SSRI-induced sexual dysfunction, including decreased libido, erectile dysfunction, delayed orgasm, and anorgasmia 1, 4
• Significantly lower rates of sexual adverse events compared to SSRIs like fluoxetine and sertraline 3

Timeline

• Most patients experience improvement within the first 2 weeks of treatment 1
• Allow 4-8 weeks for full therapeutic assessment, consistent with general antidepressant augmentation principles 3

Critical Safety Considerations

Contraindications

• Do not use in patients with seizure disorders or conditions that lower seizure threshold (including eating disorders, abrupt alcohol/benzodiazepine discontinuation, brain metastases) 3
• Avoid in highly agitated patients due to activating properties 3
• Contraindicated with MAO inhibitors (increased hypertensive reaction risk) 3

Monitoring Requirements

• Monitor for worsening depression and suicidal ideation, particularly in the first 1-2 weeks after initiation 3
• Assess for increased agitation, irritability, or unusual behavioral changes 3
• Evaluate both antidepressant response and sexual function improvement at 2-week intervals initially 3, 1

Common Pitfalls to Avoid

Dosing Errors

• Do not exceed 300 mg/day total dose when using for sexual dysfunction augmentation 3
• Avoid giving the second dose after 3 PM, which increases insomnia risk 3
• Do not increase doses too rapidly (wait at least 3 days between increases) 3

Clinical Management

• Continue the escitalopram at its current therapeutic dose—do not reduce it when adding bupropion 2
• The combination of bupropion with SSRIs is generally well-tolerated and can both boost antidepressant response and reduce sexual side effects 2
• If no improvement in sexual function occurs after 6-8 weeks at 300 mg/day, consider alternative strategies rather than exceeding maximum dose 3, 4

Alternative Considerations

If bupropion is contraindicated or ineffective:

• For men with erectile dysfunction specifically: Sildenafil or tadalafil are highly effective alternatives (sildenafil improves ability to achieve and maintain erections by approximately one full point on frequency scales, equivalent to moving from "sometimes" to "most times") 4
• Switching antidepressants to one with lower sexual side effect profiles may be considered, though this requires careful monitoring for depression recurrence 4