What is the recommended titration schedule for Wellbutrin (bupropion) in an elderly female patient in the inpatient setting?

Bupropion Titration for Elderly Female in Inpatient Setting

For an elderly female patient in the inpatient setting, start bupropion SR at 37.5 mg every morning, then increase by 37.5 mg every 3 days as tolerated, with a target dose of 150 mg twice daily and a maximum of 300 mg total daily dose. 1

Initial Dosing Strategy

• Begin with 37.5 mg once daily in the morning to minimize adverse effects and assess tolerability in elderly patients 1, 2
• This conservative starting dose is approximately 50% of the standard adult dose, which is appropriate for older adults due to increased risk of adverse reactions 1
• The morning administration leverages bupropion's activating properties while minimizing insomnia risk 1, 2

Titration Schedule

• Increase by 37.5 mg increments every 3 days as tolerated until reaching therapeutic effect or maximum recommended dose 1
• This gradual titration is necessary to minimize seizure risk while achieving therapeutic levels 1
• The inpatient setting allows for close monitoring during this titration period, which is advantageous given the need to watch for adverse effects 1

Target and Maximum Dosing

• Target dose: 150 mg twice daily (300 mg total daily dose) 1, 2
• Maximum dose: 300 mg per day for elderly patients 1, 2
• If using twice-daily dosing, administer the second dose before 3 PM to minimize insomnia risk 1, 2

Critical Safety Monitoring in the Inpatient Setting

• Monitor for increased agitation, as bupropion is an activating medication 1
• Watch for neuropsychiatric adverse effects including insomnia, anxiety, and changes in mental status 1, 2
• Assess for signs of hypomania or mania, particularly in the first 24-48 hours after any dose changes 2
• Monitor vital signs, particularly blood pressure, as bupropion should be avoided in patients with uncontrolled hypertension 1

Dose Adjustments for Comorbidities

• For moderate to severe renal impairment (GFR <90 mL/min): Reduce the total daily dose by approximately 50% 1, 2
• For moderate to severe hepatic impairment: Do not exceed 150 mg daily total 1
• These adjustments are particularly important in elderly patients who commonly have reduced renal and hepatic function 1

Absolute Contraindications

• Seizure disorders: Bupropion lowers the seizure threshold, with risk increasing at higher doses 1, 2
• Current or prior bulimia or anorexia nervosa: Increased seizure risk 1, 2
• Concurrent MAOI use or within 14 days of discontinuing MAOIs 1

Formulation Selection

• Bupropion SR (sustained-release) is preferred for elderly patients, allowing for 100-150 mg once daily initial dosing with titration to 150 mg twice daily 1, 2
• The SR formulation provides more flexible dosing compared to XL, which is beneficial when dose adjustments are needed for hepatic or renal impairment 1

Timeline for Efficacy Assessment

• Assess response after 6-8 weeks at an adequate dose 1
• In elderly patients, four to eight week acute treatment periods may be insufficient, and longer trials may be needed 3
• Most improvement in tolerability occurs within the first 2 weeks, particularly for common adverse effects like insomnia and dry mouth 4

Common Pitfalls to Avoid

• Do not exceed 300 mg total daily dose in elderly patients to minimize seizure risk (standard adult maximum is 450 mg/day, but elderly patients require lower dosing) 1, 2
• Avoid late-day dosing of the second dose, as this significantly increases insomnia risk 1, 2
• Do not titrate too rapidly, as the gradual 3-day increment schedule allows assessment of tolerability at each dose level 1
• Screen carefully for seizure risk factors before initiating therapy, as the seizure incidence is approximately 0.1% when patients are properly screened 5