Is Wellbutrin (bupropion) a suitable treatment option for a 17-year-old?

Bupropion Use in a 17-Year-Old

Bupropion is not FDA-approved for use in individuals under 18 years of age, and prescribing it to a 17-year-old requires careful consideration of the indication, close monitoring for neuropsychiatric symptoms including suicidal ideation, and informed consent acknowledging off-label use. 1

FDA Approval Status and Black Box Warnings

• Bupropion is not approved by the FDA for patients under 18 years of age, regardless of formulation or indication 1
• The medication carries a black box warning for increased risk of suicidal thoughts and actions in children, teenagers, and young adults within the first few months of treatment 1
• This warning applies across all antidepressant medications, not just bupropion specifically 1

Clinical Context for Use

For Depression/ADHD

• Bupropion has demonstrated efficacy in treating ADHD in children and adolescents in multiple clinical trials, with effectiveness comparable to methylphenidate 2
• All available open, controlled, and randomized trials showed bupropion's efficacy in improving ADHD symptoms in pediatric populations 2
• Bupropion may be particularly beneficial for adolescents with comorbid ADHD and conduct, substance use, or depressive disorders 2
• The medication is a dopamine-norepinephrine reuptake inhibitor, offering a nonstimulant alternative when stimulants are contraindicated or ineffective 2, 3

For Smoking Cessation

• While bupropion appears more effective than other pharmacologic options for adolescent smoking cessation in the short term, it is not approved by Health Canada for those under 18 years 4
• The American Academy of Pediatrics notes that tobacco-dependent adolescents who want treatment can be offered pharmacotherapy appropriate to the severity of dependence, though this requires a prescription from a licensed provider for anyone under 18 5
• More than 90% of adolescent quit attempts are unsuccessful without pharmacologic support 4

Critical Safety Monitoring Requirements

Neuropsychiatric Surveillance

• Monitor closely for new or worsening depression, suicidal thoughts or actions, anxiety, agitation, panic attacks, insomnia, irritability, hostility, aggression, impulsivity, akathisia, hypomania, or mania 1
• These symptoms may emerge when starting treatment, changing doses, or even after several weeks of stable dosing 1
• Family members and caregivers must be educated to watch for sudden changes in mood, behavior, thoughts, or feelings 1
• Schedule frequent follow-up visits, especially during the first few months of treatment 1

Seizure Risk Management

• The seizure risk with bupropion is approximately 1 in 1,000, similar to other antidepressants 6
• Maximum daily dose must not exceed 450 mg to minimize seizure risk 6, 1
• Contraindications include history of seizures, eating disorders (anorexia or bulimia), abrupt discontinuation of alcohol or benzodiazepines, or any condition lowering seizure threshold 1
• Seizure risk theoretically persists until metabolites are cleared, which takes approximately 7-9 days after discontinuation 7

Dosing Considerations for Adolescents

• Start with lower doses and titrate slowly based on response and tolerability 1
• For sustained-release formulation: typical starting dose is 100-150 mg daily, with maintenance of 100-150 mg twice daily 5
• For extended-release formulation: typical starting dose is 150 mg daily, with maintenance of 150-300 mg daily 5
• Assess stability for at least 30 days with no significant side effects before continuing 6

Special Populations and Drug Interactions

Hepatic and Renal Impairment

• In moderate to severe hepatic impairment, maximum daily dose should not exceed 150 mg, as bupropion AUC increases 3.12-fold 7
• In moderate to severe renal impairment, reduce dose by half, as exposure approximately doubles 7

Bipolar Disorder Caution

• Bupropion may precipitate manic or hypomanic episodes in patients with bipolar disorder, even when stabilized on mood stabilizers 8
• Six of 11 bipolar patients experienced manic episodes requiring bupropion discontinuation in one case series 8
• Exercise extreme caution and ensure adequate mood stabilization before initiating bupropion in any patient with personal or family history of bipolar disorder 8

Common Side Effects

• Most frequent adverse effects include nervousness, insomnia, headache, nausea, dry mouth, and constipation 1, 9
• Bupropion causes significantly less sexual dysfunction compared to SSRIs 9
• Weight gain and somnolence are less common than with tricyclic antidepressants 9

Prescribing Requirements

• A prescription from a licensed healthcare provider is legally required for anyone under 18 years to obtain bupropion 5
• Informed consent should document off-label use, potential risks including suicidal ideation and seizures, and monitoring plan 1
• Never stop bupropion suddenly; taper gradually to prevent withdrawal symptoms 1