What is the starting dose for bupropion (Bupropion) in the treatment of Major Depressive Disorder (MDD) with anxiety?

Starting Dose for Bupropion in MDD with Anxiety

For bupropion SR (sustained-release), start with 150 mg once daily in the morning for 3 days, then increase to 150 mg twice daily (300 mg total daily dose). 1, 2

Initial Dosing Strategy

• The FDA-approved starting dose for bupropion XL (extended-release) in MDD is 150 mg once daily in the morning, with an increase to the target dose of 300 mg once daily after 4 days if tolerated. 2

• For bupropion SR formulation, the American Family Physician recommends 150 mg once daily for the first 3 days, then titrating to 150 mg twice daily (300 mg total). 1

• The second dose of bupropion SR should be administered before 3 PM to minimize insomnia risk, which is particularly important given the activating properties of this medication. 1

Special Considerations for Anxiety Comorbidity

• While bupropion is FDA-approved for MDD, the presence of comorbid anxiety does not appear to significantly affect its comparative efficacy based on STAR*D trial analyses. 3

• Bupropion's activating properties may theoretically worsen anxiety in some patients, so close monitoring for increased agitation is warranted during initiation. 1

• The gradual dose titration (starting at 150 mg daily before increasing) helps minimize adverse effects including potential anxiety exacerbation. 2

Dosing Adjustments for Special Populations

• For older adults, start with a lower dose of 37.5 mg every morning, increasing by 37.5 mg every 3 days as tolerated, with a maximum of 150 mg twice daily (300 mg total). 1, 4

• For patients with moderate to severe hepatic impairment (Child-Pugh score 7-15), the maximum dose is 150 mg every other day. 2

• For patients with renal impairment (GFR <90 mL/min), reduce the total daily dose by half. 1, 2

Critical Safety Monitoring

• Bupropion is absolutely contraindicated in patients with seizure disorders, eating disorders (bulimia/anorexia), or those who have abruptly discontinued alcohol or benzodiazepines due to increased seizure risk. 1, 4, 2

• Monitor blood pressure regularly, as bupropion should be avoided in patients with uncontrolled hypertension. 1, 4

• Watch for neuropsychiatric symptoms, particularly in patients under 24 years old, as with all antidepressants. 1, 4

• The maximum dose should not exceed 450 mg per day for XL formulation or 400 mg per day for SR formulation to minimize seizure risk. 1, 2

Administration Guidelines

• Administer bupropion in the morning to leverage its activating properties and improve energy levels. 1

• Tablets should be swallowed whole and not crushed, divided, or chewed to maintain the extended-release properties and minimize seizure risk. 4, 2

• Bupropion may be taken with or without food. 4, 2

Efficacy Timeline

• Evaluate treatment response after 6-8 weeks at an adequate dose; if no response is seen, consider alternative treatment strategies. 1, 4

• The onset of action is typically 2 weeks, with full efficacy attained at 4 weeks of treatment. 5