Is 100mg bupropion (Wellbutrin) SR adequate for an adult ADHD patient seeking improved motivation and energy, and how long to wait before titrating up?

Bupropion SR 100mg for Adult ADHD: Starting Dose and Titration

Bupropion SR 100mg daily is below the recommended starting dose for adult ADHD—you should start at 100-150mg daily and titrate to 100-150mg twice daily (200-300mg total daily) after 3 days, with dose increases every 3 days until reaching the maintenance dose. 1

Recommended Starting Protocol

The most recent guidelines specify the following dosing strategy for bupropion SR in adults with ADHD:

• Initial dose: 100-150mg once daily in the morning 1
• Titration schedule: Increase by 37.5mg every 3 days 1
• Maintenance dose: 100-150mg twice daily (total 200-300mg/day) 1
• Maximum dose: 450mg per day 1

Why 100mg Once Daily Is Inadequate

Starting at 100mg SR once daily and staying there is subtherapeutic for ADHD treatment. The evidence shows:

• Therapeutic doses begin at 200mg/day: Clinical trials demonstrating efficacy used doses ranging from 150-450mg daily, with most patients requiring at least 300mg daily for optimal response 2, 3
• Response rates improve with adequate dosing: In the largest controlled trial, 53% of patients responded to bupropion XL (up to 450mg/day) versus 31% on placebo, with effect size of 0.6 3
• Early titration is safe: Studies show bupropion is well-tolerated with low discontinuation rates (5%) when titrated appropriately 3

Specific Titration Timeline

Week 1:

• Days 1-3: 100mg once daily in the morning 1
• Day 4 onward: Increase to 150mg once daily OR split to 100mg twice daily 1

Week 2:

• Advance to 150mg twice daily (300mg total) 1
• This is the typical maintenance dose for most patients 1

Weeks 3-6:

• If inadequate response at 300mg/day, may increase to 450mg/day (150mg three times daily or 300mg morning + 150mg afternoon) 1
• Assess response using standardized ADHD rating scales 3, 4

Critical Monitoring Points

Before each dose increase, assess:

• ADHD symptom severity using validated rating scales (e.g., CAARS) 4
• Side effects: Particularly insomnia, agitation, headache, and appetite changes 3
• Seizure risk factors: Bupropion lowers seizure threshold; avoid in patients with eating disorders, seizure history, or abrupt alcohol/benzodiazepine discontinuation 1
• Blood pressure and pulse: Monitor at each visit 1

Important Timing Considerations

• Give second dose before 3 PM to minimize insomnia risk 1
• Allow 4-8 weeks for full therapeutic effect, though some patients show improvement as early as week 2 1, 3
• Reassess at 6 weeks if no response is evident—consider alternative treatments 4

Common Pitfalls to Avoid

• Staying at subtherapeutic doses: 100mg once daily will likely produce minimal benefit for ADHD symptoms 2, 3
• Titrating too slowly: The 3-day interval is evidence-based and safe; waiting weeks between increases delays therapeutic benefit 1
• Missing the second daily dose: Bupropion SR requires twice-daily dosing for sustained ADHD symptom control throughout the day 1
• Using in agitated patients: Bupropion is activating and should not be used in patients with significant agitation 1

When Bupropion Is Appropriate for ADHD

Bupropion is particularly useful as:

• Alternative to stimulants when stimulants are contraindicated, not tolerated, or ineffective 2, 3
• Adjunct for comorbid depression given its antidepressant properties 5
• Option for patients with substance use concerns as it lacks abuse potential 2
• Treatment for comorbid bipolar disorder when combined with mood stabilizers 5

Expected Outcomes

With appropriate dosing (300-450mg/day):

• Moderate symptom reduction: Approximately 50% decrease in ADHD symptom severity 3, 4
• Clinical improvement: 50-53% of patients achieve clinically significant improvement 3
• All-day coverage: Benefits extend through morning, afternoon, and evening when dosed twice daily 3
• Effect size: 0.5-0.6, which is moderate but clinically meaningful 2, 3