What is the recommended dosing of Wellbutrin (bupropion) for an adult patient with depression and a history of smoking?

Wellbutrin Dosing for Depression and Smoking Cessation

For an adult patient with both depression and smoking history, start bupropion SR at 150 mg once daily for 3 days, then increase to 150 mg twice daily (300 mg total daily dose), beginning treatment 1-2 weeks before the target smoking quit date. 1

Standard Dosing Protocol

For Major Depressive Disorder

• Initial dose: 150 mg once daily for 3 days 1
• Maintenance dose: 150 mg twice daily (300 mg total daily) 1
• Maximum dose: 400 mg/day for SR formulation or 450 mg/day for XL formulation 1

For Smoking Cessation

• Standard dose: 150 mg twice daily (300 mg total) of SR formulation 1
• Treatment initiation: Begin 1-2 weeks before target quit date to establish therapeutic drug levels 1
• Treatment duration: 7-12 weeks after quit date, with efficacy assessment at completion 1

Critical Timing Considerations

Administer the first dose in the morning and the second dose before 3 PM to minimize insomnia risk. 1 This timing is essential because bupropion has activating properties that can disrupt sleep if taken late in the day. 1

Dual Benefit for Your Patient Population

Bupropion is particularly advantageous for patients with comorbid depression and smoking, as it addresses both conditions simultaneously through a single medication. 1 This represents an efficient treatment strategy that may improve adherence compared to multiple medications. 1

The medication demonstrated efficacy in smokers with a history of major depression, showing a significant dose-response effect for smoking cessation independent of depression history. 2 Additionally, when added to SSRI treatment in depressed patients, bupropion SR achieved 32% abstinence rates at 9 weeks without emergent depression. 3

Titration Strategy for Special Circumstances

For patients requiring more gradual titration (elderly, multiple medications, or tolerability concerns):

• Start: 37.5 mg once daily in the morning 1
• Titrate: Increase by 37.5 mg every 3 days as tolerated 1
• Target: 150 mg twice daily (maximum 300 mg/day) 1

Absolute Contraindications

Do not prescribe bupropion if the patient has: 1, 4

• Any seizure disorder or history of seizures (seizure risk approximately 0.1% at 300 mg/day) 1, 5
• Current or recent (within 14 days) MAOI use 1
• Abrupt discontinuation of alcohol, benzodiazepines, barbiturates, or antiepileptic drugs 1
• Eating disorders (bulimia or anorexia nervosa) due to increased seizure risk 1
• Uncontrolled hypertension 1

Required Dose Adjustments

Hepatic Impairment

• Moderate to severe: Maximum 150 mg daily (one tablet) 1
• Mild: Consider dose reduction and/or decreased frequency 1

Renal Impairment

• Moderate to severe (GFR <90 mL/min): Reduce total daily dose by 50% 1
• End-stage renal disease: Avoid use 1

Monitoring Requirements

Initial Phase (First 1-2 weeks)

• Mental status examination focusing on suicidal ideation, particularly in patients under 24 years old (black box warning for increased suicidal thoughts) 1
• Blood pressure and heart rate monitoring, especially during first 12 weeks 1
• Watch for neuropsychiatric symptoms including agitation, anxiety, or behavioral changes 1

Treatment Response Assessment

• Allow 6-8 weeks at adequate dose before determining treatment response for depression 1
• Assess smoking cessation efficacy after 7-12 weeks of treatment 1
• Energy levels may improve more rapidly (within first few weeks) compared to other antidepressants 1

Common Pitfalls to Avoid

Do not exceed 300 mg/day for smoking cessation to maintain seizure risk at 0.1%. 1 The maximum dose for depression treatment is higher (400 mg/day SR or 450 mg/day XL), but for smoking cessation specifically, the 300 mg limit must be observed. 1

Do not start smoking cessation treatment without the 1-2 week lead time for drug levels to build up before the quit date. 1 This pre-loading period is essential for therapeutic efficacy.

Monitor for weight changes: Among continuously abstinent smokers, bupropion at 300 mg/day resulted in mean weight gain of only 1.5 kg compared to 2.9 kg with placebo. 6 This is an additional benefit for patients concerned about post-cessation weight gain.

Clinical Advantages

Bupropion demonstrates a favorable side effect profile with lower rates of sexual dysfunction compared to SSRIs. 1 In fact, 16% of patients on SSRIs who added bupropion spontaneously reported improvement in SSRI-associated sexual dysfunction. 3

The most common adverse events (insomnia and dry mouth) are generally transient and often resolve without intervention, with only 6-12% discontinuation rates in clinical trials. 5