How do you taper off Wellbutrin (bupropion) 150mg Extended Release (ER) and start Effexor (venlafaxine) in an adult patient with a history of depression?

How to Taper Off Wellbutrin 150mg ER and Start Effexor

For a patient on Wellbutrin (bupropion) 150mg ER, you can typically stop the medication without a formal taper at this dose, then wait 24 hours before starting Effexor (venlafaxine) at 37.5-75mg daily, titrating up as tolerated. 1, 2

Discontinuing Wellbutrin 150mg ER

Bupropion at 150mg daily does not require a gradual taper before discontinuation. 3, 1 The FDA label for bupropion specifies that tapering is only recommended when discontinuing the 300mg dose—in that case, you would decrease to 150mg before stopping. 1 Since your patient is already at 150mg, you can proceed directly to discontinuation. 1

Key Considerations for Bupropion Discontinuation:

• No formal taper needed at 150mg: The available evidence does not provide explicit protocols for tapering bupropion below 150mg, and the FDA label only recommends tapering from 300mg to 150mg before stopping. 3, 1

• Monitor for mood changes: While bupropion has minimal withdrawal symptoms compared to serotonergic antidepressants, monitor the patient within 1-2 weeks after discontinuation for worsening depression or suicidal ideation, particularly in patients under 24 years old. 4, 3

• Ensure adequate treatment duration: Do not discontinue prematurely—treatment for a first episode of major depression should last at least 4 months. 3 Only proceed with discontinuation if the patient has completed adequate treatment duration or if switching is clinically necessary. 3

Starting Effexor (Venlafaxine)

Begin venlafaxine 24 hours after the last dose of bupropion. 1, 2 Unlike switching between serotonergic antidepressants or MAOIs, there is no required washout period between bupropion and venlafaxine since they work through different mechanisms. 1, 2

Venlafaxine Initiation Protocol:

• Starting dose: Begin with 37.5-75mg once daily. 2 The lower starting dose (37.5mg) is preferable if the patient has anxiety, is elderly, or has concerns about tolerability. 2

• Titration schedule: After 4-7 days at the starting dose, increase to 75mg daily if tolerated, then to 150mg daily (the typical therapeutic dose for depression) after another week. 2

• Target dose: Most patients with major depressive disorder require 75-225mg daily for adequate response. 2

• Timing: Venlafaxine can be taken with or without food, but consistent timing helps maintain steady levels and reduces side effects. 2

Critical Safety Monitoring

During the Transition:

• Screen for bipolar disorder: Before starting venlafaxine, ensure the patient has been adequately screened for bipolar disorder, as antidepressants can precipitate manic episodes. 2 This is particularly important when switching medications. 2

• Monitor for suicidality: The FDA black box warning applies to venlafaxine—closely monitor for worsening depression, suicidal thoughts, or unusual behavioral changes, especially in the first few months and particularly in patients under 25 years old. 2

• Watch for serotonin syndrome: Although bupropion is not serotonergic, be vigilant for serotonin syndrome symptoms when starting venlafaxine, especially if the patient is on other serotonergic medications. 2 Symptoms include mental status changes, autonomic instability, neuromuscular symptoms, and GI disturbances. 2

• Blood pressure monitoring: Venlafaxine can increase blood pressure, particularly at higher doses. 2 Check blood pressure before starting and periodically during treatment. 2

Common Pitfalls to Avoid:

• Don't assume all patients need a taper: While gradual tapering is critical for many antidepressants (especially SSRIs and SNRIs), bupropion at 150mg can typically be stopped without a formal taper. 3, 1, 5

• Don't start venlafaxine too quickly: Allow 24 hours after the last bupropion dose to ensure the patient tolerates the discontinuation before introducing a new medication. 1, 2

• Don't ignore withdrawal symptoms: If the patient develops significant symptoms after stopping bupropion (though uncommon), consider restarting at a lower dose and tapering more gradually. 3, 6

• Don't rush venlafaxine titration: Venlafaxine has a higher risk of discontinuation symptoms than many antidepressants due to its short half-life. 5 Starting low and going slow establishes better tolerance and reduces the risk of future withdrawal issues if discontinuation becomes necessary. 5

Alternative Approach: Cross-Taper (If Needed)

If the patient has severe depression or high relapse risk, consider a brief cross-taper: 6

• Day 1-3: Continue bupropion 150mg ER, start venlafaxine 37.5mg
• Day 4-7: Stop bupropion, continue venlafaxine 37.5mg
• Day 8+: Increase venlafaxine to 75mg and continue titration as above

This approach minimizes the period without antidepressant coverage but requires careful monitoring for drug interactions and side effects. 6 However, for most patients, the sequential approach (stop bupropion, wait 24 hours, start venlafaxine) is simpler and equally safe. 1, 2, 6