From the Research
For patients on dialysis, a conservative starting dose of bupropion is typically 100 mg every other day of the immediate-release formulation or 150 mg every 3 days of the extended-release formulation, as recommended by the most recent study 1. This medication should be used with caution in dialysis patients as bupropion and its metabolites can accumulate in renal impairment, potentially increasing the risk of adverse effects such as seizures. Bupropion is primarily metabolized by the liver, but approximately 20% of the drug and its metabolites are eliminated through the kidneys. While dialysis does not efficiently remove bupropion, dose adjustment is still necessary due to the reduced renal clearance. Patients should be monitored closely for side effects including insomnia, headache, dry mouth, nausea, and most importantly, seizures, as the seizure risk may be elevated in this population. Gradual dose titration based on clinical response and tolerability is recommended, with a maximum daily dose that should generally not exceed 150 mg of immediate-release or 300 mg of extended-release formulation in dialysis patients. If the patient experiences adverse effects, consider maintaining a lower dose or switching to an alternative antidepressant with better established safety in renal failure. The most recent and highest quality study on this topic is from 2004 1, which provides guidance on the pharmacokinetics of bupropion in haemodialysis patients. Other studies, such as those from 2007 2 and 2012 3, also support the need for dose adjustment in patients with renal impairment, but the 2004 study provides the most specific guidance for patients on dialysis. A more recent study from 2016 4 provides a general review of the effectiveness of bupropion as an antidepressant, but does not provide specific guidance for patients on dialysis. Therefore, the recommendation is based on the most recent and highest quality study available, which is the 2004 study 1. Some key points to consider when prescribing bupropion to patients on dialysis include:
- Starting with a low dose and gradually titrating up as needed and tolerated
- Monitoring closely for side effects, particularly seizures
- Considering alternative antidepressants with better established safety in renal failure if adverse effects occur
- Being aware of the potential for accumulation of bupropion and its metabolites in renal impairment.