What is the recommended dose of Wellbutrin (bupropion) for a patient trying to quit smoking?

Wellbutrin (Bupropion) Dosing for Smoking Cessation

For smoking cessation, use bupropion SR 150 mg twice daily (300 mg total per day), starting 1-2 weeks before the target quit date and continuing for 7-12 weeks. 1, 2

Standard Dosing Protocol

Titration schedule:

• Days 1-3: 150 mg once daily in the morning 1, 2
• Day 4 onward: 150 mg twice daily (morning and early afternoon, with second dose before 3 PM to minimize insomnia) 1, 2
• Maximum dose: 300 mg/day for smoking cessation—never exceed this to maintain seizure risk at 0.1% 1, 2

Critical timing:

• Begin treatment 1-2 weeks before the quit date to establish therapeutic drug levels 1, 2
• Continue for 7-12 weeks after the quit date 1, 2
• Assess efficacy formally at the end of this treatment period 1, 2

Efficacy Data

Bupropion improves 12-month sustained abstinence rates by approximately 9-10 percentage points above placebo (from 12-16% with placebo to 19-30% with bupropion). 2, 3, 4 The highest abstinence rates (35.5% at 12 months) occur when combining bupropion with nicotine replacement therapy, though this difference versus bupropion alone (30.3%) was not statistically significant. 3

Combination with Nicotine Replacement Therapy

Start nicotine patches on the actual quit date (not when starting bupropion), while continuing bupropion at 150 mg twice daily. 1 This combination addresses nicotine withdrawal through different mechanisms and shows the highest cessation rates in clinical trials. 1, 3

Absolute Contraindications

Do not prescribe bupropion if the patient has:

• Any seizure disorder or history of seizures 1, 2
• Current or recent (within 14 days) MAOI use 1, 2
• Eating disorders (bulimia or anorexia nervosa) 1, 5
• Abrupt discontinuation of alcohol, benzodiazepines, or antiepileptic drugs 1
• Severe hepatic cirrhosis 5
• Uncontrolled hypertension 1, 2

Dose Adjustments for Special Populations

Hepatic impairment:

• Moderate to severe: Maximum 150 mg daily (one tablet total per day) 1, 2

Renal impairment:

• Moderate to severe (GFR <90 mL/min): Reduce total daily dose by 50% 1, 2

Monitoring Requirements

Monitor for:

• Neuropsychiatric adverse effects (hostility, agitation, depressed mood, suicidal thoughts), especially in patients under 24 years 1, 2
• Blood pressure and heart rate, particularly in first 12 weeks 1, 2
• Seizure risk factors throughout treatment 1, 2

Common Side Effects

Most frequent adverse events include:

• Insomnia (most common—administer second dose before 3 PM) 1, 6, 3
• Dry mouth 5, 6, 3
• Headache 6, 3
• Nausea 1

These side effects are typically transient and often resolve without intervention; they can be managed by dose reduction if necessary. 6 Discontinuation rates due to adverse events are low (6-12% in clinical trials). 6

Seizure Risk

The seizure risk at 300 mg/day is approximately 0.1% (1 in 1,000), similar to other antidepressants. 2, 5 This risk increases significantly if the maximum dose is exceeded or if contraindications are ignored. 1, 2

Clinical Advantages

Bupropion may be particularly beneficial for:

• Patients with comorbid depression who want to quit smoking, addressing both conditions simultaneously 1, 2
• Patients concerned about weight gain, as bupropion is associated with reduced weight gain compared to placebo (1.5-1.7 kg versus 2.1 kg at 7 weeks) 3, 4

Behavioral Support Integration

All efficacy data for bupropion comes from studies that included behavioral support. 2 Combining pharmacotherapy with counseling programs can increase 6-month cessation rates from 6.8% to 21.3% compared to verbal advice alone. 2 Provide structured behavioral support, set a definite quit date, and arrange weekly follow-up sessions for at least four weeks. 7

Treatment Failure

If the patient has not achieved significant progress toward abstinence by weeks 7-12, reassess the treatment plan. 2 Consider adding nicotine replacement therapy if not already prescribed, or evaluate for unaddressed barriers to cessation. 1