Can I prescribe bupropion sustained‑release (Wellbutrin) for smoking cessation in an adult smoker without seizure disorder, eating disorder, recent monoamine‑oxidase inhibitor use, or uncontrolled hypertension, and what is the appropriate dosing schedule?

Bupropion Sustained-Release for Smoking Cessation

Yes, you can prescribe bupropion SR (Wellbutrin) 150 mg twice daily for smoking cessation in this patient, starting 1–2 weeks before the target quit date and continuing for 7–12 weeks after quitting. 1, 2

Prescribing Protocol

Pre-Treatment Screening

Before prescribing, confirm the patient does not have any of these absolute contraindications:

• Any seizure disorder or prior seizure 1, 2
• Current or recent (within 14 days) MAOI use 1, 2
• Eating disorder (bulimia or anorexia nervosa) 1, 3
• Uncontrolled hypertension 1, 4
• Severe hepatic cirrhosis 3, 5
• Closed-angle glaucoma 1, 4
• Abrupt discontinuation of alcohol, benzodiazepines, or antiepileptic drugs 1

Dosing Schedule

The standard regimen is:

• Days 1–3: 150 mg once daily in the morning 1, 2
• Day 4 through end of treatment: 150 mg twice daily (total 300 mg/day) 1, 2
• Maximum dose: Do not exceed 300 mg/day for smoking cessation—this maintains seizure risk at approximately 0.1% (1 in 1,000) 1, 2, 3

Critical timing: Start bupropion 1–2 weeks before the planned quit date to establish therapeutic drug levels before the cessation attempt. 1, 2 Do not start on the quit date itself—this lead time is essential for efficacy. 1

Treatment Duration

Continue bupropion for 7–12 weeks after the quit date, then formally assess efficacy. 1, 2 If the patient has successfully quit, extending therapy beyond 12 weeks may help prevent relapse. 2

Expected Efficacy

Bupropion increases 12-month abstinence rates by approximately 9–10 percentage points compared to placebo (≈19% quit rate versus 11% with placebo), when combined with behavioral support. 1, 2, 3 This benefit is independent of the patient's depression history, though patients with comorbid depression may experience dual benefit. 1, 2

Monitoring Requirements

Baseline Assessment

• Measure blood pressure and heart rate before initiating therapy 1, 4
• Screen for psychiatric history and assess suicide risk, especially in patients younger than 24 years 2, 4

During Treatment

• Monitor blood pressure periodically, particularly in the first 12 weeks, as bupropion can cause modest elevations 1, 4
• Assess for neuropsychiatric symptoms (hostility, agitation, depressed mood, suicidal ideation), especially in patients under 24 years 1, 2, 4
• Instruct the patient to discontinue bupropion and contact you immediately if severe neuropsychiatric symptoms emerge 4

Common Side Effects

The most frequent adverse effects are:

• Insomnia (≈24% versus 15% with placebo)—mitigate by taking the second daily dose before 3 PM 1, 6
• Dry mouth (≈13% versus 5% with placebo) 1, 6
• Headache and nausea (higher than placebo) 1, 6

These effects are generally transient and often resolve without intervention; if necessary, they can be managed by dose reduction. 6

Serious Adverse Events (Rare)

• Seizure risk: Approximately 0.1% (1 in 1,000) at the 300 mg/day dose 1, 2, 3
• Severe hypersensitivity reactions: Approximately 0.1% (1 in 1,000) 1, 3
• Neuropsychiatric events: The large EAGLES trial (n = 8,144) found no significant increase in neuropsychiatric adverse events with bupropion compared to nicotine patch or placebo, even among participants with pre-existing psychiatric disorders 1, 2

Dose Adjustments for Special Populations

• Moderate to severe hepatic impairment: Maximum 150 mg daily (one tablet) 1, 2
• Moderate to severe renal impairment (GFR <90 mL/min): Reduce total daily dose by 50% 1, 2

Combination with Nicotine Replacement Therapy

Adding nicotine replacement therapy (NRT) to bupropion yields a 12-month abstinence rate of 35.5% versus 30.3% with bupropion alone, though this difference did not reach statistical significance. 1, 2 The combination is safe and can be used in patients with established cardiovascular disease. 2 Start NRT on the actual quit date, not when starting bupropion. 1

Behavioral Support Integration

Bupropion should be combined with behavioral counseling for optimal outcomes. 2 Evidence for bupropion efficacy comes primarily from studies that included behavioral support. 2 Comprehensive programs with individualized counseling plus pharmacotherapy can increase 6-month cessation rates from 6.8% to 21.3% compared to verbal advice alone. 2

Critical Clinical Pitfalls to Avoid

• Do not start bupropion on the quit date—the 1–2 week lead time is mandatory for therapeutic drug levels 1, 2
• Do not exceed 300 mg/day for smoking cessation—higher doses increase seizure risk 1, 2
• Do not skip meticulous screening for seizure-risk factors before initiating therapy 1, 2
• Do not prescribe if the patient has uncontrolled hypertension—this is an absolute contraindication 1, 4

Discontinuation

After the 7–12 week treatment course, bupropion can be stopped abruptly without tapering in most patients, as it does not cause a classic withdrawal syndrome. 7 Monitor for depression relapse weekly for 4 weeks after discontinuation. 7