Should bupropion be avoided in patients with Chronic Kidney Disease (CKD) stage 4, also known as Severe Impaired Renal Function?

From the Guidelines

Bupropion should be avoided in patients with end-stage renal disease, but for CKD stage 4, the dose should be reduced by one-half, as indicated in the study 1. When considering the use of bupropion in patients with chronic kidney disease (CKD) stage 4, it's crucial to weigh the potential benefits against the risks, particularly focusing on morbidity, mortality, and quality of life. The primary concern with bupropion in renal impairment is the accumulation of the drug and its active metabolites, which could increase the risk of adverse effects such as seizures, agitation, and insomnia.

• The medication is primarily metabolized by the liver, but a significant portion is excreted through the kidneys, necessitating dose adjustments in patients with renal impairment.
• According to the guideline evidence 1, in patients with moderate to severe renal impairment, the total daily dose of bupropion should be reduced by one-half.
• Close monitoring for adverse effects is essential, and alternative antidepressants with less renal clearance might be considered if side effects worsen or tolerance becomes an issue.
• Regular assessment of both renal function and therapeutic response is recommended during treatment, ensuring that the benefits of bupropion use outweigh the potential risks in patients with CKD stage 4. Given the information from 1, the approach to using bupropion in CKD stage 4 should prioritize caution, reduced dosing, and vigilant monitoring to optimize patient outcomes in terms of morbidity, mortality, and quality of life.

From the FDA Drug Label

Bupropion and its metabolites are cleared renally and may accumulate in such patients to a greater extent than usual Monitor closely for adverse reactions that could indicate high bupropion or metabolite exposures [see Dosage and Administration (2.7)and Clinical Pharmacology (12.3)]. Consider a reduced dose and/or dosing frequency of bupropion hydrochloride extended-release tablets (XL) in patients with renal impairment (glomerular filtration rate: <90 mL/min).

Bupropion use in CKD 4:

• The drug label recommends considering a reduced dose and/or dosing frequency in patients with renal impairment (glomerular filtration rate: <90 mL/min) 2.
• CKD 4 is defined as a glomerular filtration rate (GFR) of 15-29 mL/min, which is lower than the threshold of 90 mL/min mentioned in the label.
• It is recommended to avoid or use with caution bupropion in patients with CKD 4, as the risk of adverse reactions may be greater due to decreased renal function.
• Monitoring for adverse reactions is advised.

From the Research

Bupropion Use in CKD 4 Patients

• The use of bupropion in patients with chronic kidney disease (CKD) stage 4 requires careful consideration due to altered drug pharmacokinetics 3.
• A systematic review of antidepressant use in CKD patients found that bupropion clearance is markedly reduced in CKD stages 3-5, suggesting the need for dose reduction 3.
• However, there is limited evidence on the effectiveness and safety of bupropion in CKD 4 patients, and more research is needed to inform clinical decision-making 3.
• In general, patients with CKD require careful monitoring and dose adjustment of medications due to the risk of adverse drug reactions 4, 5.

Dose Reduction and Monitoring

• Dose reduction of bupropion may be necessary in CKD 4 patients to minimize the risk of adverse effects 3.
• Healthcare providers should carefully monitor patients with CKD 4 who are taking bupropion, including regular assessments of kidney function and adjustment of the dose as needed 4, 5.
• The use of bupropion in CKD 4 patients should be individualized, taking into account the patient's specific clinical needs and medical history 6.

Comparative Safety and Efficacy

• Bupropion has been shown to be effective as an antidepressant in various patient populations, including those with CKD 6.
• However, the comparative safety and efficacy of bupropion in CKD 4 patients versus other antidepressants is not well established, and more research is needed to inform clinical decision-making 7, 6.