Can You Still Use Bupropion in This Case?

Yes, bupropion can still be used in most clinical scenarios unless specific absolute contraindications are present—the decision hinges entirely on screening for seizure risk, uncontrolled hypertension, eating disorders, abrupt substance withdrawal, MAOI use, and known hypersensitivity. 1

Absolute Contraindications That Would Prohibit Bupropion Use

Before prescribing or continuing bupropion, you must verify the patient does not have any of the following:

Seizure disorder or any condition predisposing to seizures (prior head trauma, brain tumor, stroke, epilepsy, brain metastases) 2, 1
Current or prior diagnosis of bulimia or anorexia nervosa (markedly increased seizure risk) 2, 1
Abrupt discontinuation of alcohol, benzodiazepines, barbiturates, or antiepileptic drugs (precipitates withdrawal seizures) 2, 1
Current use of MAOIs or within 14 days of stopping an MAOI (risk of hypertensive crisis) 2, 1
Uncontrolled hypertension (bupropion elevates blood pressure and heart rate) 2, 1
Known hypersensitivity to bupropion (angioedema, serum sickness-like reactions occur in ~0.1% of patients) 1, 3
Concurrent opioid therapy when using naltrexone-bupropion combination products (naltrexone precipitates severe opioid withdrawal) 2

Relative Contraindications Requiring Dose Adjustment or Extreme Caution

If the patient has moderate-to-severe hepatic impairment, the maximum dose is 150 mg every other day; for mild hepatic impairment, reduce dose and/or frequency 2, 1

If the patient has moderate-to-severe renal impairment (eGFR <90 mL/min), reduce the total daily dose by 50% (e.g., 150 mg once daily instead of 300 mg); avoid entirely in end-stage renal disease 2, 1

Critical Safety Screening Before Initiating or Continuing Bupropion

Cardiovascular Assessment

Measure baseline blood pressure and heart rate before starting bupropion 2, 1
Monitor blood pressure periodically during treatment, especially in the first 12 weeks, as bupropion can cause elevations 2, 1
If blood pressure becomes uncontrolled (≥140/90 mm Hg or ≥130/80 mm Hg in high-risk patients), reduce dose or discontinue 2

Neuropsychiatric Assessment

Screen for suicidal ideation, agitation, irritability, or unusual behavioral changes, particularly in patients younger than 24 years (highest risk in first 1–2 months) 2, 1
Assess for history of bipolar disorder; if present, do not use bupropion as monotherapy—initiate mood stabilizers (lithium, valproate, lamotrigine) or atypical antipsychotics first 2
Monitor for agitation or behavioral activation during treatment, as bupropion's activating properties can worsen agitation 2

Drug Interaction Review

Verify the patient is not taking tamoxifen (bupropion inhibits CYP2D6 and reduces tamoxifen efficacy) 2, 1
Check for drugs that lower seizure threshold (antipsychotics, tricyclics, systemic corticosteroids, theophylline, stimulants) and dose bupropion cautiously 1
Confirm the patient is not on chronic opioid therapy if considering naltrexone-bupropion combination 2

Dosing Strategy to Minimize Seizure Risk

Start low and titrate gradually: Begin with 150 mg once daily for 3–4 days, then increase to 150 mg twice daily (300 mg total) if tolerated 2, 1
Maximum dose for depression: 450 mg/day (XL formulation) or 400 mg/day (SR formulation) 2, 1
Maximum dose for smoking cessation: 300 mg/day (do not exceed to maintain seizure risk at 0.1%) 2, 1
Timing of second dose: Administer the second SR dose before 3 PM to minimize insomnia risk 2

The seizure risk at 300 mg/day is approximately 0.1% (1 in 1,000 patients); this risk increases markedly above 450 mg/day 2, 4

Special Populations Where Bupropion May Be Particularly Beneficial

Patients with depression and low energy, apathy, or hypersomnia (bupropion's activating properties improve energy levels) 2
Patients concerned about sexual dysfunction (bupropion has significantly lower rates of sexual dysfunction compared to SSRIs) 2
Patients concerned about weight gain (bupropion is associated with minimal weight gain or even weight loss) 2
Patients with comorbid depression and nicotine dependence (bupropion addresses both conditions simultaneously) 2
Older adults (>65 years) when dosed appropriately (start at 50% of standard adult doses; bupropion has minimal anticholinergic effects compared to tricyclics) 2

Monitoring Timeline After Initiation

Weeks 1–2: Assess for suicidal ideation, agitation, irritability, or unusual behavioral changes (highest risk period for suicide attempts) 2, 1
First 12 weeks: Monitor blood pressure and heart rate periodically 2, 1
6–8 weeks: Assess for adequate therapeutic response before considering treatment modification 2
Ongoing: Monitor for neuropsychiatric adverse effects, including agitation, restlessness, and behavioral changes 2

Common Pitfalls to Avoid

Do not exceed 450 mg/day (seizure risk increases markedly above this threshold) 2, 1
Do not skip the intensive monitoring window in weeks 1–2 (highest risk for emergent suicidal ideation, especially in patients <24 years) 2
Do not combine with MAOIs or initiate within 14 days of MAOI discontinuation (risk of hypertensive crisis) 2, 1
Do not use in patients abruptly discontinuing alcohol, benzodiazepines, or antiepileptic drugs (withdrawal seizures) 2, 1
Do not prescribe to patients with eating disorders (bulimia/anorexia markedly increases seizure risk) 2, 1
Do not use naltrexone-bupropion combination in patients on opioid therapy (precipitates severe withdrawal) 2

When Bupropion Should Be Avoided Entirely

Highly agitated patients (bupropion's activating effects worsen agitation) 2
Patients with uncontrolled hypertension (bupropion elevates blood pressure) 2, 1
Patients with end-stage renal disease (metabolites accumulate; hemodialysis does not clear hydroxybupropion) 2
Patients with severe hepatic cirrhosis (maximum dose 150 mg every other day) 2, 1

Bottom Line

Bupropion remains safe and effective for first-line use in major depressive disorder and smoking cessation when absolute contraindications are ruled out and dosing guidelines are followed. 5, 6 The key is meticulous screening for seizure risk factors, uncontrolled hypertension, eating disorders, and MAOI use before prescribing. 1 If none of these contraindications are present, bupropion can be used safely with appropriate monitoring. 2, 1

Can I still use bupropion in this patient?

Help us tailor your experience