Wellbutrin Tablets
Name: Wellbutrin Tablets
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Wellbutrin Tablets Dosage and Administration
General Instructions for Use
To minimize the risk of seizure, increase the dose gradually [see Warnings and Precautions (5.3)]. WELLBUTRIN SR tablets should be swallowed whole and not crushed, divided, or chewed. WELLBUTRIN SR may be taken with or without food.
The usual adult target dose for WELLBUTRIN SR is 300 mg per day, given as 150 mg twice daily. Initiate dosing with 150 mg per day given as a single daily dose in the morning. After 3 days of dosing, the dose may be increased to the 300-mg-per-day target dose, given as 150 mg twice daily. There should be an interval of at least 8 hours between successive doses. A maximum of 400 mg per day, given as 200 mg twice daily, may be considered for patients in whom no clinical improvement is noted after several weeks of treatment at 300 mg per day. To avoid high peak concentrations of bupropion and/or its metabolites, do not exceed 200 mg in any single dose.
It is generally agreed that acute episodes of depression require several months or longer of antidepressant drug treatment beyond the response in the acute episode. It is unknown whether the dose of WELLBUTRIN SR needed for maintenance treatment is identical to the dose that provided an initial response. Periodically reassess the need for maintenance treatment and the appropriate dose for such treatment.
Dose Adjustment in Patients with Hepatic Impairment
In patients with moderate to severe hepatic impairment (Child-Pugh score: 7 to 15), the maximum dose of WELLBUTRIN SR is 100 mg per day or 150 mg every other day. In patients with mild hepatic impairment (Child-Pugh score: 5 to 6), consider reducing the dose and/or frequency of dosing [see Use in Specific Populations (8.7), Clinical Pharmacology (12.3)].
Dose Adjustment in Patients with Renal Impairment
Consider reducing the dose and/or frequency of WELLBUTRIN SR in patients with renal impairment (Glomerular Filtration Rate less than 90 mL per min) [see Use in Specific Populations (8.6), Clinical Pharmacology (12.3)].
Switching a Patient to or from a Monoamine Oxidase Inhibitor (MAOI) Antidepressant
At least 14 days should elapse between discontinuation of an MAOI intended to treat depression and initiation of therapy with WELLBUTRIN SR. Conversely, at least 14 days should be allowed after stopping WELLBUTRIN SR before starting an MAOI antidepressant [see Contraindications (4), Drug Interactions (7.6)].
Use of WELLBUTRIN SR with Reversible MAOIs Such as Linezolid or Methylene Blue
Do not start WELLBUTRIN SR in a patient who is being treated with a reversible MAOI such as linezolid or intravenous methylene blue. Drug interactions can increase the risk of hypertensive reactions. In a patient who requires more urgent treatment of a psychiatric condition, non-pharmacological interventions, including hospitalization, should be considered [see Contraindications (4), Drug Interactions (7.6)].
In some cases, a patient already receiving therapy with WELLBUTRIN SR may require urgent treatment with linezolid or intravenous methylene blue. If acceptable alternatives to linezolid or intravenous methylene blue treatment are not available and the potential benefits of linezolid or intravenous methylene blue treatment are judged to outweigh the risks of hypertensive reactions in a particular patient, WELLBUTRIN SR should be stopped promptly, and linezolid or intravenous methylene blue can be administered. The patient should be monitored for 2 weeks or until 24 hours after the last dose of linezolid or intravenous methylene blue, whichever comes first. Therapy with WELLBUTRIN SR may be resumed 24 hours after the last dose of linezolid or intravenous methylene blue.
The risk of administering methylene blue by non-intravenous routes (such as oral tablets or by local injection) or in intravenous doses much lower than 1 mg per kg with WELLBUTRIN SR is unclear. The clinician should, nevertheless, be aware of the possibility of a drug interaction with such use [see Contraindications (4), Drug Interactions (7.6)].
Adverse Reactions
The following adverse reactions are discussed in greater detail in other sections of the labeling:
• Suicidal thoughts and behaviors in adolescents and young adults [see Boxed Warning, Warnings and Precautions (5.1)] • Neuropsychiatric symptoms and suicide risk in smoking cessation treatment [see Boxed Warning, Warnings and Precautions (5.2)] • Seizure [see Warnings and Precautions (5.3)] • Hypertension [see Warnings and Precautions (5.4)] • Activation of mania or hypomania [see Warnings and Precautions (5.5)] • Psychosis and other neuropsychiatric reactions [see Warnings and Precautions (5.6)] • Angle-closure glaucoma [see Warnings and Precautions (5.7)] • Hypersensitivity reactions [see Warnings and Precautions (5.8)]Clinical Trials Experience
Because clinical trials are conducted under widely varying conditions, adverse reaction rates observed in the clinical trials of a drug cannot be directly compared with rates in the clinical trials of another drug and may not reflect the rates observed in clinical practice.
Adverse Reactions Leading to Discontinuation of Treatment
In placebo‑controlled clinical trials, 4%, 9%, and 11% of the placebo, 300-mg-per-day, and 400-mg-per-day groups, respectively, discontinued treatment due to adverse reactions. The specific adverse reactions leading to discontinuation in at least 1% of the 300-mg-per-day or 400-mg-per-day groups and at a rate at least twice the placebo rate are listed in Table 2.
| Adverse Reaction | Placebo (n = 385) | WELLBUTRIN SR 300 mg/day (n = 376) | WELLBUTRIN SR 400 mg/day (n = 114) |
| Rash | 0.0% | 2.4% | 0.9% |
| Nausea | 0.3% | 0.8% | 1.8% |
| Agitation | 0.3% | 0.3% | 1.8% |
| Migraine | 0.3% | 0.0% | 1.8% |
Commonly Observed Adverse Reactions
Adverse reactions from Table 3 occurring in at least 5% of subjects treated with WELLBUTRIN SR and at a rate at least twice the placebo rate are listed below for the 300- and 400‑mg-per-day dose groups.
WELLBUTRIN SR 300 mg per day: Anorexia, dry mouth, rash, sweating, tinnitus, and tremor.
WELLBUTRIN SR 400 mg per day: Abdominal pain, agitation, anxiety, dizziness, dry mouth, insomnia, myalgia, nausea, palpitation, pharyngitis, sweating, tinnitus, and urinary frequency.
Adverse reactions reported in placebo-controlled trials are presented in Table 3. Reported adverse reactions were classified using a COSTART‑based Dictionary.
| Body System/ Adverse Reaction | WELLBUTRIN SR 300 mg/day (n = 376) | WELLBUTRIN SR 400 mg/day (n = 114) | Placebo (n = 385) |
| Body (General) | |||
| Headache | 26% | 25% | 23% |
| Infection | 8% | 9% | 6% |
| Abdominal pain | 3% | 9% | 2% |
| Asthenia | 2% | 4% | 2% |
| Chest pain | 3% | 4% | 1% |
| Pain | 2% | 3% | 2% |
| Fever | 1% | 2% | |
| Cardiovascular | |||
| Palpitation | 2% | 6% | 2% |
| Flushing | 1% | 4% | |
| Migraine | 1% | 4% | 1% |
| Hot flashes | 1% | 3% | 1% |
| Digestive | |||
| Dry mouth | 17% | 24% | 7% |
| Nausea | 13% | 18% | 8% |
| Constipation | 10% | 5% | 7% |
| Diarrhea | 5% | 7% | 6% |
| Anorexia | 5% | 3% | 2% |
| Vomiting | 4% | 2% | 2% |
| Dysphagia | 0% | 2% | 0% |
| Musculoskeletal | |||
| Myalgia | 2% | 6% | 3% |
| Arthralgia | 1% | 4% | 1% |
| Arthritis | 0% | 2% | 0% |
| Twitch | 1% | 2% | |
| Nervous system | |||
| Insomnia | 11% | 16% | 6% |
| Dizziness | 7% | 11% | 5% |
| Agitation | 3% | 9% | 2% |
| Anxiety | 5% | 6% | 3% |
| Tremor | 6% | 3% | 1% |
| Nervousness | 5% | 3% | 3% |
| Somnolence | 2% | 3% | 2% |
| Irritability | 3% | 2% | 2% |
| Memory decreased | 3% | 1% | |
| Paresthesia | 1% | 2% | 1% |
| Central nervous system stimulation | 2% | 1% | 1% |
| Respiratory | |||
| Pharyngitis | 3% | 11% | 2% |
| Sinusitis | 3% | 1% | 2% |
| Increased cough | 1% | 2% | 1% |
| Skin | |||
| Sweating | 6% | 5% | 2% |
| Rash | 5% | 4% | 1% |
| Pruritus | 2% | 4% | 2% |
| Urticaria | 2% | 1% | 0% |
| Special senses | |||
| Tinnitus | 6% | 6% | 2% |
| Taste perversion | 2% | 4% | |
| Blurred vision or diplopia | 3% | 2% | 2% |
| Urogenital | |||
| Urinary frequency | 2% | 5% | 2% |
| Urinary urgency | 2% | 0% | |
| Vaginal hemorrhagea | 0% | 2% | |
| Urinary tract infection | 1% | 0% |
aIncidence based on the number of female subjects.
Hyphen denotes adverse events occurring in greater than 0 but less than 0.5% of subjects.
Other Adverse Reactions Observed during the Clinical Development of Bupropion
In addition to the adverse reactions noted above, the following adverse reactions have been reported in clinical trials with the sustained‑release formulation of bupropion in depressed subjects and in nondepressed smokers, as well as in clinical trials with the immediate‑release formulation of bupropion.
Adverse reaction frequencies represent the proportion of subjects who experienced a treatment‑emergent adverse reaction on at least one occasion in placebo‑controlled trials for depression (n = 987) or smoking cessation (n = 1,013), or subjects who experienced an adverse reaction requiring discontinuation of treatment in an open‑label surveillance trial with WELLBUTRIN SR (n = 3,100). All treatment‑emergent adverse reactions are included except those listed in Table 3, those listed in other safety‑related sections of the prescribing information, those subsumed under COSTART terms that are either overly general or excessively specific so as to be uninformative, those not reasonably associated with the use of the drug, and those that were not serious and occurred in fewer than 2 subjects.
Adverse reactions are further categorized by body system and listed in order of decreasing frequency according to the following definitions of frequency: Frequent adverse reactions are defined as those occurring in at least 1/100 subjects. Infrequent adverse reactions are those occurring in 1/100 to 1/1,000 subjects, while rare events are those occurring in less than 1/1,000 subjects.
Body (General): Infrequent were chills, facial edema, and photosensitivity. Rare was malaise.
Cardiovascular: Infrequent were postural hypotension, stroke, tachycardia, and vasodilation. Rare were syncope and myocardial infarction.
Digestive: Infrequent were abnormal liver function, bruxism, gastric reflux, gingivitis, increased salivation, jaundice, mouth ulcers, stomatitis, and thirst. Rare was edema of tongue.
Hemic and Lymphatic: Infrequent was ecchymosis.
Metabolic and Nutritional: Infrequent were edema and peripheral edema.
Musculoskeletal: Infrequent were leg cramps.
Nervous System: Infrequent were abnormal coordination, decreased libido, depersonalization, dysphoria, emotional lability, hostility, hyperkinesia, hypertonia, hypesthesia, suicidal ideation, and vertigo. Rare were amnesia, ataxia, derealization, and hypomania.
Respiratory: Rare was bronchospasm.
Special Senses: Infrequent were accommodation abnormality and dry eye.
Urogenital: Infrequent were impotence, polyuria, and prostate disorder.
Changes in Body Weight
In placebo‑controlled trials, subjects experienced weight gain or weight loss as shown in Table 4.
| Weight Change | WELLBUTRIN SR 300 mg/day (n = 339) | WELLBUTRIN SR 400 mg/day (n = 112) | Placebo (n = 347) |
| Gained >5 lbs | 3% | 2% | 4% |
| Lost >5 lbs | 14% | 19% | 6% |
In clinical trials conducted with the immediate‑release formulation of bupropion, 35% of subjects receiving tricyclic antidepressants gained weight, compared with 9% of subjects treated with the immediate‑release formulation of bupropion. If weight loss is a major presenting sign of a patient’s depressive illness, the anorectic and/or weight‑reducing potential of WELLBUTRIN SR should be considered.
Postmarketing Experience
The following adverse reactions have been identified during post-approval use of WELLBUTRIN SR and are not described elsewhere in the label. Because these reactions are reported voluntarily from a population of uncertain size, it is not always possible to reliably estimate their frequency or establish a causal relationship to drug exposure.
Body (General)
Arthralgia, myalgia, and fever with rash and other symptoms suggestive of delayed hypersensitivity. These symptoms may resemble serum sickness [see Warnings and Precautions (5.8)].
Cardiovascular
Complete atrioventricular block, extrasystoles, hypotension, hypertension (in some cases severe), phlebitis, and pulmonary embolism.
Digestive
Colitis, esophagitis, gastrointestinal hemorrhage, gum hemorrhage, hepatitis, intestinal perforation, pancreatitis, and stomach ulcer.
Endocrine
Hyperglycemia, hypoglycemia, and syndrome of inappropriate antidiuretic hormone.
Hemic and Lymphatic
Anemia, leukocytosis, leukopenia, lymphadenopathy, pancytopenia, and thrombocytopenia. Altered PT and/or INR, infrequently associated with hemorrhagic or thrombotic complications, were observed when bupropion was coadministered with warfarin.
Metabolic and Nutritional
Glycosuria.
Musculoskeletal
Muscle rigidity/fever/rhabdomyolysis and muscle weakness.
Nervous System
Abnormal electroencephalogram (EEG), aggression, akinesia, aphasia, coma, completed suicide, delirium, delusions, dysarthria, euphoria, extrapyramidal syndrome (dyskinesia, dystonia, hypokinesia, parkinsonism), hallucinations, increased libido, manic reaction, neuralgia, neuropathy, paranoid ideation, restlessness, suicide attempt, and unmasking tardive dyskinesia.
Respiratory
Pneumonia.
Skin
Alopecia, angioedema, exfoliative dermatitis, hirsutism, and Stevens-Johnson syndrome.
Special Senses
Deafness, increased intraocular pressure, and mydriasis.
Urogenital
Abnormal ejaculation, cystitis, dyspareunia, dysuria, gynecomastia, menopause, painful erection, salpingitis, urinary incontinence, urinary retention, and vaginitis.
Overdosage
Human Overdose Experience
Overdoses of up to 30 grams or more of bupropion have been reported. Seizure was reported in approximately one-third of all cases. Other serious reactions reported with overdoses of bupropion alone included hallucinations, loss of consciousness, sinus tachycardia, and ECG changes such as conduction disturbances (including QRS prolongation) or arrhythmias. Fever, muscle rigidity, rhabdomyolysis, hypotension, stupor, coma, and respiratory failure have been reported mainly when bupropion was part of multiple drug overdoses.
Although most patients recovered without sequelae, deaths associated with overdoses of bupropion alone have been reported in patients ingesting large doses of the drug. Multiple uncontrolled seizures, bradycardia, cardiac failure, and cardiac arrest prior to death were reported in these patients.
Overdosage Management
Consult a Certified Poison Control Center for up-to-date guidance and advice. Telephone numbers for certified poison control centers are listed in the Physician’s Desk Reference (PDR). Call 1-800-222-1222 or refer to www.poison.org.
There are no known antidotes for bupropion. In case of an overdose, provide supportive care, including close medical supervision and monitoring. Consider the possibility of multiple drug overdose. Ensure an adequate airway, oxygenation, and ventilation. Monitor cardiac rhythm and vital signs. Induction of emesis is not recommended.
Nonclinical Toxicology
Carcinogenesis, Mutagenesis, Impairment of Fertility
Lifetime carcinogenicity studies were performed in rats and mice at bupropion doses up to 300 and 150 mg per kg per day, respectively. These doses are approximately 7 and 2 times the MRHD, respectively, on a mg per m2 basis. In the rat study there was an increase in nodular proliferative lesions of the liver at doses of 100 to 300 mg per kg per day (approximately 2 to 7 times the MRHD on a mg per m2 basis); lower doses were not tested. The question of whether or not such lesions may be precursors of neoplasms of the liver is currently unresolved. Similar liver lesions were not seen in the mouse study, and no increase in malignant tumors of the liver and other organs was seen in either study.
Bupropion produced a positive response (2 to 3 times control mutation rate) in 2 of 5 strains in the Ames bacterial mutagenicity assay. Bupropion produced an increase in chromosomal aberrations in 1 of 3 in vivo rat bone marrow cytogenetic studies.
A fertility study in rats at doses up to 300 mg per kg per day revealed no evidence of impaired fertility.
Clinical Studies
The efficacy of the immediate‑release formulation of bupropion in the treatment of major depressive disorder was established in two 4‑week, placebo‑controlled trials in adult inpatients with MDD (Trials 1 and 2 in Table 6) and in one 6‑week, placebo‑controlled trial in adult outpatients with MDD (Trial 3 in Table 6). In the first trial, the dose range of bupropion was 300 mg to 600 mg per day administered in divided doses; 78% of subjects were treated with doses of 300 mg to 450 mg per day. This trial demonstrated the effectiveness of the immediate‑release formulation of bupropion by the Hamilton Depression Rating Scale (HDRS) total score, the HDRS depressed mood item (Item 1), and the Clinical Global Impressions severity score (CGI-S). The second trial included 2 doses of the immediate‑release formulation of bupropion (300 and 450 mg per day) and placebo. This trial demonstrated the effectiveness of the immediate‑release formulation of bupropion, but only at the 450‑mg-per-day dose. The efficacy results were significant for the HDRS total score and the CGI-S score, but not for HDRS Item 1. In the third trial, outpatients were treated with 300 mg per day of the immediate‑release formulation of bupropion. This trial demonstrated the efficacy of the immediate‑release formulation of bupropion as measured by the HDRS total score, the HDRS Item 1, the Montgomery‑Asberg Depression Rating Scale (MADRS), the CGI-S score, and the CGI-Improvement Scale (CGI-I) score.
Table 6. Efficacy of Immediate-Release Bupropion for the Treatment of Major Depressive Disorder
| Trial Number | Treatment Group | Primary Efficacy Measure: HDRS | ||
| Mean Baseline Score (SD) | LS Mean Score at Endpoint Visit (SE) | Placebo-subtracted Differencea (95% CI) | ||
| Trial 1 | Immediate-Release Bupropion 300-600 mg/dayb (n = 48) | 28.5 (5.1) | 14.9 (1.3) | -4.7 (-8.8, -0.6) |
| Placebo (n = 27) | 29.3 (7.0) | 19.6 (1.6) | -- | |
| Mean Baseline Score (SD) | LS Mean Change from Baseline (SE) | Placebo-subtracted Differencea (95% CI) | ||
| Trial 2 | Immediate-Release Bupropion 300 mg/day (n = 36) | 32.4 (5.9) | -15.5 (1.7) | -4.1 |
| Immediate-Release Bupropion 450 mg/dayb (n = 34) | 34.8 (4.6) | -17.4 (1.7) | -5.9 (-10.5, -1.4) | |
| Placebo (n = 39) | 32.9 (5.4) | -11.5 (1.6) | -- | |
| Trial 3 | Immediate-Release Bupropion 300 mg/dayb (n = 110) | 26.5 (4.3) | -12.0 (NA) | -3.9 (-5.7, -1.0) |
| Placebo (n = 106) | 27.0 (3.5) | -8.7 (NA) | -- | |
n: sample size; SD: standard deviation; SE: standard error; LS Mean: least-squares mean; CI: unadjusted confidence interval included for doses that were demonstrated to be effective; NA: not available.
aDifference (drug minus placebo) in least-squares estimates with respect to the primary efficacy parameter. For Trial 1, it refers to the mean score at the endpoint visit; for Trials 2 and 3, it refers to the mean change from baseline to the endpoint visit.
bDoses that are demonstrated to be statistically significantly superior to placebo.
Although there are not as yet independent trials demonstrating the antidepressant effectiveness of the sustained‑release formulation of bupropion, trials have demonstrated the bioequivalence of the immediate‑release and sustained‑release forms of bupropion under steady‑state conditions, i.e., bupropion sustained‑release 150 mg twice daily was shown to be bioequivalent to 100 mg 3 times daily of the immediate‑release formulation of bupropion, with regard to both rate and extent of absorption, for parent drug and metabolites.
In a longer-term trial, outpatients meeting DSM-IV criteria for major depressive disorder, recurrent type, who had responded during an 8-week open trial on WELLBUTRIN SR (150 mg twice daily) were randomized to continuation of their same dose of WELLBUTRIN SR or placebo for up to 44 weeks of observation for relapse. Response during the open phase was defined as CGI Improvement score of 1 (very much improved) or 2 (much improved) for each of the final 3 weeks. Relapse during the double-blind phase was defined as the investigator’s judgment that drug treatment was needed for worsening depressive symptoms. Patients receiving continued treatment with WELLBUTRIN SR experienced significantly lower relapse rates over the subsequent 44 weeks compared with those receiving placebo.
How Supplied/Storage and Handling
WELLBUTRIN SR sustained‑release tablets, 100 mg of bupropion hydrochloride, are blue, round, biconvex, film‑coated tablets printed with “WELLBUTRIN SR 100” in bottles of 60 (NDC 0173-0947-55) tablets.
WELLBUTRIN SR sustained‑release tablets, 150 mg of bupropion hydrochloride, are purple, round, biconvex, film‑coated tablets printed with “WELLBUTRIN SR 150” in bottles of 60 (NDC 0173-0135-55) tablets.
WELLBUTRIN SR sustained-release tablets, 200 mg of bupropion hydrochloride, are light pink, round, biconvex, film-coated tablets printed with “WELLBUTRIN SR 200” in bottles of 60 (NDC 0173-0722-00) tablets.
Store at room temperature, 20° to 25°C (68° to 77°F); excursions permitted between 15°C and 30°C (59°F and 86°F) [see USP Controlled Room Temperature]. Protect from light and moisture.