Augmentation Strategy for Bupropion SR in Major Depressive Disorder
Evidence-Based Augmentation Options
- The American College of Physicians recommends adding an SSRI, such as citalopram, sertraline, or escitalopram, to bupropion SR 150mg BID for patients with major depressive disorder who have not achieved adequate response, with moderate-quality evidence showing equivalent efficacy 1, 2
- Adding an SSRI to bupropion is supported by moderate-quality evidence from the STAR*D trial, which demonstrated similar efficacy when augmenting citalopram with bupropion compared to augmenting with buspirone or cognitive therapy, with bupropion augmentation having significantly fewer discontinuations due to adverse events (12.5%) compared to buspirone augmentation (20.6%; P < 0.001) 1, 2, 3
- Low-quality evidence from STAR*D showed no difference in response or remission when switching from bupropion to cognitive therapy versus switching to another antidepressant, such as sertraline or venlafaxine, with cognitive behavioral therapy having numerically lower discontinuation rates due to adverse events (9.2%) compared to medication augmentation (18.8%) 4, 5, 6
Clinical Decision Algorithm
- The American Psychiatric Association suggests assessing current response to bupropion SR 150mg BID, and considering augmentation with an SSRI, such as citalopram 20-40mg daily, sertraline 50-200mg daily, or escitalopram 10-20mg daily, if partial response is achieved after an adequate trial, with moderate-quality evidence supporting this approach 1, 2
- The American College of Physicians recommends monitoring for adverse events when combining bupropion with SSRIs, with a low risk of serotonin syndrome, and suggests continuing aspirin 81mg for cardiovascular prophylaxis, but not relying on it for antidepressant effects 3, 6