Bupropion

Depression The evidence overall supports the effectiveness of bupropion over placebo for the treatment of depression. Evidence-based guidelines consistently recommend bupropion as a treatment option for adults with major depressive disorder; some support first-line use for major depressive disorder, but there is limited guidance for treatment-resistant depression. Some peer-reviewed studies suggest the quality of evidence is low. Evidence suggests that the effectiveness of bupropion for depression is similar to that of other antidepressants. Bupropion also improves depression in bipolar disorder, however the risk of an affective switch is similar to other antidepressants. Bupropion has several features that distinguish it from other antidepressants: for instance, unlike the majority of antidepressants, it does not usually cause sexual dysfunction, and the occurrence of sexual side effects is not different from placebo. Bupropion treatment is not associated with weight gain; on the contrary, the majority of studies observed significant weight loss in bupropion-treated participants. Bupropion is more effective than selective serotonin reuptake inhibitors (SSRIs) at improving symptoms of hypersomnia and fatigue in depressed patients. Bupropion is effective in the treatment of anxious depression and, contrary to common belief, does not exacerbate anxiety in this context. The effectiveness of bupropion for anxious depression is equivalent to that of SSRIs in the case of depression with low or moderate anxiety, whereas SSRIs show a modest effectiveness advantage in terms of response rates for depression with high anxiety. and it is supported by clinical trials. Smoking cessation Prescribed as an aid for smoking cessation, bupropion reduces the severity of craving for nicotine and withdrawal symptoms such as depressed mood, irritability, difficulty concentrating, and increased appetite. Initially, bupropion slows the weight gain that often occurs in the first weeks after quitting smoking. With time, however, this effect becomes negligible. It is unclear whether extending bupropion treatment helps to prevent relapse of smoking. Overall, six months after the therapy, bupropion increases the likelihood of quitting smoking approximately 1.6-fold as compared to placebo. In this respect, bupropion is as effective as nicotine replacement therapy but inferior to varenicline. Combining bupropion and nicotine replacement therapy does not improve the quitting rate. In children and adolescents, the use of bupropion for smoking cessation does not appear to offer any significant benefits. The evidence for its use to aid smoking cessation in pregnant women is insufficient. Attention deficit hyperactivity disorder In the United States, the treatment of attention deficit hyperactivity disorder (ADHD) is not an approved indication of bupropion, and it is not mentioned in the 2019 guideline on ADHD treatment from the American Academy of Pediatrics. Systematic reviews of bupropion for the treatment of ADHD in both adults and children note that bupropion may be effective for ADHD but warn that this conclusion has to be interpreted with caution, because clinical trials were of low quality due to small sizes and risk of bias. Similarly to atomoxetine, bupropion has a delayed onset of action for ADHD, and several weeks of treatment are required for therapeutic effects. This is in contrast to stimulants, such as amphetamine and methylphenidate, which have an immediate onset of effect in the condition. A range of studies indicate that bupropion not only produces fewer sexual side effects than other antidepressants but can actually help to alleviate sexual dysfunction including sexual dysfunction induced by SSRI antidepressants. There have also been small studies suggesting that bupropion or a bupropion/trazodone combination may improve some measures of sexual function in women who have hypoactive sexual desire disorder (HSDD) and are not depressed. According to an expert consensus recommendation from the International Society for the Study of Women's Sexual Health, bupropion can be considered as an off-label treatment for HSDD despite limited safety and efficacy data. Likewise, a 2022 systematic review and meta-analysis of bupropion for sexual desire disorder in women reported that although data were limited, bupropion appeared to be dose-dependently effective for the condition. Weight loss Bupropion, when used for treating long-term weight gain over six to twelve months, results in an average weight loss of compared to a placebo. The combination drug naltrexone/bupropion has been approved by the US Food and Drug Administration (FDA) for the treatment of obesity. Other uses Bupropion is not effective in the treatment of cocaine dependence, but it is showing promise in reducing drug use in treating amphetamine-type stimulant use and cravings. Based on studies indicating that bupropion lowers the level of the pro-inflammatory cytokine tumor necrosis factor alpha (TNF-α), there have been suggestions that it might be useful in treating inflammatory bowel disease, psoriasis, and other autoimmune conditions, but very little clinical evidence is available. Bupropion is not proven to be effective in treating chronic low back pain. The drug may be useful in the treatment of excessive daytime sleepiness (EDS) and narcolepsy. Bupropion has been used to treat disorders of diminished motivation, like apathy, abulia, and akinetic mutism. Accordingly, the drug has been found to increase effort expenditure and improve motivational deficits in animal models. However, only limited benefits of bupropion in the treatment of apathy have been observed in clinical trials in various conditions. and postural orthostatic tachycardia syndrome (POTS). Available forms Bupropion is available as an oral tablet in several different formulations. == Contraindications ==

The US Food and Drug Administration (FDA) prescription label advises that bupropion should not be prescribed to individuals with epilepsy or other conditions that lower the seizure threshold, such as anorexia nervosa, bulimia nervosa, or benzodiazepine or alcohol withdrawal. It should be avoided in individuals who are taking monoamine oxidase inhibitors (MAOIs). The label recommends that caution should be exercised when treating people with liver damage, severe kidney disease, and severe hypertension, and in children, adolescents, and young adults due to the increased risk of suicidal ideation. == Side effects ==

The common adverse effects of bupropion with the greatest difference from placebo are dry mouth, nausea, constipation, insomnia, anxiety, tremor, and excessive sweating. It is also associated with about 20% increased risk of headache. Bupropion raises blood pressure in some people. One study showed an average rise of 6mmHg in systolic blood pressure in 10% of patients. The prescribing information notes that hypertension, sometimes severe, is observed in some people taking bupropion, both with and without pre-existing hypertension. Bupropion has not been associated with QT prolongation at therapeutic doses but has been associated with QT prolongation in overdose. Seizure is a rare but serious adverse effect of bupropion. It is strongly dose-dependent: for the immediate release preparation, the seizure incidence is 0.4% at 300 to 450mg per day; the incidence climbs almost 10-fold for the higher-than-recommended dose of 600mg. Rare cases of liver toxicity leading to death or liver transplantation have been reported for bupropion. The prescribing information warns about bupropion triggering an angle-closure glaucoma attack. Bupropion has rarely been associated with instances of Stevens–Johnson syndrome. Bupropion use by mothers in the first trimester of pregnancy is associated with a 23% increase in the odds of congenital heart defects in their children. Psychiatric The US Food and Drug Administration (FDA) requires all antidepressants, including bupropion, to carry a boxed warning stating that antidepressants may increase the risk of suicide in people younger than 25. This warning is based on a statistical analysis conducted by the FDA, which found a two-fold increase in suicidal thought and behavior in children and adolescents, and a 1.5-fold increase in the 18–24 age group. For this analysis, the FDA combined the results of 295trials of 11antidepressants to obtain statistically significant results. Bupropion prescribed for smoking cessation results in a 25% increase in the risk of psychiatric side effects, in particular, anxiety (about 40% increase) and insomnia (about 80% increase). In most cases, the psychotic symptoms are eliminated by reducing the dose, ceasing treatment, or adding antipsychotic medication. Rarely, bupropion has been associated with induction of compulsive behavior. == Overdose ==

Bupropion is considered moderately dangerous in overdose. According to an analysis of US National Poison Data System, adjusted for the number of prescriptions, bupropion and venlafaxine are the two new-generation antidepressants (i.e., non-tricyclic antidepressants) that result in the highest mortality and morbidity. For significant overdoses, seizures have been reported in about a third of all cases; other serious effects include hallucinations, loss of consciousness, and abnormal heart rhythms. When bupropion was one of several kinds of pills taken in an overdose, fever, muscle rigidity, muscle damage, hypertension or hypotension, stupor, coma, and respiratory failure have been reported. While recovery was seen in most cases, death has been reported, due to multiple uncontrolled seizures and myocardial infarction. == Interactions ==

Since bupropion is metabolized to hydroxybupropion by the enzyme CYP2B6, drug interactions with CYP2B6 inhibitors are possible: This includes such medications as paroxetine, sertraline, norfluoxetine (active metabolite of fluoxetine), diazepam, clopidogrel, and orphenadrine. The expected result is an increase in bupropion and a decrease in hydroxybupropion blood concentration. The reverse effect (decrease of bupropion and increase of hydroxybupropion) can be expected with CYP2B6 inducers such as carbamazepine, clotrimazole, rifampicin, ritonavir, St John's wort, and phenobarbital. Indeed, carbamazepine decreases exposure to bupropion by 90% and increases exposure to hydroxybupropion by 94%. Ritonavir, lopinavir/ritonavir, and efavirenz have been shown to decrease levels of bupropion and/or its metabolites. Bupropion and its metabolites are inhibitors of CYP2D6, with hydroxybupropion responsible for most of the inhibition. Additionally, bupropion and its metabolites may decrease the expression of CYP2D6 in the liver. The end effect is a significant slowing of the clearance of other drugs metabolized by this enzyme. For instance, bupropion has been found to increase area-under-the-curve of desipramine, a CYP2D6 substrate, five-fold. As another example, the ratio of dextromethorphan (a drug that is mainly metabolized by CYP2D6) to its major metabolite dextrorphan increased approximately 35-fold when it was administered to people being treated with 300 mg/day bupropion. venlafaxine, Bupropion prevents norepinephrine and dopamine release induced by methamphetamine and has been found to reduce the subjective and sympathomimetic effects of methamphetamine in humans. Bupropion lowers the seizure threshold, and therefore can potentially interact with other medications that also lower it, such as antipsychotics, tricyclic antidepressants, theophylline, and systemic corticosteroids. == Pharmacology ==

Pharmacodynamics The mechanism of action of bupropion in the treatment of depression and for other indications is unclear. Pharmacological actions of bupropion, to a substantial degree, are due to its active metabolites hydroxybupropion, threo-hydrobupropion, and erythro-hydrobupropion that are present in the blood plasma at comparable or much higher levels. Bupropion has also been shown to increase reuptake of dopamine by striatal VMAT2, though it is unknown if this effect is more pronounced than other DRIs. These findings raise questions about the role of dopamine reuptake inhibition in the pharmacology of bupropion, and suggest that other actions may be responsible for its therapeutic effects. Bupropion has a particularly odd pattern of inducing DAT inhibition, since it displays markedly enhanced binding affinity towards the DAT-(NET S1) mutant (DAT with NET primary binding site) over normal (wild-type) DAT, and noticeably diminished binding affinity towards the NET-(DAT S1) mutant (NET with DAT primary binding site) over regular (wild-type) NET. In spite of clear preference for NET binding site by itself, bupropion retains overall preference for complete DAT, implying that bupropion may make use of non-binding sites on the DAT molecule to exert its own binding, as well as the potential of augmented affinity for NET if its binding site is otherwise conformationally exposed. Bupropion has been claimed to be a sigma σ1 receptor agonist. Its antidepressant-like effects in rodents depend on σ1 receptor activation. They are enhanced and inhibited by σ1 receptor agonists and antagonists, respectively. In contrast to many other phenethylamines and amphetamines, bupropion is not an agonist of the trace amine-associated receptor 1 (TAAR1). Bupropion has been found to have a mixture of anti-inflammatory and pro-inflammatory activity through modulation of the immune system. One such mechanism underlying these effects may be reduced levels of the pro-inflammatory cytokine tumor necrosis factor alpha (TNFα). Pharmacokinetics After oral administration, bupropion is rapidly and completely absorbed, reaching the peak blood plasma concentration after 1.5 hours (tmax). Sustained-release (SR) and extended-release (XL) formulations have been designed to slow down absorption, resulting in tmax of 3 hours and 5 hours, respectively. Based on this, some researchers have advocated monitoring of the blood level of bupropion and hydroxybupropion. The metabolism of bupropion also seems to follow biphasic pharmacokinetics: the redistribution alpha phase with half-life of about 1 hour precedes the metabolism beta phase of about 12–30 hours. This might explain why abuse is unfeasible due to a short "high", as well as support the use of extended-release formulas to maintain a consistent concentration of bupropion. The metabolism of bupropion is highly species-dependent. As an example, oral bupropion results in hydroxybupropion levels that are 16-fold higher than those of bupropion itself in humans, whereas in rats, oral bupropion results in levels of bupropion that are 3.4-fold higher than those of hydroxybupropion. Bupropion has also been found to produce self-administration when given intravenously in monkeys. == Chemistry ==

Bupropion is an aminoketone that belongs to the class of substituted cathinones and the more general class of substituted phenethylamines. Bupropion is a small-molecule compound with the molecular formula C13H18ClNO and a molecular weight of 239.74g/mol. It is a highly lipophilic compound, There have been reported cases of false-positive urine amphetamine tests in persons taking bupropion. Synthesis It is synthesized in two chemical steps starting from the phenone 3'-chloro-propiophenone. The alpha position adjacent to the ketone group is first brominated followed by nucleophilic displacement of the bromine atom of the resulting alpha-bromoketone group with t-butylamine and then treatment with hydrochloric acid to give bupropion as the hydrochloride salt in 75–85% overall yield. Analogues A number of analogues of bupropion exist, such as hydroxybupropion, radafaxine, and manifaxine, among others. These compounds are norepinephrine–dopamine reuptake inhibitors (NDRIs) similarly to bupropion. They have been encountered as cathinone designer and recreational drugs. The analogue of bupropion with the N-tert-butyl group replaced with an N-cyclopropyl group is 3-chloro-N-cyclopropylcathinone (3Cl-CpC; PAL-433, RTI-6037-39). It is a hybrid serotonin releasing agent (SRA) and serotonin–norepinephrine–dopamine reuptake inhibitor (SNDRI) and was being investigated for potential treatment of cocaine dependence. == History ==

blood plasma bupropion levels with bupropion IR 100 mg t.i.d. (3/day), bupropion SR 150 mg b.i.d. (2/day), and bupropion XL 300 mg q.d. (1/day) However, a significant incidence of seizures at the originally recommended dosage (400–600 mg/day) caused the withdrawal of the drug in 1986. Subsequently, the risk of seizures was found to be highly dose-dependent, and bupropion was reintroduced to the market in 1989 with a lower maximum recommended daily dose of 450 mg/day. In 1996, the US Food and Drug Administration (FDA) approved a sustained-release formulation of alcohol-resistant bupropion called Wellbutrin SR, a tablet intended to be taken twice a day (as compared with three times a day for immediate-release Wellbutrin). In 2003, the FDA approved another sustained-release formulation called Wellbutrin XL, a hard-shelled tablet intended for once-daily dosing. Wellbutrin SR and XL are available in generic form in the United States and Canada. In 1997, bupropion was approved by the FDA for use as a smoking cessation aid under the name Zyban. In October 2007, two providers of consumer information on nutritional products and supplements, ConsumerLab.com and The People's Pharmacy, released the results of comparative tests of different brands of bupropion. The People's Pharmacy received multiple reports of increased side effects and decreased efficacy of generic bupropion, which prompted it to ask ConsumerLab.com to test the products in question. The tests showed that "one of a few generic versions of Wellbutrin XL 300 mg, sold as Budeprion XL 300 mg, didn't perform the same as the brand-name pill in the lab." The FDA investigated these complaints and concluded that Budeprion XL is equivalent to Wellbutrin XL regarding bioavailability of bupropion and its main active metabolite hydroxybupropion. The FDA also said that coincidental natural mood variation is the most likely explanation for the apparent worsening of depression after the switch from Wellbutrin XL to Budeprion XL. On 3 October 2012, however, the FDA reversed this opinion, announcing that "Budeprion XL 300 mg fails to demonstrate therapeutic equivalence to Wellbutrin XL 300 mg." The FDA did not test the bioequivalence of any of the other generic versions of Wellbutrin XL 300 mg, but requested that the four manufacturers submit data on this question to the FDA by March 2013. It was approved on the basis of bioequivalence with Wellbutrin XL. In 2009, the FDA issued a health advisory warning that the prescription of bupropion for smoking cessation has been associated with reports of unusual behavior changes, agitation, and hostility. Some people, according to the advisory, have become depressed or have had their depression worsen, have had thoughts about suicide or dying, or have attempted suicide. This advisory was based on a review of anti-smoking products that identified 75 reports of "suicidal adverse events" for bupropion over ten years. Based on the results of follow-up trials this warning was removed in 2016. In 2012, the US Justice Department announced that GlaxoSmithKline had agreed to plead guilty and pay a $3 billion fine, in part for promoting the unapproved use of Wellbutrin for weight loss and sexual dysfunction. In 2017, the European Medicines Agency (EMA) recommended suspending a number of nationally approved medicines due to misrepresentation of bioequivalence study data by Micro Therapeutic Research Labs in India. The products recommended for suspension included several 300 mg modified-release bupropion tablets. Following EMA's call for an industry-wide review of medicines for the possible presence of nitrosamines, GlaxoSmithKline paused batch release and distribution of bupropion 150 mg tablets in November 2022. In July 2023, EMA raised the acceptable daily intake of nitrosamine impurities, leading GlaxoSmithKline to announce that distribution of bupropion 150 mg tablets would resume "across the EU and Europe" by the end of 2023. == Society and culture ==

Recreational use Recreational use of bupropion is uncommon. Case reports describe the recreational use of bupropion as producing a "high" similar to cocaine or amphetamine usage but with less intensity. There have been some anecdotal and case-study reports of bupropion abuse, but the bulk of evidence indicates that the subjective effects of bupropion when taken orally are markedly different from those of addictive stimulants such as cocaine or amphetamine. However, bupropion, by non-conventional routes of administration like injection or insufflation, has been reported to be used recreationally in the United States and Canada, notably in prisons. Bupropion has also been encountered as a novel designer drug or adulterant in the United States and Europe. Legal status In Russia bupropion is banned as a narcotic drug, due to it being a derivative of methcathinone. In Australia, France, and the UK, smoking cessation is the only licensed use of bupropion, and no generics are marketed. Brand names Brand names include Wellbutrin, Aplenzin, and Zyban. == Research ==

A meta-analysis concluded that it was effective and well-tolerated, especially for avoiding weight gain or sexual side effects. == See also ==