What medication can be added to a regimen of lamotrigine (Lamictal) 200mg, bupropion (Wellbutrin) 200mg, and propranolol (Inderal) 10mg twice daily (bid) as needed for anxiety, for a patient experiencing increased anxiety?

Medication Options for Increased Anxiety with Current Regimen

For a patient on lamotrigine 200mg, bupropion 200mg, and as-needed propranolol 10mg BID reporting increased anxiety, buspirone (BuSpar) is the most appropriate medication to add, starting at 5mg twice daily and titrating up to a maximum of 20mg three times daily as needed. 1

Assessment of Current Medication Regimen

The patient is currently taking:

• Lamotrigine 200mg (mood stabilizer)
• Bupropion 200mg (antidepressant)
• Propranolol 10mg BID as needed (beta-blocker for anxiety)

This combination presents several important considerations:

• Bupropion can be activating and may potentially worsen anxiety symptoms 1
• Propranolol is only being used as needed and at a relatively low dose
• The patient is already on a mood stabilizer (lamotrigine)

First-Line Recommendation: Buspirone

Buspirone is the most appropriate choice for several reasons:

• It's specifically indicated for mild to moderate anxiety 1
• It has minimal drug interactions with the current regimen
• It doesn't cause dependence like benzodiazepines
• It can be safely combined with lamotrigine and bupropion

Dosing and Administration:

• Start at 5mg twice daily
• May take 2-4 weeks to become fully effective
• Can be titrated up to 20mg three times daily (maximum dose) 1

Alternative Options (If Buspirone Is Ineffective)

1. Gabapentin

• Starting dose: 100-300mg nightly
• Can increase to 900-3600mg daily in divided doses
• Particularly useful for anxiety with neuropathic components 1
• Safe to use with lamotrigine and other medications in the current regimen

2. Short-Term Benzodiazepine (with caution)

If anxiety is severe and immediate relief is needed:

• Lorazepam 0.5-1mg orally up to four times daily as needed (maximum 4mg/24 hours) 1
• Important caution: Regular use can lead to tolerance, addiction, and cognitive impairment; paradoxical agitation occurs in about 10% of patients 1
• Should be limited to short-term use (ideally less than 2 weeks) 2

3. Adjust Current Medications

• Consider increasing propranolol to a scheduled rather than as-needed basis
• However, propranolol alone has limited efficacy for generalized anxiety 3

Medications to Avoid

1. Additional SSRIs/SNRIs - May interact with bupropion and increase risk of serotonin syndrome
2. Alprazolam - Higher risk of dependence and withdrawal compared to other benzodiazepines 4
3. Additional antipsychotics - Would be excessive for anxiety management in this context

Monitoring and Follow-up

• Assess response to buspirone after 2-4 weeks (full effect may take time)
• Monitor for side effects including dizziness, headache, and nausea
• If inadequate response after 4-6 weeks at maximum tolerated dose, consider alternatives
• Evaluate for any worsening of anxiety that might be related to bupropion (which can be activating) 1

Patient Education Points

• Buspirone takes time to work (2-4 weeks for full effect)
• Continue using propranolol as needed for acute anxiety symptoms during this period
• Avoid alcohol and other CNS depressants
• Practice non-pharmacological anxiety management techniques (deep breathing, mindfulness)

This approach prioritizes a medication with good efficacy for anxiety that has minimal risk of dependence and is compatible with the patient's current medication regimen.