Medication Options to Enhance Focus with Vyvanse
Atomoxetine (Strattera) is the most appropriate medication to add to Vyvanse for enhancing focus in a patient already taking Wellbutrin and Lexapro. 1
Current Medication Analysis
The patient is currently on:
- Vyvanse (lisdexamfetamine) - a stimulant for ADHD
- Wellbutrin (bupropion) - a norepinephrine and dopamine reuptake inhibitor
- Lexapro (escitalopram) - an SSRI antidepressant
This combination already targets multiple neurotransmitter systems:
- Dopamine (Vyvanse, Wellbutrin)
- Norepinephrine (Vyvanse, Wellbutrin)
- Serotonin (Lexapro)
Recommended Augmentation Strategy
First-Line Option: Atomoxetine (Strattera)
- Mechanism: Selective norepinephrine reuptake inhibitor
- Rationale: Provides a non-stimulant approach to ADHD that complements Vyvanse through a different mechanism 1
- Dosing: Start at 40 mg daily, titrate to 60 mg then 80 mg/day with maximum dose of 100 mg/day
- Advantages:
- Does not increase risk of seizures (unlike adding more stimulants)
- No significant drug interactions with current medications
- Shown to be effective for ADHD when stimulants provide incomplete response
Alternative Option: Viloxazine
- Recently shown to be significantly more efficacious than placebo in treating ADHD in adults 1
- Non-stimulant option that may complement Vyvanse's effects
Medications to Avoid
Additional Stimulants
- Adding another stimulant (e.g., methylphenidate) would increase risk of side effects without necessarily improving efficacy
- May increase cardiovascular risks and anxiety
Additional SSRIs
- Patient is already on Lexapro (escitalopram)
- Adding another SSRI could increase risk of serotonin syndrome, especially with concurrent bupropion 2
Modafinil/Armodafinil
- While sometimes used off-label for ADHD, these have limited evidence when combined with stimulants
- May increase risk of stimulant-related side effects
Important Considerations and Monitoring
Drug Interaction Concerns
- Monitor for potential serotonin syndrome with the current combination of Lexapro and Wellbutrin 2
- Adding atomoxetine requires monitoring for:
- Blood pressure and heart rate (check baseline and periodically)
- Liver function tests (baseline and as clinically indicated)
- Emergence of suicidal ideation, particularly early in treatment
Timing of Medications
- Vyvanse should be taken in the morning due to its potential to cause insomnia
- Wellbutrin doses should be taken before 3 PM to minimize sleep disturbance 3
- Atomoxetine can be taken once daily, typically in the morning
Follow-up Schedule
- Initial follow-up: 2-4 weeks after starting atomoxetine
- Assess for:
- Improvement in focus and attention
- Side effects (most commonly nausea, dry mouth, decreased appetite)
- Vital sign changes
Evidence for Combination Approaches
Research suggests that targeting multiple neurotransmitter systems can be beneficial for patients with incomplete response to stimulants alone. The combination of Vyvanse with atomoxetine provides complementary mechanisms of action:
- Vyvanse increases dopamine and norepinephrine release
- Atomoxetine selectively inhibits norepinephrine reuptake
- This dual approach may provide more consistent coverage throughout the day
Studies examining escitalopram with stimulants have shown that this combination can enhance neurotransmitter efflux in brain regions associated with attention and cognition 4, supporting the rationale for maintaining the current Lexapro while adding atomoxetine.