Can I add Wellbutrin (bupropion) to Strattera (atomoxetine) for treating fatigue?

Adding Wellbutrin to Strattera for Fatigue

Yes, adding Wellbutrin (bupropion) to Strattera (atomoxetine) can be an effective strategy for managing fatigue, particularly when Strattera alone is not providing adequate relief of fatigue symptoms.

Pharmacological Rationale

• Strattera (atomoxetine) works primarily as a selective norepinephrine reuptake inhibitor, affecting noradrenergic pathways 1
• Wellbutrin (bupropion) functions as a norepinephrine-dopamine reuptake inhibitor with different mechanisms of action 1
• The combination provides complementary neurotransmitter effects:
  • Atomoxetine primarily affects norepinephrine
  • Bupropion affects both norepinephrine and dopamine pathways
  • This dual mechanism may better address fatigue symptoms 2

Dosing Recommendations

For adding Wellbutrin to existing Strattera therapy:

• Start with Wellbutrin SR 100-150 mg once daily in the morning 1
• Titrate gradually to maintenance dose of 100-150 mg twice daily (SR) or 150-300 mg once daily (XL) 1
• Maximum recommended dose: 450 mg per day 1
• Take the second dose early enough in the day to prevent insomnia 1

Efficacy for Fatigue

• Medications with dopaminergic and noradrenergic action like bupropion have shown effectiveness in improving symptoms of fatigue 2
• Bupropion has demonstrated efficacy in treating fatigue in patients with chronic fatigue syndrome who did not respond to other treatments 3
• The combination of noradrenergic and dopaminergic effects may provide better symptom relief than either medication alone 4

Monitoring and Precautions

Key Safety Considerations:

1. Blood pressure and heart rate monitoring:

   • Both medications can affect cardiovascular parameters
   • Monitor vital signs regularly, especially during dose adjustments 1

2. Seizure risk:

   • Bupropion may lower seizure threshold
   • Avoid in patients with seizure disorders 1

3. Drug interactions:

   • Avoid combining with MAOIs (must wait at least 14 days after discontinuing MAOIs) 1
   • Use caution with other serotonergic drugs to avoid serotonin syndrome 1

4. Psychiatric effects:

   • Monitor for anxiety, agitation, or worsening mood
   • Watch for suicidal ideation, particularly in younger patients 1

Common Side Effects:

• Insomnia (avoid taking bupropion late in the day) 1
• Headache, nausea, dry mouth 1
• Decreased appetite 1
• Anxiety or jitteriness 1

Alternative Approaches for Fatigue

If the Strattera-Wellbutrin combination is not appropriate:

1. Methylphenidate:

   • Starting dose: 2.5-5 mg daily or twice daily
   • Gradually titrate to 5-30 mg/day divided twice daily 5
   • Administer early in the day to minimize insomnia

2. Modafinil:

   • Starting dose: 50-100 mg daily
   • Can increase to 50-400 mg/day 5
   • Particularly effective for severe fatigue

3. Non-pharmacological approaches:

   • Regular moderate exercise (30 minutes, 3-4 times weekly) 5
   • Sleep hygiene optimization 5
   • Energy conservation strategies 5

Special Considerations

• Renal impairment: Reduce bupropion dose by half (1 tablet twice daily) in moderate to severe renal impairment 1
• Hepatic impairment: Limit bupropion to 1 tablet daily in moderate to severe hepatic impairment 1
• Discontinuation: After 12 weeks, if less than 5% weight loss is achieved with bupropion, consider discontinuation as the patient may be a poor responder 1

The combination of Strattera and Wellbutrin appears to be a reasonable approach for managing fatigue, with complementary mechanisms that may provide better symptom relief than monotherapy.