What alternative medication can be used for a patient with Attention Deficit Hyperactivity Disorder (ADHD) who is allergic to Wellbutrin (bupropion)?

Alternative Medications for ADHD Patient with Bupropion Allergy

For a patient with ADHD who developed an allergic rash to Wellbutrin (bupropion), the most appropriate medication switch would be to a stimulant medication such as methylphenidate or amphetamine as first-line treatment, or atomoxetine as a second-line non-stimulant option.

First-Line Options: Stimulant Medications

Stimulant medications are the most effective treatment for ADHD and should be considered first:

Methylphenidate Options:

• Immediate-release methylphenidate: Start at 5 mg twice daily (morning and noon)
• Extended-release methylphenidate: Start at 10 mg once daily in the morning
• Titrate weekly by 5-10 mg to optimal effect, not exceeding 60 mg daily 1
• Maximum dose: up to 1.0 mg/kg 1

Amphetamine Options:

• Mixed amphetamine salts (Adderall): Start at 5-10 mg daily
• Titrate up to maximum of 50 mg daily based on symptom control 1
• Lisdexamfetamine: Maximum dose 70 mg per day 1

Efficacy Considerations:

• Approximately 70% of patients respond to either amphetamine or methylphenidate alone
• Nearly 90% respond if both stimulant classes are tried 1
• Stimulants have larger effect sizes (more pronounced efficacy) compared to non-stimulants 2

Second-Line Options: Non-Stimulant Medications

If stimulants are contraindicated, not tolerated, or ineffective, consider these non-stimulant options:

Atomoxetine:

• Dosing: Start low and titrate to target dose of 1.2 mg/kg/day in patients ≤70 kg or 80 mg/day in patients >70 kg 1
• Maximum dose: 1.4 mg/kg/day or 100 mg/day, whichever is lower 1
• Efficacy: Medium effect size compared to placebo, smaller than stimulants 2
• Onset: Treatment effects typically observed after 6-12 weeks (slower than stimulants) 2
• Benefits: Non-controlled substance, "around-the-clock" effects 2, 3

Alpha-2 Agonists:

• Extended-release guanfacine:

  • Available in 1,2,3, and 4 mg tablets
  • Recommended dosing: once-daily (0.1 mg/kg as rule of thumb) 2
  • Maximum dose: 6 mg daily 2

• Extended-release clonidine:

  • Available in 0.1 and 0.2 mg tablets
  • Start with 0.1 mg at bedtime, can increase to twice-daily
  • Maximum dose: 0.4 mg/day 2

Considerations for Medication Selection

Advantages of Non-Stimulants:

1. No abuse potential (not controlled substances)
2. 24-hour symptom coverage
3. May be beneficial for specific comorbidities:
   • Guanfacine/clonidine: helpful for sleep disturbances 2
   • Atomoxetine: may benefit patients with comorbid anxiety or autism spectrum disorder 2

Side Effect Profiles:

• Atomoxetine: Less effect on appetite and growth compared to stimulants; adverse effects generally less frequent and less pronounced than alpha-2 agonists 2
• Guanfacine/Clonidine: Common side effects include somnolence, fatigue, irritability, insomnia, and nightmares; evening administration often preferred due to sedation 2

Monitoring Recommendations

1. Initial titration: Weekly contact (in person or by phone) to assess target symptoms and side effects 1
2. Follow-up: At least monthly until symptoms stabilize 1
3. Regular monitoring: Weight, appetite, vital signs (heart rate and blood pressure) 1
4. Side effects to monitor:
   • For stimulants: insomnia, decreased appetite, headaches, abdominal pain
   • For atomoxetine: somnolence, decreased appetite, dizziness
   • For alpha-2 agonists: somnolence, fatigue, hypotension/bradycardia

Treatment Algorithm

1. First attempt: Trial of methylphenidate (unless contraindicated)
2. If ineffective or not tolerated: Trial of amphetamine formulation
3. If both stimulant classes fail or are contraindicated: Trial of atomoxetine
4. If atomoxetine fails: Consider extended-release guanfacine or clonidine

Remember that medication should be part of a comprehensive treatment plan that includes educational accommodations and behavioral interventions when appropriate 1.