What alternative Attention Deficit Hyperactivity Disorder (ADHD) medication can be prescribed for a patient who experienced adverse reactions to both Wellbutrin (bupropion) SR and XL generics?

Alternative ADHD Medications After Wellbutrin Reactions

For a patient who has reacted to both Wellbutrin SR and XL generics, stimulant medications are the recommended first-line treatment for ADHD due to their superior efficacy compared to non-stimulants. 1, 2

First-Line Options

Stimulant Medications

• Methylphenidate-based medications (Ritalin, Concerta, Focalin)

  • Start with 5-10 mg daily and titrate based on response
  • Higher efficacy than non-stimulants with effect size of approximately 1.0
  • Common side effects: appetite loss, abdominal pain, headaches, sleep disturbance 1

• Amphetamine-based medications (Adderall, Vyvanse, Dexedrine)

  • Start with low dose (5-10 mg daily) and titrate based on response
  • Particularly effective for adult ADHD
  • Monitor for insomnia, decreased appetite, cardiovascular effects 2

Second-Line Options (Non-Stimulants)

Atomoxetine (Strattera)

• Selective norepinephrine reuptake inhibitor
• Starting dose: 0.5 mg/kg/day
• Target dose: 1.2 mg/kg/day (maximum 100 mg)
• Effect size approximately 0.7 (less than stimulants)
• Side effects: initial somnolence, gastrointestinal symptoms, decreased appetite 1, 2
• Monitor for liver injury and suicidal ideation, especially during first few months 2

Alpha-2 Adrenergic Agonists

• Extended-release guanfacine (Intuniv)

  • Starting dose: 1 mg daily
  • Effect size approximately 0.7
  • Side effects: somnolence, dry mouth 1, 2

• Extended-release clonidine (Kapvay)

  • Starting dose: 0.1 mg daily
  • Effect size approximately 0.7
  • Side effects: somnolence, dry mouth 1, 2

Decision Algorithm

1. Rule out contraindications to stimulants:

   • History of cardiovascular disease
   • Uncontrolled hypertension
   • History of substance abuse
   • Severe anxiety that might be exacerbated

2. If no contraindications exist:

   • Try methylphenidate-based medication first
   • If ineffective or poorly tolerated, switch to amphetamine-based medication

3. If stimulants are contraindicated or ineffective:

   • Try atomoxetine as first non-stimulant option
   • If ineffective or poorly tolerated, try extended-release guanfacine or clonidine

Special Considerations

For Patients with Comorbidities

• Anxiety disorders: Consider atomoxetine or alpha-2 agonists as they may be better tolerated 1, 2
• Tic disorders/Tourette's syndrome: Alpha-2 agonists may be beneficial 2
• Substance use disorders: Avoid stimulants; atomoxetine is preferred 2

Monitoring Requirements

• For all medications: Regular assessment of blood pressure, heart rate, weight, and symptom response
• For atomoxetine: Additional monitoring for liver function and suicidal ideation
• For stimulants: Growth monitoring in children, cardiovascular parameters

Important Caveats

• The reaction to Wellbutrin (bupropion) does not necessarily predict reaction to other classes of ADHD medications
• Despite evidence supporting bupropion for ADHD 3, 4, 5, its efficacy is lower than stimulants and other non-stimulants
• Combination therapy (e.g., stimulant + alpha-2 agonist) may be considered for partial response, but only extended-release guanfacine and clonidine are FDA-approved as adjunctive therapies 1

Remember that medication efficacy varies significantly between individuals, and what works best for one patient may not work for another. Close monitoring during initiation and dose titration is essential for all ADHD medications.