What is the preferred treatment between Wellbutrin (bupropion) and Strattera (atomoxetine) for adult Attention Deficit Hyperactivity Disorder (ADHD)?

Wellbutrin vs Strattera for Adult ADHD

Atomoxetine (Strattera) is preferred over bupropion (Wellbutrin) for adult ADHD when stimulants cannot be used, as atomoxetine is FDA-approved specifically for adult ADHD while bupropion is considered a second-line agent with only modest efficacy. 1

Medication Comparison

Atomoxetine (Strattera)

• FDA-approved specifically for adult ADHD
• First-line non-stimulant option when stimulants are contraindicated
• Particularly beneficial for patients with:
  • Substance use disorders or risk of stimulant abuse
  • Comorbid anxiety
  • Tic disorders or Tourette's syndrome 1
• Dosing: Start at 0.5 mg/kg/day, target dose 1.2 mg/kg/day (maximum 1.4 mg/kg/day or 100 mg/day) 1
• Efficacy: Demonstrated 28-30% reduction in ADHD symptoms versus 18-20% with placebo 2, 3
• Can be administered once daily or split into two doses 2

Bupropion (Wellbutrin)

• Second-line treatment option for ADHD 1
• Shows only modest efficacy compared to stimulants 1
• May be appropriate for specific situations:
  • Patients with comorbid depression and ADHD
  • Pregnant or breastfeeding individuals (as an alternative, though less efficacious) 1

Clinical Decision Algorithm

1. First consideration: Are stimulants contraindicated?

   • If stimulants are appropriate → Use stimulants as first-line
   • If stimulants are contraindicated → Proceed to non-stimulant options

2. Non-stimulant selection:

   • Choose atomoxetine if:

     • Patient has substance use disorder or risk of stimulant abuse
     • Patient has comorbid anxiety
     • Patient has tic disorders
     • Patient needs FDA-approved treatment specifically for adult ADHD

   • Consider bupropion if:

     • Patient has comorbid depression
     • Atomoxetine is not tolerated or contraindicated

Safety Considerations

Atomoxetine

• FDA black box warning for increased risk of suicidal ideation, particularly during first few months 1
• Common side effects: dry mouth, insomnia, nausea, decreased appetite, constipation, dizziness, sweating, sexual problems 2, 3
• Modest increases in heart rate and blood pressure that typically normalize after discontinuation 2
• No QT interval prolongation 2
• Withdrawal rates due to adverse events: 7.8-9.3% (vs 2.4-4.3% for placebo) 2

Bupropion

• Less effective than stimulants for core ADHD symptoms 1
• Slower onset of action compared to stimulants 1
• Lower abuse potential than stimulants 1

Clinical Pearls

• Atomoxetine is the only non-stimulant medication specifically FDA-approved for adult ADHD 2, 4
• Regular monitoring is essential when using atomoxetine, particularly for blood pressure, heart rate, and suicidal ideation 1
• Atomoxetine can be administered as a single daily dose, improving convenience and adherence 2
• Unlike stimulants, atomoxetine is not a controlled substance, making prescription management easier for long-term treatment 2, 3
• Atomoxetine may take 4-6 weeks to reach full therapeutic effect, unlike the rapid onset of stimulants