When is Wellbutrin (bupropion) preferred over Strattera (atomoxetine) in treating Attention Deficit Hyperactivity Disorder (ADHD)?

When to Use Wellbutrin Over Strattera in ADHD

Bupropion (Wellbutrin) should be preferred over atomoxetine (Strattera) in ADHD patients with comorbid depression or substance use disorders, as it can address both conditions simultaneously while having a lower abuse potential. 1

Patient-Specific Considerations for Choosing Bupropion

Bupropion is a second-line treatment option for ADHD that shows modest efficacy but is less effective than stimulant medications. However, there are specific clinical scenarios where bupropion may be the preferred choice over atomoxetine:

1. Comorbid Depression

   • Bupropion has antidepressant properties and can effectively treat both ADHD and depression simultaneously 1, 2
   • Atomoxetine carries an FDA black box warning for increased risk of suicidal ideation, particularly during the first few months of treatment 1, 3

2. Substance Use Disorders

   • Bupropion has lower abuse potential and may be preferred for patients with substance use disorders 1
   • Both medications are non-stimulants and thus preferable to stimulants in patients with substance abuse risk

3. Tolerability Profile

   • Bupropion is less likely to cause somnolence compared to atomoxetine 3
   • Atomoxetine more commonly causes gastrointestinal side effects (nausea, decreased appetite) 3

4. Bipolar Disorder

   • Bupropion may be effective in treating ADHD in patients with comorbid bipolar disorder without significant activation of mania 2

When Atomoxetine Would Be Preferred Over Bupropion

Despite the above scenarios, atomoxetine remains the first-line non-stimulant treatment for ADHD and would be preferred over bupropion in the following situations:

1. Tic Disorders/Tourette's Syndrome

   • Atomoxetine doesn't worsen tics and is recommended for patients with these comorbidities 1

2. Comorbid Anxiety

   • Atomoxetine may be beneficial for patients with comorbid anxiety disorders 1

3. FDA Approval Status

   • Atomoxetine is FDA-approved specifically for ADHD treatment, while bupropion is used off-label for this indication 3, 4

4. Efficacy Considerations

   • Atomoxetine has more robust evidence supporting its efficacy in ADHD compared to bupropion 3, 4

Safety Considerations

When prescribing either medication, be aware of these important safety considerations:

• Bupropion

  • Risk of seizures, especially at higher doses
  • Contraindicated in patients with seizure disorders or eating disorders
  • Requires careful dosing to minimize risk of adverse effects

• Atomoxetine

  • Black box warning for suicidal ideation
  • Requires monitoring of blood pressure and heart rate
  • Can cause liver injury in rare cases 3

Clinical Algorithm for Decision-Making

1. First, determine if stimulants are contraindicated (substance abuse risk, tics, anxiety)
2. If stimulants are contraindicated, assess for comorbidities:
   • If depression is present → Choose bupropion
   • If substance use disorder is present → Choose bupropion
   • If anxiety or tics are present → Choose atomoxetine
   • If bipolar disorder is present → Consider bupropion with mood stabilizer
3. If no specific comorbidities, start with atomoxetine as the first-line non-stimulant option
4. Monitor response and tolerability, and be prepared to switch if needed

Dosing Considerations

• Atomoxetine: Start at 0.5 mg/kg/day, target dose 1.2 mg/kg/day (max 1.4 mg/kg/day or 100 mg/day) 1
• Bupropion: Usually started at 150 mg daily of the sustained-release formulation, with potential increase to 150 mg twice daily 4, 2

Remember that while both medications are alternatives to stimulants, they are generally less effective than stimulants for ADHD symptom control 1, 4.