Medication Management for ADHD: Transitioning to Auvelity
For a patient currently taking bupropion 300 mg XR, Burbery 200 mg, and sertraline 25 mg who is experiencing severe ADHD symptoms, you should discontinue both bupropion and sertraline before starting Auvelity, as Auvelity contains bupropion and there is risk of serotonin syndrome with concurrent sertraline use.
Understanding the Current Medication Regimen
The patient is currently taking:
- Burbery 200 mg daily (appears to be a typo, likely referring to Buproban/bupropion)
- Wellbutrin (bupropion) 300 mg extended-release daily
- Zoloft (sertraline) 25 mg daily
This regimen includes duplicate bupropion therapy (Burbery and Wellbutrin) and a low dose of sertraline, with the patient experiencing inadequate control of ADHD symptoms.
Why Medication Adjustment is Necessary
Duplicate bupropion therapy: The patient is taking two forms of bupropion (Burbery and Wellbutrin), which is redundant and potentially increases side effect risk.
Auvelity composition: Auvelity is a fixed-dose combination of dextromethorphan and bupropion 1. Since the patient is already taking bupropion, adding Auvelity would result in excessive bupropion dosing.
Drug interactions: Combining sertraline with Auvelity increases the risk of serotonin syndrome due to the serotonergic effects of both medications 2.
Recommended Medication Transition Plan
Step 1: Discontinue Current Medications
- Bupropion (both forms): Taper by reducing to 150 mg daily for 1 week before discontinuing 3.
- Sertraline: Taper over 1-2 weeks to avoid withdrawal symptoms by reducing to 12.5 mg for 7 days before discontinuing 2.
Step 2: Washout Period
- Allow 1-2 days after complete discontinuation of both medications before starting Auvelity.
Step 3: Initiate Auvelity
- Start Auvelity at the standard initial dose according to prescribing information.
- Auvelity contains bupropion, which has shown efficacy for ADHD with an effect size of 0.7 4, 5.
Evidence Supporting This Approach
Bupropion has demonstrated efficacy for ADHD in adults as shown in multiple studies:
- A Cochrane review found that bupropion decreased ADHD symptom severity and increased the proportion of patients achieving clinical improvement 4.
- A randomized, double-blind study showed bupropion to be more effective than placebo in treating adults with ADHD 5.
The American Academy of Pediatrics recognizes bupropion as a second-line option for ADHD when stimulants are not tolerated or effective 6. While not FDA-approved specifically for ADHD, bupropion's dopaminergic and noradrenergic effects make it a reasonable option for ADHD treatment 7.
Monitoring and Follow-up
- Schedule follow-up within 3-4 weeks of initiating Auvelity to assess efficacy and side effects 6.
- Monitor for common adverse effects including dizziness, nausea, headache, diarrhea, somnolence, dry mouth, and insomnia 1.
- Assess for seizure risk, as both bupropion and Auvelity carry this risk, particularly at higher doses 1.
- Monitor for suicidal thoughts, especially during the initial treatment period, as antidepressants carry a boxed warning regarding this risk 1.
Important Considerations and Cautions
- Seizure risk: Bupropion can lower seizure threshold; this risk may be dose-dependent 3.
- Serotonin syndrome: Combining sertraline with Auvelity increases this risk, hence the recommendation to discontinue sertraline 2.
- Withdrawal symptoms: Tapering sertraline is important to minimize withdrawal effects 8.
- Therapeutic gap: The patient may experience a temporary worsening of symptoms during the transition period.
By following this medication transition plan, you can safely switch your patient from their current regimen to Auvelity for management of their ADHD symptoms while minimizing the risks of drug interactions and adverse effects.