Is Wellbutrin (bupropion) or Strattera (atomoxetine) better for treating Attention Deficit Hyperactivity Disorder (ADHD) and mood disorders in a teenager with a history of myoclonic seizures?

Atomoxetine (Strattera) is Better than Bupropion (Wellbutrin) for ADHD in a Teen with History of Seizures

For a teenager with ADHD and mood issues who has a history of myoclonic seizures, atomoxetine (Strattera) is clearly the better choice over bupropion (Wellbutrin) due to bupropion's contraindication in patients with seizure disorders. 1

Rationale for Choosing Atomoxetine

Safety Considerations

• Bupropion (Wellbutrin) should not be used in patients with seizure disorders according to clinical guidelines 1
• Bupropion can lower the seizure threshold and may trigger seizures, making it particularly risky for someone with a history of myoclonic seizures, even if the last episode was 7 years ago
• Atomoxetine has no specific contraindication for patients with seizure history in standard dosing 1, 2

Efficacy for ADHD

• Atomoxetine is a non-stimulant medication specifically approved for ADHD with established efficacy 1
• Multiple randomized, double-blind, placebo-controlled trials have demonstrated atomoxetine's effectiveness in treating ADHD symptoms in children and adolescents 3
• Atomoxetine improves ADHD symptoms throughout waking hours with effects persisting to the next morning with a single morning dose 3

Mood Benefits

• Atomoxetine has shown improvements in several aspects of quality of life measurement including social and family functioning 3
• It has demonstrated positive effects on self-esteem 3
• Atomoxetine can be effective in managing ADHD with comorbid conditions 3

Dosing and Administration

For atomoxetine (Strattera):

• Starting dose: 0.5 mg/kg/day 1
• Target dose: 1.2 mg/kg/day 1, 3
• Can be administered either as a single daily dose or split into two evenly divided doses 2, 4

Monitoring Recommendations

• Regular assessment of ADHD and mood symptoms using standardized scales
• Monitor blood pressure and heart rate at each visit (atomoxetine can cause statistically but not clinically significant increases) 2
• Initial follow-up within 2-4 weeks after medication initiation 1
• Monitor for potential side effects:
  • Common side effects include headache, abdominal pain, decreased appetite, vomiting, somnolence, and nausea 2
  • Most adverse events are mild to moderate in severity 2

Important Considerations

Advantages of Atomoxetine

• No abuse potential, not a controlled substance 2, 4
• Effective throughout the day with once-daily dosing 3
• No evidence of rebound symptoms upon discontinuation 3
• Can be combined with behavioral interventions for optimal outcomes 1

Cautions

• While rare, there is a case report of atomoxetine overdose resulting in seizure 5, but this was at a massive dose (2840 mg) far exceeding therapeutic levels
• Regular assessment for suicidal ideation is essential (black box warning for suicidal ideation exists) 2
• Initial weight and height monitoring is recommended as temporary growth effects may occur 2

Treatment Approach

1. Begin atomoxetine at 0.5 mg/kg/day
2. Gradually increase to target dose of 1.2 mg/kg/day over several weeks
3. Combine with behavioral interventions (parent training in behavior management and/or CBT) 1
4. Monitor for effectiveness and side effects at 2-4 week intervals initially
5. Assess long-term response and adjust as needed

Long-term studies show atomoxetine maintains effectiveness for up to 18 months in responders 3, with clinical improvement observed in approximately 78% of patients after 3 months of treatment 6.