What about using Qelbree (viloxazine) in patients with Attention Deficit Hyperactivity Disorder (ADHD) and Postural Orthostatic Tachycardia Syndrome (POTS)?

Viloxazine (Qelbree) in ADHD Patients with POTS

Viloxazine (Qelbree) should be used with caution in patients with both ADHD and POTS, as there is no published information on its safety specifically in patients with POTS, and alternative agents with more established safety profiles would be preferred. 1, 2

Mechanism and Considerations

Viloxazine is a selective norepinephrine reuptake inhibitor (NRI) that was approved by the FDA for ADHD treatment in children, adolescents, and adults 3, 4. Unlike stimulants, viloxazine has:

• Decreased risk of substance abuse and drug dependence 3
• Activity in both noradrenergic and serotonergic pathways 3
• A relatively rapid onset of action (significant effects by week 2 in adult studies) 5

Concerns for POTS Patients

For patients with POTS, medication selection requires special consideration:

• Clinicians should be cautious with medications that may reduce blood pressure, as they could exacerbate orthostatic symptoms in POTS patients 2
• Norepinephrine reuptake inhibition (the mechanism of viloxazine) could theoretically affect autonomic function and heart rate, which may be problematic in POTS

Dosing Information

If viloxazine is considered after other options:

• Starting dose: 200 mg once daily 1
• Titration: Increase by 200 mg increments at weekly intervals based on response and tolerability 1
• Maximum daily dose: 600 mg/day 1, 5

Alternative Medications for ADHD in POTS Patients

Based on current guidelines, these alternatives may be more appropriate:

1. Atomoxetine (Strattera):

   • Starting dose: 0.5 mg/kg/day
   • Target dose: 1.2 mg/kg/day 2

2. Guanfacine (Intuniv):

   • Starting dose: 0.1 mg/kg once daily
   • Particularly useful for patients with comorbid anxiety 2

3. Bupropion:

   • Starting dose: 100-150 mg daily (sustained-release) or 37.5 mg every morning
   • Target dose: 150 mg twice daily 2

Monitoring Recommendations

For ADHD patients with POTS who are prescribed viloxazine:

• Monitor blood pressure and heart rate closely, especially during dose adjustments
• Watch for common side effects: insomnia (14.8%), fatigue (11.6%), nausea (10.1%), decreased appetite (10.1%), dry mouth (9.0%), and headache (9.0%) 5
• Assess for worsening of orthostatic symptoms
• Regular follow-up within 2-4 weeks after medication initiation 2

Efficacy Considerations

Viloxazine has demonstrated efficacy in:

• Reducing ADHD symptoms in children, adolescents, and adults 4, 5
• Improving executive function 5
• Enhancing peer relations and social activities, though with modest effect sizes 6

Important Caveats

• There are no published studies on viloxazine in patients with POTS 2
• Limited data exists on viloxazine's efficacy for ADHD treatment in adults 1
• The discontinuation rate due to adverse events in adult studies was 9.0% for viloxazine versus 4.9% for placebo 5

Given the lack of specific data on viloxazine in POTS patients and the potential for cardiovascular effects, a more established non-stimulant medication like guanfacine might be a safer initial choice for patients with both conditions.