Is it safe to combine Wellbutrin (Bupropion) XL 150 mg once daily with Strattera (Atomoxetine) for Attention Deficit Hyperactivity Disorder (ADHD) symptoms and comorbid symptoms of anxiety and depression in a patient currently taking Wellbutrin, and what is the recommended starting dose?

Combining Wellbutrin XL and Strattera for ADHD with Comorbid Anxiety and Depression

The combination of Wellbutrin XL 150 mg once daily with Strattera is generally safe and effective for treating ADHD with comorbid anxiety and depression, with a recommended starting dose of Strattera at 40 mg daily for an obese 38-year-old patient, gradually titrating to an effective dose. 1, 2

Safety of Combining Wellbutrin XL and Strattera

• Bupropion (Wellbutrin) and atomoxetine (Strattera) have different primary mechanisms of action, with bupropion activating proopiomelanocortin neurons in the hypothalamus and inhibiting norepinephrine and dopamine reuptake, while atomoxetine selectively inhibits presynaptic norepinephrine reuptake in the prefrontal cortex 1, 3
• Neither medication is a monoamine oxidase inhibitor (MAOI), which would be a contraindication for combination therapy 2
• Both medications can be safely combined as they don't have significant pharmacokinetic interactions that would increase risk of serotonin syndrome or other serious adverse effects 3
• The combination may actually provide complementary benefits for patients with both ADHD and depression/anxiety symptoms 4

Recommended Starting Dose of Strattera

• For an adult patient already taking Wellbutrin XL 150 mg daily, the recommended starting dose of Strattera is 40 mg once daily 1
• This starting dose allows for assessment of tolerability before dose increases 1
• After 7-14 days, the dose can be increased to 60 mg daily, and then to 80 mg daily if needed 1
• The maximum recommended dose should be the lesser of 1.4 mg/kg/day or 100 mg/day total 1

Dosing Considerations for This Patient

• For an obese 38-year-old patient, weight-based dosing is important, but the maximum dose should still not exceed 100 mg/day regardless of weight 1
• Morning dosing of both medications is preferred to minimize sleep disturbances 5
• The current Wellbutrin XL dose of 150 mg once daily is appropriate as a starting dose and may be maintained if providing adequate response 2, 6
• If depression symptoms are not adequately controlled, Wellbutrin XL could be increased to 300 mg once daily, while carefully monitoring for side effects 2, 6

Monitoring Recommendations

• Monitor blood pressure and heart rate regularly, as both medications can cause modest increases 3
• Watch for insomnia, which is more common with bupropion, and somnolence, which is more common with atomoxetine 3
• Assess for gastrointestinal side effects including nausea, decreased appetite, and dry mouth, which are common with both medications 1, 3
• Evaluate mood changes and suicidal ideation, particularly during the initial weeks of treatment and with dose adjustments 3
• Monitor weight, as both medications may be associated with weight loss 1, 3

Potential Benefits of This Combination

• Bupropion can help address depression symptoms while atomoxetine targets ADHD symptoms 3, 4
• The combination may provide more comprehensive symptom relief than either medication alone for patients with comorbid conditions 4
• Bupropion's activating properties may help offset potential sedation from atomoxetine 3, 5
• Both medications have once-daily dosing options, which can improve adherence 2, 3

Common Pitfalls to Avoid

• Avoid rapid dose escalation of either medication, as this increases risk of side effects 1, 2
• Don't exceed the maximum recommended doses (100 mg/day for atomoxetine, 450 mg/day for bupropion XL) 1, 2
• Be cautious in patients with seizure disorders, as bupropion may lower seizure threshold 2
• Avoid adding other serotonergic medications without careful consideration of potential interactions 1
• Don't discontinue either medication abruptly; taper if discontinuation is necessary 1