Starting Dose for Strattera (Atomoxetine) When Already on Effexor and Wellbutrin
Start atomoxetine at 40 mg once daily, then titrate to 60 mg after 7-14 days, and potentially to 80 mg if needed, with a maximum dose of 100 mg/day or 1.4 mg/kg/day (whichever is less). 1
Initial Dosing Strategy
The standard starting dose for atomoxetine is 40 mg once daily, regardless of concurrent antidepressant use 1. This conservative approach is particularly important when combining with venlafaxine (Effexor) and bupropion (Wellbutrin), as all three medications affect different neurotransmitter systems and require careful monitoring.
Titration Schedule
- Week 1-2: Begin with 40 mg daily 1
- Week 2-4: Increase to 60 mg daily if tolerated 1
- Week 4+: May increase to 80 mg daily if needed for therapeutic effect 1
- Maximum dose: Do not exceed 100 mg/day or 1.4 mg/kg/day, whichever is lower 1
The titration intervals of 7-14 days allow adequate time to assess tolerability and response before dose escalation 1.
Critical Safety Considerations with This Combination
Seizure Risk from Bupropion
- Bupropion lowers the seizure threshold and requires gradual dose titration 1
- The maximum safe dose for bupropion SR is 400 mg/day 2, 1
- Ensure bupropion doses are not taken late in the day (second dose before 3 PM) to minimize insomnia 2
Drug Interaction Monitoring
- This triple combination (atomoxetine + venlafaxine + bupropion) affects norepinephrine, serotonin, and dopamine systems simultaneously 1, 3
- Monitor for increased agitation, as bupropion is activating 2
- Watch for blood pressure elevations, as both venlafaxine and atomoxetine can increase blood pressure 4, 1
Absolute Contraindications
- Active seizure disorder or history of seizures (due to bupropion) 1
- Current MAOI use or within 14 days of MAOI discontinuation 1
- Eating disorders (anorexia nervosa or bulimia) if on bupropion 1
Monitoring Parameters
- Blood pressure: Check at baseline and regularly during titration, as both venlafaxine and atomoxetine can cause hypertension 4, 1
- Neuropsychiatric symptoms: Monitor for increased agitation, anxiety, or mood changes 2, 1
- Seizure precautions: Ensure no risk factors for seizures develop (alcohol withdrawal, benzodiazepine discontinuation) 1
Clinical Rationale for This Approach
The combination of atomoxetine (norepinephrine reuptake inhibitor), venlafaxine (serotonin-norepinephrine reuptake inhibitor), and bupropion (norepinephrine-dopamine reuptake inhibitor) provides complementary mechanisms of action 1, 3. Starting atomoxetine at the standard 40 mg dose allows assessment of tolerability in the context of existing antidepressant therapy without overwhelming the patient's system 1.
Common Pitfalls to Avoid
- Do not start at higher doses thinking the patient is already on antidepressants—the standard 40 mg starting dose applies 1
- Do not rush titration—allow the full 7-14 days between dose increases to assess tolerability 1
- Do not exceed maximum doses of any medication in the regimen to minimize adverse effects and seizure risk 2, 1
- Do not ignore timing of bupropion doses—late-day dosing significantly increases insomnia risk 2