Combining Wellbutrin and Strattera: Safety and Clinical Use
Yes, combining Wellbutrin (bupropion) and Strattera (atomoxetine) is generally safe and can be used together for treating ADHD, particularly when monotherapy proves inadequate. 1, 2
Evidence for Combination Therapy
Clinical Experience and Efficacy
Combination therapy has been demonstrated effective in clinical practice for patients who do not respond adequately to single-agent treatment, as these medications impact dopaminergic and noradrenergic networks through different mechanisms. 1
Both bupropion and atomoxetine are recognized as effective non-stimulant options for adult ADHD, with effect sizes in adults approaching those seen in children when robust doses are used. 2
The combination can extend duration of symptom relief and alleviate a wider range of impairing symptoms than either agent alone. 1
Safety Considerations
Monitor cardiovascular parameters closely, as both medications can affect blood pressure and heart rate:
Pulse and blood pressure monitoring is recommended with both drugs due to their cardiovascular effects. 2
When combining medications, there may be additive effects on blood pressure and pulse. 3
Seizure risk requires particular attention with bupropion:
Bupropion is contraindicated in patients with seizure disorders, brain metastases, or eating disorders due to increased seizure risk. 4, 5
Maximum daily dose of bupropion should not exceed 300 mg when used in combination to minimize seizure risk. 4
Neuropsychiatric monitoring is essential:
Both medications carry warnings about monitoring for depression, suicidal ideation, agitation, or unusual behavior, particularly in the first months of treatment or after dose changes. 4, 2
While these side effects are uncommon, the substantial benefits of treatment typically outweigh these risks. 4
Practical Dosing Approach
Start with standard monotherapy dosing before combining:
Atomoxetine: Begin at 40 mg daily, titrate every 7-14 days to 60-80 mg daily, with maximum of 1.4 mg/kg/day or 100 mg daily. 4
Bupropion: Start at 150 mg daily, increase to 150 mg twice daily if tolerated, with maximum 300 mg daily. 4
If combining both medications, use careful monitoring as there is limited research establishing safety and effectiveness of this specific combination strategy. 1
Clinical Monitoring Requirements
Baseline and ongoing blood pressure and pulse measurements 2
Assessment for neuropsychiatric symptoms including mood changes, suicidal thoughts, agitation 4, 2
Evaluation for seizure risk factors before initiating bupropion 4, 5
Regular assessment of ADHD symptom response to determine if combination therapy provides added benefit 1
Common Pitfalls to Avoid
Do not exceed maximum recommended doses when combining, particularly for bupropion (300 mg/day maximum). 4
Do not use bupropion in patients with seizure disorders, brain metastases, or eating disorders—these are absolute contraindications. 4, 5
Do not combine with MAO inhibitors if using bupropion, due to risk of hypertensive reactions. 4
Do not assume combination is necessary without adequate trial of monotherapy at robust doses. 1, 2