Can a Patient on Wellbutrin Start Strattera?
Yes, a patient on bupropion (Wellbutrin) can start atomoxetine (Strattera), as there are no absolute contraindications to this combination, though careful monitoring for side effects is essential. 1
Key Safety Considerations
No Direct Drug Interaction Contraindication
- The combination of atomoxetine and bupropion is not listed among absolute contraindications for either medication 1
- Atomoxetine does not inhibit or induce CYP enzymes that would affect bupropion metabolism 2
- Both medications have been studied together in ADHD treatment protocols 3, 4
Absolute Contraindications to Monitor (But Not Related to Combination)
The following would prevent starting this combination, but are patient-specific rather than drug-drug interactions 1:
- Active seizure disorder or history of seizures (bupropion contraindication)
- Anorexia nervosa or bulimia nervosa (bupropion contraindication)
- Abrupt discontinuation of alcohol or benzodiazepines
- Current MAOI use or within 14 days of MAOI discontinuation
Seizure Risk Management
- Bupropion lowers the seizure threshold, requiring gradual dose titration to minimize risk 1
- Start bupropion SR at 100-150 mg once daily, increasing by 37.5-75 mg every 3 days as tolerated 1
- Maximum dose: 400 mg/day for SR formulation, 450 mg/day for IR formulation 1
Atomoxetine Dosing When Adding to Bupropion
- Start atomoxetine at 40 mg daily 1
- Titrate every 7-14 days to 60 mg, then 80 mg if needed 1
- Maximum recommended dose: lesser of 1.4 mg/kg/day or 100 mg/day 1
Monitoring Requirements
Cardiovascular Monitoring
- Monitor pulse and blood pressure regularly with both medications, as both have cardiovascular effects 3
- Extremely rare case reports of sudden death exist with atomoxetine, though causality is difficult to establish 3
Psychiatric Monitoring
- Observe for agitation, irritability, suicidal thinking, self-harming behavior, or unusual behavior with atomoxetine, particularly in the first months of treatment or after dose changes 3
Common Pitfalls to Avoid
CYP2D6 Considerations
- Bupropion inhibits CYP2D6 pathway, which could theoretically increase atomoxetine levels in extensive metabolizers 5
- However, atomoxetine's safety profile remains similar across CYP2D6 phenotypes, so this interaction is clinically manageable 2
- In CYP2D6 poor metabolizers (who already have 10-fold higher atomoxetine levels), bupropion's CYP2D6 inhibition would have minimal additional effect 2
Misinterpreting Early Side Effects
- Early symptoms like restlessness or agitation could be misinterpreted as worsening of underlying psychiatric condition rather than medication side effects 5
- If concerning symptoms emerge, consider medication-related causes before adding additional psychiatric medications 5