Can I take Wellbutrin (bupropion) while on Strattera (atomoxetine) 60mg?

Can You Add Wellbutrin to Strattera 60mg Without Re-titrating?

Yes, you can add Wellbutrin (bupropion) to your current Strattera (atomoxetine) 60mg dose without needing to re-titrate the Strattera, and you have the flexibility to reduce Strattera to 40mg if complications arise. 1, 2

Starting the Combination Safely

Begin bupropion at a low dose (100-150 mg SR once daily in the morning) while maintaining your Strattera 60mg, with gradual titration of bupropion every 3 days as tolerated. 1 This approach allows you to:

• Keep your hard-won Strattera dose stable at 60mg initially 1, 2
• Add bupropion slowly to minimize adverse effects 1
• Reserve the option to reduce Strattera to 40mg only if needed 1

The American Academy of Child and Adolescent Psychiatry notes there are no published case reports of serious adverse events when combining these medications, and the combination is considered reasonable given their complementary noradrenergic mechanisms. 2

Critical Monitoring in the First 24-48 Hours

Watch closely for early warning signs within the first 24-48 hours after starting bupropion or any dose changes: 2

• Neuropsychiatric symptoms: Agitation, anxiety, irritability, unusual thoughts or behaviors 3, 4
• Neuromuscular signs: Tremors, clonus (rhythmic muscle contractions), hyperreflexia, muscle rigidity 3, 2
• Autonomic symptoms: Elevated blood pressure, rapid heart rate, sweating, restlessness 3, 2
• Seizure risk indicators: New-onset tremor, confusion, or any jerking movements 1, 4

While serotonin syndrome is primarily a concern with serotonergic drugs, the guideline emphasizes monitoring for mental status changes and autonomic hyperactivity when combining any psychotropic medications. 3, 2

Absolute Contraindications to This Combination

Do not proceed with this combination if you have: 1

• Active seizure disorder or history of seizures 1, 4
• Current or past eating disorder (anorexia nervosa or bulimia nervosa) 1, 4
• Recent alcohol or benzodiazepine use that you're stopping abruptly 1
• Current MAOI use or stopped an MAOI within the past 14 days 1, 4

Bupropion Dosing Strategy

Start with bupropion SR 100-150 mg once daily in the morning, increasing by 37.5-75 mg every 3 days as tolerated, with a maintenance dose of 100-150 mg twice daily (SR formulation). 1 The maximum dose is 400 mg/day for SR formulation or 450 mg/day for immediate-release. 1

Gradual dose titration is essential to minimize seizure risk, which is bupropion's most serious adverse effect. 1, 4 The seizure rate at therapeutic doses (≤450 mg/day in divided doses) is comparable to other antidepressants, but increases significantly with higher doses or rapid titration. 5

When to Reduce Strattera to 40mg

Consider reducing Strattera from 60mg to 40mg if you experience: 1, 2

• Persistent agitation or insomnia beyond the first week 2
• Significant tremor or muscle tension 2
• Blood pressure elevation (monitor if you have pre-existing cardiac conditions) 2
• Intolerable side effects that don't resolve with time 1

The American Academy of Child and Adolescent Psychiatry recommends starting atomoxetine at a lower dose (40mg or less) if bupropion is already being taken, so the reverse strategy—reducing Strattera after adding bupropion—is clinically sound. 2

Practical Management Timeline

Follow this monitoring schedule: 2

• Days 1-2: Watch intensively for early adverse effects, especially neuropsychiatric and autonomic symptoms 2
• Week 2: Schedule your first follow-up to assess tolerability and efficacy 2
• Monthly thereafter: Continue monitoring once stabilized on the combination 2

Drug Interaction Considerations

Atomoxetine does not cause clinically significant interactions with CYP2D6 or CYP3A substrates at therapeutic doses. 6 While in vitro studies predicted potential inhibition of these enzymes, definitive in vivo studies showed that atomoxetine administration with substrates of CYP2D6 and CYP3A does not result in clinically significant drug interactions. 6

Bupropion is metabolized by CYP2B6 and has minimal interaction potential with atomoxetine, which is primarily metabolized by CYP2D6. 7, 6 This makes the combination pharmacokinetically favorable.

Common Adverse Effects to Expect

With bupropion addition, anticipate: 4, 7, 8

• Dry mouth (most common) 7, 5
• Agitation or restlessness (8.2% with extra doses) 8
• Insomnia (more common than with atomoxetine alone) 9
• Tremor (7.1% with extra doses) 8
• Nausea (6.7% with extra doses) 8

With atomoxetine at 60mg, you're already experiencing: 9

• Possible decreased appetite 9
• Mild increases in heart rate and blood pressure 9
• Potential somnolence (more common than with stimulants) 9

Critical Safety Pitfall to Avoid

Never take extra doses of bupropion if you miss a dose. 8 A study of inadvertent extra doses showed that 38.4% of patients experienced adverse effects, with seizures occurring in 0.8% (twice the rate of therapeutic dosing). 8 Doses were significantly higher in patients with adverse effects (p=0.045). 8

Cardiovascular Monitoring

Monitor blood pressure and heart rate, particularly if you have pre-existing cardiac conditions. 2 Both medications can cause modest increases in blood pressure and heart rate, and the combination may have additive effects. 2, 9 The American Academy of Child and Adolescent Psychiatry specifically recommends cardiovascular monitoring when combining these agents. 2

Your Backup Plan is Sound

Your strategy to reduce Strattera to 40mg if complications arise is clinically appropriate and supported by dosing guidelines. 1, 2 The 40mg dose is a standard therapeutic dose with established efficacy, and you can make this adjustment without a prolonged re-titration period. 1