What is the best approach to manage morning nausea in a patient with Attention Deficit Hyperactivity Disorder (ADHD) taking Strattera (Atomoxetine) 60mg with dinner and Wellbutrin (Bupropion) 100mg SR with a protein shake in the morning?

Managing Morning Nausea in ADHD Patient on Strattera and Wellbutrin

The morning nausea is most likely caused by Wellbutrin (bupropion), and you should take the Wellbutrin with food rather than just a protein shake, or consider splitting the dose to reduce gastrointestinal side effects. 1

Immediate Management Strategy

First-Line Approach: Optimize Wellbutrin Administration

• Take Wellbutrin with a substantial meal, not just a protein shake, as gastrointestinal side effects including nausea are common with bupropion and can be mitigated by taking it with food 2
• The protein shake alone may not provide sufficient gastric buffering to prevent nausea 1
• Nausea is one of the most common adverse effects of bupropion SR, occurring in patients taking the medication 2

Timing Considerations

• Consider moving the Wellbutrin dose to later in the morning (e.g., mid-morning with a full breakfast) rather than immediately upon waking 1
• The current 100 mg SR dose is below the typical therapeutic range of 150-300 mg daily, so dose reduction is not immediately necessary 1
• Ensure the second dose (if titrating up) is given before 3 PM to minimize insomnia risk 1

Pharmacological Management if Symptoms Persist

Short-Term Antiemetic Support

If dietary modifications fail after 5-7 days, consider adding:

• Metoclopramide 5-10 mg taken 30 minutes before the Wellbutrin dose as a dopamine receptor antagonist that also promotes gastric emptying 1, 3
• Alternatively, ondansetron 4 mg as needed in the morning, though this may cause constipation 1, 4
• Avoid long-term antiemetic use; these should be temporary measures while the patient adjusts to the medication 1, 3

Rule Out Other Causes

• Assess for gastroesophageal reflux or gastritis, which can present as morning nausea and may be exacerbated by medications 1
• Consider adding a proton pump inhibitor or H2 receptor antagonist if reflux symptoms are present 1
• Evaluate for constipation, as both Strattera and Wellbutrin can cause this, and constipation can manifest as nausea 1

Critical Pitfalls to Avoid

• Do not immediately discontinue Wellbutrin given the positive response in energy and motivation after only 4 days; nausea often resolves with continued use and proper administration 2
• Do not assume the nausea is from Strattera since it's been well-tolerated for 21 days at 60 mg and the nausea coincides with Wellbutrin initiation 2
• Monitor for seizure risk factors if considering dose escalation of Wellbutrin, though at 100 mg SR the risk is minimal 1, 2, 5
• Avoid combining multiple antiemetics initially; start with dietary modifications and single-agent antiemetic therapy if needed 1, 4

Expected Timeline

• Nausea typically improves within 1-2 weeks as tolerance develops to bupropion's gastrointestinal effects 2
• If nausea persists beyond 2 weeks despite interventions, consider switching to bupropion XL formulation (once daily) which has a more gradual absorption profile and may be better tolerated 6
• The current positive effects on energy and motivation suggest the medication is working and should be continued with supportive measures 1, 7

Monitoring Parameters

• Reassess nausea severity in 7 days after implementing food-based administration 2
• Monitor for other gastrointestinal symptoms including dry mouth (common with bupropion) and constipation 2
• Track adherence, as inconsistent dosing can perpetuate gastrointestinal side effects 2