What is the recommended approach to manage my medication regimen, considering my history of treatment-resistant depression, generalized anxiety, and ADD, and my goal to optimize ADD treatment by switching from Rexulti to Buspar, while taking Adderall XR 70mg and Concerta 108mg?

Immediate Medication Management Strategy

You need to work with your prescriber to gradually taper and discontinue Rexulti before switching to Buspar, while simultaneously reducing your stimulant doses back to therapeutic levels (Adderall XR 30-40mg or Concerta 36-54mg) over 2-4 weeks, as your current regimen represents dangerous polypharmacy with supratherapeutic stimulant dosing that poses significant cardiovascular and psychiatric risks.

Critical Safety Issues

Your current medication regimen presents several urgent concerns:

• Supratherapeutic stimulant dosing: Adderall XR 70mg exceeds the FDA maximum recommended dose of 60mg/day for adults, and Concerta 108mg far exceeds the maximum of 72mg/day 1, 2
• Dangerous polypharmacy: Taking both Adderall XR and Concerta simultaneously is not evidence-based and dramatically increases risks of cardiovascular events, psychosis, and substance use disorder 2
• Tolerance development: Your escalating doses suggest tolerance and potential stimulant use disorder rather than inadequate ADD treatment 3

Understanding the Rexulti-Stimulant Interaction

Your observation about Rexulti (brexpiprazole) and Vraylar (cariprazine) blunting stimulant effects is pharmacologically accurate:

• Both are partial dopamine D2/D3 agonists that can antagonize the dopaminergic effects of stimulants 2
• This interaction likely contributed to your dose escalation pattern 3
• However, the solution is NOT higher stimulant doses but rather addressing the underlying polypharmacy

Recommended Transition Algorithm

Step 1: Coordinate with Your Prescriber (Week 1)

• Do not make changes independently - abrupt discontinuation of either Rexulti or high-dose stimulants carries serious risks 2
• Schedule urgent appointment to discuss medication rationalization
• Request psychiatric consultation if not already seeing a psychiatrist 3

Step 2: Gradual Rexulti Taper (Weeks 1-4)

• Taper Rexulti by 0.5-1mg every 5-7 days to minimize withdrawal and mood destabilization 2
• Monitor closely for depression recurrence, anxiety worsening, or psychotic symptoms 3
• Do not start Buspar until Rexulti is fully discontinued - allow 1-2 week washout period 4

Step 3: Simultaneous Stimulant Dose Reduction (Weeks 1-4)

• Choose ONE stimulant - continuing both is medically inappropriate 2
• If choosing Adderall XR: reduce by 10mg every 3-5 days targeting 30-40mg/day 1
• If choosing Concerta: reduce by 18mg every 3-5 days targeting 36-54mg/day 1
• Your perceived "tolerance" will likely resolve as Rexulti's dopamine antagonism diminishes 3

Step 4: Buspar Initiation (Week 5-6)

• Start Buspar 5mg twice daily after Rexulti washout complete 4
• Increase by 5mg every 2-3 days as tolerated, targeting 15-30mg/day divided doses 4
• Buspar does NOT blunt stimulant effects - it works via serotonin 5-HT1A receptors, not dopamine 4
• Takes 2-4 weeks for full anxiolytic effect 4

Addressing Your Depression and Anxiety

The evidence does not support your current approach:

• Buspar for depression augmentation: Low-quality evidence shows buspirone augmentation of antidepressants has similar efficacy to bupropion but higher discontinuation rates due to side effects 5
• Better alternatives exist: If depression remains inadequately treated after Rexulti discontinuation, consider augmentation with bupropion (which may also help ADD) or switching to an SNRI like venlafaxine 5
• Cognitive therapy: Low-quality evidence shows cognitive therapy is as effective as medication switching for treatment-resistant depression 5

Common Pitfalls to Avoid

• Expecting immediate stimulant efficacy: After months of supratherapeutic dosing, your dopamine system needs time to recalibrate - expect 4-8 weeks 3
• Attributing all ADD symptoms to medication: At these doses, you may be experiencing stimulant-induced anxiety, irritability, and paradoxical attention problems 2
• Switching medications without addressing polypharmacy: Adding Buspar while maintaining current regimen will not solve the fundamental problem 1, 3

What You Should Tell Your Prescriber

Present this specific request:

1. "I need help tapering off Rexulti because of dopamine antagonism affecting my ADD treatment"
2. "I want to reduce my stimulant dose to therapeutic levels (one medication only)"
3. "After Rexulti is discontinued, I'd like to try Buspar for anxiety"
4. "I need close monitoring during this transition for depression recurrence"

If your prescriber is unwilling to address this dangerous polypharmacy, seek a second opinion from a psychiatrist specializing in mood and attention disorders 2, 3.