Is taking Rexulti (brexpiprazole) before sleep and then Adderall (amphetamine and dextroamphetamine) or Concerta (methylphenidate) upon waking an effective approach for managing anxiety and Attention Deficit Disorder (ADD)?

Your Current Medication Timing Strategy Is Reasonable and Supported by Clinical Practice

Taking Rexulti (brexpiprazole) before sleep and stimulants (Adderall or Concerta) upon waking is a clinically sound approach that leverages the pharmacological properties of each medication while minimizing potential adverse interactions. 1

Rationale for This Timing Strategy

Morning Stimulant Administration

• Stimulants should be taken early in the morning to minimize sleep interference, which is exactly what you're doing by taking them upon waking 1
• Both Adderall (amphetamine-dextroamphetamine) and Concerta (methylphenidate) are effective first-line treatments for ADHD in adults, with stimulants showing efficacy rates of 23-75% in adult ADHD populations 2
• The 6-8 hour sleep window before taking your stimulant allows complete clearance of any residual sedating effects from Rexulti 1

Evening Brexpiprazole Administration

• Brexpiprazole taken before sleep can address anxiety symptoms while avoiding daytime sedation, and its timing prevents overlap with peak stimulant effects 3
• Brexpiprazole is FDA-approved as adjunctive therapy for major depressive disorder and has a favorable tolerability profile with lower activation-like adverse effects (such as akathisia) compared to other atypical antipsychotics 3
• Taking it at bedtime may actually help counteract stimulant-induced sleep disturbances, which are common side effects of both Adderall and Concerta 1, 4

Key Monitoring Requirements

Cardiovascular Monitoring

• Regular blood pressure and heart rate monitoring is essential with Adderall use, as amphetamines cause α-adrenergic vasoconstriction and β-adrenergic increases in heart rate and stroke volume 1, 5

Sleep Quality Assessment

• Monitor for changes in sleep quality and daytime alertness to ensure the regimen isn't creating a cycle of medication dependence 1
• Common stimulant side effects include insomnia and decreased appetite, which should be tracked 4

Anxiety and Mood Symptoms

• Track anxiety levels throughout the day, as stimulants can occasionally exacerbate anxiety symptoms despite their effectiveness for ADHD 2
• If anxiety worsens, the American Academy of Child and Adolescent Psychiatry recommends treating the primary mood/anxiety disorder first before optimizing ADHD treatment 2

Optimizing Your Regimen

If Sleep Problems Persist

• Adding an alpha-agonist (guanfacine or clonidine) in the evening can help address stimulant-related sleep disturbances without discontinuing effective ADHD treatment 6
• Alpha-agonists are recommended as first-line options for comorbid sleep disorders in ADHD patients on stimulants 6

Choosing Between Adderall and Concerta

• Amphetamine-class medications (Adderall) are more likely to cause sleep onset delay compared to methylphenidate (Concerta) 6
• If you experience more sleep difficulties with Adderall, switching to Concerta may provide equivalent ADHD symptom control with less sleep interference 6, 4
• Individual response varies significantly—approximately 39% of patients show clinically meaningful differences in side effects between these two stimulants while maintaining therapeutic benefit 4

Common Pitfalls to Avoid

Dose Timing

• Never take stimulants later in the day, as this will directly interfere with your nighttime Rexulti and sleep quality 1
• Start with the lowest effective dose of both medications to minimize side effects and interactions 1

Substance Use Considerations

• Be aware that stimulants have DEA Schedule II controlled substance status with high potential for abuse, and both medications should be used exactly as prescribed 1, 5
• The American Academy of Child and Adolescent Psychiatry specifically warns about prescribing psychostimulants to adults with comorbid substance abuse disorder 2

Avoiding Medication Dependence Cycles

• Don't automatically add sleep medications if insomnia develops—first optimize stimulant timing and dosing, or consider switching between Adderall and Concerta 6, 1
• Your current approach of using Rexulti (which you're already taking for anxiety) at bedtime is preferable to adding dedicated hypnotics 1