Non-Stimulant Recommendation for ADHD, Sleep, and Anxiety After Discontinuing Vyvanse
Atomoxetine is the recommended non-stimulant medication for this patient, as it addresses ADHD without worsening insomnia or anxiety, has no significant drug interactions with the current medication regimen, and can be dosed in the evening to minimize any residual activating effects. 1, 2
Rationale for Atomoxetine Selection
Atomoxetine is the only FDA-approved non-stimulant with robust evidence for adult ADHD treatment and serves as the guideline-recommended second-line option when stimulants are discontinued. 1, 2
Atomoxetine demonstrates similar cardiovascular effects to stimulants but causes less appetite suppression and fewer growth/height problems, making it safer in patients already on metoprolol and losartan for cardiovascular management. 1
Evening dosing of atomoxetine (entire dose at bedtime) is explicitly recommended when somnolence or fatigue occur, which can actually benefit this patient's insomnia rather than worsen it. 1
Atomoxetine has demonstrated efficacy in ADHD patients with comorbid anxiety, making it particularly appropriate for this patient taking lorazepam as needed. 1
Drug Interaction Safety Profile
Atomoxetine has no clinically significant interactions with bupropion, trazodone, eszopiclone (Lunesta), metoprolol, losartan, tirzepatide (Zepbound), or atorvastatin (Lipitor). 1, 3
Bupropion is a potent CYP2D6 inhibitor that increases metoprolol levels 4- to 6-fold, but this interaction is already present in the current regimen and does not involve atomoxetine. 3
Mirtazapine and sertraline have minimal CYP2D6 inhibition and would be safe alternatives if atomoxetine metabolism needs consideration, though atomoxetine remains the preferred ADHD-specific agent. 3
Dosing Strategy
Start atomoxetine 40 mg once daily in the morning for the first week, then increase to 80 mg daily (can be split as 40 mg twice daily or given as a single evening dose). 1, 2
If daytime sedation occurs, switch the entire dose to bedtime administration, which may actually improve sleep maintenance without interfering with trazodone or Lunesta. 1
Target dose is 80–100 mg daily; maximum dose is 100 mg daily in adults, with full therapeutic effects requiring 4–8 weeks of treatment. 2
Addressing Sleep and Anxiety Concerns
The current sleep regimen (trazodone 50–100 mg + Lunesta) should be optimized before adding atomoxetine by implementing Cognitive Behavioral Therapy for Insomnia (CBT-I) as first-line treatment, which provides superior long-term outcomes compared to medication alone. 4
Trazodone at 50 mg is below the therapeutic range for insomnia (150–200 mg), and the patient is already doubling the dose; consider consolidating to a single 100–150 mg dose at bedtime rather than taking two 50 mg tablets. 5
Lunesta (eszopiclone) is appropriate for combined sleep-onset and maintenance insomnia and should be continued at the current dose while atomoxetine is initiated. 4
Lorazepam should be tapered and discontinued because benzodiazepines carry significant risks of dependence, cognitive impairment, falls, and respiratory depression, especially when combined with multiple sedating agents (trazodone + Lunesta). 4
Alternative Non-Stimulant Options (If Atomoxetine Fails)
Guanfacine extended-release (1–4 mg at bedtime) is a second-line non-stimulant that improves ADHD symptoms and promotes sleep through alpha-2 agonism, though it may cause hypotension in patients already on metoprolol and losartan. 1
Clonidine extended-release (0.1–0.4 mg at bedtime) has similar benefits to guanfacine for ADHD and sleep but carries higher risk of sedation and cardiovascular effects. 1
Bupropion dose optimization (already at 450 mg maximum) will not provide additional ADHD benefit, and increasing further is contraindicated due to seizure risk. 6, 7
Medications to Avoid
Tricyclic antidepressants (desipramine, nortriptyline) should be avoided due to cardiotoxic effects, especially in patients on metoprolol and losartan, and desipramine carries specific safety warnings in adults. 7
Venlafaxine appears effective for ADHD but lacks controlled trial data and may worsen anxiety or insomnia in some patients. 7
SSRIs (sertraline, fluoxetine, paroxetine) are ineffective for ADHD core symptoms and often aggravate inattention, causing frontal apathy and disinhibition. 7
Critical Implementation Steps
Discontinue Vyvanse completely and wait 24–48 hours before starting atomoxetine to avoid overlapping stimulant effects. 1
Initiate atomoxetine 40 mg every morning with food to minimize nausea, and monitor blood pressure weekly for the first month given concurrent metoprolol/losartan use. 2
Increase to 80 mg daily after 1 week (either 40 mg twice daily or 80 mg at bedtime if sedation occurs). 1, 2
Optimize sleep hygiene and initiate CBT-I concurrently, including stimulus control, sleep restriction, and cognitive restructuring. 4
Taper lorazepam by 25% every 1–2 weeks while maintaining trazodone and Lunesta for sleep support. 4
Reassess ADHD symptoms, sleep quality, and anxiety at 4 weeks, adjusting atomoxetine to 100 mg daily if response is insufficient. 2
Common Pitfalls to Avoid
Do not add guanfacine or clonidine to atomoxetine initially; use monotherapy first to assess efficacy and avoid excessive sedation or hypotension. 1
Do not increase bupropion above 450 mg in an attempt to improve ADHD symptoms, as this exceeds the maximum safe dose and increases seizure risk. 6
Do not continue lorazepam long-term alongside trazodone and Lunesta, as this creates dangerous polypharmacy with additive CNS depression and respiratory risk. 4
Do not assume atomoxetine will work immediately; full therapeutic effects require 4–8 weeks, and premature discontinuation is a common cause of treatment failure. 2