From the Research
Based on the patient's current medication regimen, adding low-dose naltrexone (LDN) and pitolisant appears to be relatively safe from an interaction standpoint, though careful monitoring would be advisable. For this 40-year-old perimenopausal woman with multiple symptoms including daytime fatigue, brain fog, and joint pain, I recommend a stepwise approach to medication adjustments.
Medication Adjustments
- For her fatigue and brain fog, pitolisant (Wakix) starting at 8.9mg daily and titrating up to 17.8mg daily could be beneficial as it promotes wakefulness through histamine H3 receptor antagonism without the direct stimulant effects of Adderall, as supported by the most recent evidence 1.
- LDN (typically 1.5-4.5mg at bedtime) might help with her joint pain and potentially improve energy by modulating inflammation and immune function.
Additional Considerations
- Additional considerations for her symptom complex include bupropion XL 150-300mg daily, which could address both fatigue and ADHD symptoms while potentially allowing reduction of Adderall use, as suggested by studies on combination pharmacotherapy for adult ADHD 2.
- For joint pain, a trial of prescription-strength omega-3 fatty acids (2-4g daily) might provide anti-inflammatory benefits without significant drug interactions.
- Her constipation might benefit from adding a daily osmotic laxative like polyethylene glycol (Miralax) 17g daily, which would work well with her existing psyllium fiber.
- For perimenopausal symptoms contributing to her symptom complex, low-dose vaginal estrogen could be considered if not contraindicated, as it has minimal systemic absorption and might help with some neurovegetative symptoms.
Monitoring and Introduction of New Medications
When introducing these medications, I suggest starting one at a time with at least 2-3 weeks between additions to monitor for efficacy and side effects. The combination of her current SSRI (fluoxetine) with trazodone and potentially LDN requires monitoring for serotonin effects, though this combination is frequently used safely in clinical practice, as noted in guidance for the use of trazodone in major depressive disorder and concomitant conditions 3.
Lifestyle Interventions
Furthermore, therapeutic exercise, as discussed in recent literature 4, could be beneficial for her overall health, including her joint pain, fatigue, and potentially her mental health symptoms, by improving physical function and reducing symptoms of chronic conditions. Encouraging physical activity that she enjoys and can incorporate into her daily routine, as suggested by studies on engaging patients in exercise 5, may also enhance compliance and overall well-being.