Combination Therapy with Atomoxetine and Bupropion

Dosing Recommendations

The American College of Obstetricians and Gynecologists recommends a starting dose of 40 mg daily for atomoxetine, which can be titrated every 7-14 days to 60 mg, then 80 mg if needed, with a maximum recommended dose of the lesser of 1.4 mg/kg/day or 100 mg/day 1, 2
The American Academy of Family Physicians recommends starting with bupropion SR 100-150 mg once daily in the morning, increasing by 37.5-75 mg every 3 days as tolerated, with a maintenance dose of 100-150 mg twice daily (SR formulation) and a maximum dose of 400 mg/day for SR formulation, 450 mg/day for IR formulation 1, 3, 4

The American Academy of Family Physicians advises that bupropion lowers the seizure threshold, and it should not be used in patients with seizure disorders, with gradual dose titration essential to minimize seizure risk 3, 4
The American College of Obstetricians and Gynecologists recommends avoiding MAOIs, allowing at least 14 days between discontinuation of MAOIs and starting bupropion 1

The American Academy of Family Physicians states that absolute contraindications to this combination include active seizure disorder or history of seizures, anorexia nervosa or bulimia nervosa (for bupropion), abrupt discontinuation of alcohol or benzodiazepines (seizure risk), current MAOI use or within 14 days of MAOI discontinuation, and pregnancy (use caution—both medications have limited safety data) 1, 2, 3, 4

The American College of Obstetricians and Gynecologists recommends that both medications should be used with caution in pregnancy and breastfeeding, with risk-benefit discussion essential if considering during pregnancy or lactation 1, 2