From the Guidelines
For a 70-year-old patient starting atomoxetine, an EKG is recommended to assess cardiovascular risk, especially if the patient has pre-existing heart disease, arrhythmias, hypertension, or other cardiovascular conditions, as noted in the clinical practice guideline for the diagnosis, evaluation, and treatment of attention-deficit/hyperactivity disorder in children and adolescents 1.
When considering the use of atomoxetine in older adults, it is essential to weigh the potential benefits against the risks, particularly cardiovascular risks. Atomoxetine can cause increases in heart rate and blood pressure, which may be more significant in older adults with higher baseline cardiovascular risk. The guideline suggests that clinicians should obtain a personal and family cardiac history and perform additional evaluation, including an electrocardiogram (ECG), if risk factors are present before starting nonstimulant medications like atomoxetine 1.
Key points to consider when deciding whether to perform an EKG in a 70-year-old patient starting atomoxetine include:
- Presence of pre-existing heart disease, arrhythmias, hypertension, or other cardiovascular conditions
- Use of other medications that might affect cardiac function
- Patient's overall cardiovascular risk profile
- Potential benefits of atomoxetine in managing attention-deficit/hyperactivity disorder (ADHD) symptoms
Given the potential for atomoxetine to affect cardiovascular parameters, obtaining an EKG represents a prudent approach to establish baseline cardiac status before starting this medication, especially in older adults with higher cardiovascular risk 1.
From the FDA Drug Label
Assessing Cardiovascular Status in Patients being Treated with Atomoxetine Children, adolescents, or adults who are being considered for treatment with atomoxetine should have a careful history (including assessment for a family history of sudden death or ventricular arrhythmia) and physical exam to assess for the presence of cardiac disease, and should receive further cardiac evaluation if findings suggest such disease (e.g., electrocardiogram and echocardiogram).
The patient is 70 years old, and according to the label, adults should have a careful history and physical exam to assess for the presence of cardiac disease.
- An electrocardiogram (EKG) is mentioned as a possible further cardiac evaluation if findings suggest cardiac disease. However, it is not explicitly stated that an EKG is required for a 70-year-old patient. Therefore, based on the information provided in the drug label, no conclusion can be drawn regarding the necessity of an EKG for a 70-year-old patient 2.
From the Research
Atomoxetine and EKG Requirements
- The requirement for an EKG for a 70-year-old patient taking atomoxetine is not explicitly stated in the provided studies.
- However, studies have investigated the cardiovascular effects of atomoxetine, including its impact on QT intervals and heart rate 3, 4, 5, 6.
- According to a study published in 2003, atomoxetine was not associated with QT interval prolongation in children, adolescents, and adults with ADHD 3.
- Another study published in 2012 found that atomoxetine did not cause clinically significant alterations in QT dispersion, systolic and diastolic blood pressure, heart rate, corrected QT interval, and left ventricular systolic functions in children with ADHD 4.
- A study published in 2013 examined the effects of atomoxetine on the QT interval in healthy CYP2D6 poor metabolizers and found that atomoxetine was not associated with a clinically significant change in QT(c) 5.
- The American Journal of Emergency Medicine published a study in 2013 discussing the electrocardiographic implications of the prolonged QT interval, which may be relevant to the consideration of EKG requirements for patients taking certain medications, including atomoxetine 7.
- A review published in 2010 examined the cardiovascular effects of methylphenidate, amphetamines, and atomoxetine in the treatment of ADHD and found that the effects of atomoxetine on QTc remain uncertain 6.