From the Guidelines
The patient's dose of atomoxetine should be increased to 40mg daily, with a target dose of 80mg daily, as the current dose of 18mg is below the therapeutic range for adults. This recommendation is based on the most recent evidence from 1, which suggests that atomoxetine typically starts at 40mg daily and can be increased after 3 days to a target dose of 80mg daily. The maximum recommended dose is 100mg daily, and the patient should be monitored for side effects such as increased blood pressure, heart rate, decreased appetite, nausea, dry mouth, or insomnia. Atomoxetine works by inhibiting norepinephrine reuptake, enhancing noradrenergic function in the prefrontal cortex, which improves attention and executive function. Unlike stimulants, atomoxetine has a gradual onset of action, with full therapeutic effects sometimes taking 2-4 weeks to develop, so patient education about expectations is important. It is also important to consider the patient's individual needs and response to the medication, as well as potential comorbidities, when adjusting the dose. As noted in 1, atomoxetine has been shown to be efficacious in treating ADHD, but its effect sizes compared to placebo are generally in the medium range and smaller than those of stimulants. However, atomoxetine has several potential benefits, including its non-controlled status and "around-the-clock" effects, which make it a useful option for certain patients. Overall, increasing the patient's dose of atomoxetine to 40mg daily, with a target dose of 80mg daily, is the most appropriate course of action, based on the available evidence from 1.
From the FDA Drug Label
In 2 identical, 10-week, randomized, double-blind, placebo-controlled acute treatment studies (Study 5, N=280; Study 6, N=256), patients received either atomoxetine hydrochloride or placebo. Atomoxetine hydrochloride was administered as a divided dose in the early morning and late afternoon/early evening and titrated according to clinical response in a range of 60 to 120 mg/day The mean final dose of atomoxetine hydrochloride for both studies was approximately 95 mg/day.
The patient is currently taking 18mg of atomoxetine, which is below the recommended dose range of 60 to 120 mg/day for adults. Considering the patient's age and the fact that they have not shown any improvement, it may be appropriate to titrate the dose upwards to achieve a therapeutic effect, while closely monitoring for any potential side effects. The target dose should be within the recommended range, and the patient's response should be regularly assessed to determine the optimal dose. 2
From the Research
Patient Response to Atomoxetine
- The patient, a 28-year-old with ADHD, was prescribed 18mg of atomoxetine and reported no significant improvement in symptoms 3, 4, 5, 6.
- According to studies, atomoxetine can take several weeks to have a full effect, with the median time to response being around 3.7 weeks 4.
- It is possible that the patient may need to continue taking the medication for a longer period to experience its full benefits.
Dosage and Administration
- Atomoxetine can be administered once or twice daily, and its dosage can be adjusted based on the patient's response to treatment 3, 5, 6.
- The patient's current dosage of 18mg may be adequate, but it may be necessary to reassess and adjust the dosage if the patient's symptoms do not improve over time.
Comparison with Other Treatments
- Atomoxetine has been shown to be effective in reducing symptoms of ADHD, although its effect size may be lower than that of stimulants such as methylphenidate 3, 4.
- However, atomoxetine has been found to be more effective in reducing anxiety symptoms in some patients, particularly after 4 weeks of treatment 7.
Next Steps
- The patient should continue taking the prescribed dosage of atomoxetine and be monitored for any changes in symptoms or side effects.
- If the patient's symptoms do not improve after an adequate trial period, alternative treatments or adjustments to the current treatment plan may be considered 4, 5, 6.