Strattera Starting Dose
For children and adolescents up to 70 kg, start Strattera at approximately 0.5 mg/kg/day, and for those over 70 kg and adults, start at 40 mg/day. 1
Weight-Based Dosing Algorithm
Children and Adolescents ≤70 kg
- Initial dose: 0.5 mg/kg/day
- When to increase: After a minimum of 3 days
- Target dose: 1.2 mg/kg/day (administered as single morning dose OR divided into morning and late afternoon/evening doses)
- Maximum dose: 1.4 mg/kg/day or 100 mg/day, whichever is less 1
The FDA label is explicit that no additional benefit has been demonstrated for doses higher than 1.2 mg/kg/day 1. Research supports this weight-based titration approach, with studies demonstrating that 1.2 mg/kg/day is as effective as 1.8 mg/kg/day and represents the appropriate initial target for most patients 2.
Children and Adolescents >70 kg and Adults
- Initial dose: 40 mg/day
- When to increase: After a minimum of 3 days
- Target dose: 80 mg/day (single morning dose OR divided doses)
- Further titration: After 2-4 additional weeks at 80 mg, may increase to maximum of 100 mg if optimal response not achieved
- Maximum dose: 100 mg/day 1
Real-world data reveal a critical problem: adults frequently receive suboptimal dosing with an average of only 60 mg/day rather than the recommended 80 mg/day target 3. This underdosing is associated with poor patient outcomes and shorter treatment duration. Adults who reach the 80 mg dose have significantly longer therapy duration (159.3 vs 65.6 days over one year) compared to those who don't 4.
Special Dosing Adjustments
CYP2D6 Poor Metabolizers or Strong Inhibitor Use
When prescribing with strong CYP2D6 inhibitors (paroxetine, fluoxetine, quinidine) or in known CYP2D6 poor metabolizers:
- Children/adolescents ≤70 kg: Start at 0.5 mg/kg/day, increase to usual target of 1.2 mg/kg/day ONLY if symptoms fail to improve after 4 weeks AND initial dose is well tolerated
- Children/adolescents >70 kg and adults: Start at 40 mg/day, increase to 80 mg/day ONLY if symptoms fail to improve after 4 weeks AND initial dose is well tolerated 1
This adjustment is critical because approximately 7% of the population are poor metabolizers with significantly higher plasma levels and longer half-lives, leading to increased adverse effects 5.
Hepatic Impairment
- Moderate hepatic impairment (Child-Pugh Class B): Reduce initial and target doses to 50% of normal
- Severe hepatic impairment (Child-Pugh Class C): Reduce initial and target doses to 25% of normal 1
Critical Timing Considerations
Allow adequate time at target dose before judging efficacy—approximately 4-6 weeks. 3 Among patients who eventually reach 80 mg/day, 71.7% of monotherapy patients achieve this by Day 30 4. Premature dose adjustments or discontinuation before allowing sufficient time at therapeutic doses is a common pitfall that undermines treatment success.
Safety Monitoring Requirements
Close monitoring is mandatory, particularly during initial months and dose changes, for:
- Suicidal ideation (black box warning in children/adolescents based on 12 placebo-controlled trials) 5, 6
- Cardiovascular parameters (heart rate and blood pressure increases possible) 6
- Gastrointestinal symptoms (nausea, vomiting, abdominal pain—especially if dose escalated too rapidly) 5, 6
The most common adverse effects include nausea, vomiting, fatigue, decreased appetite, abdominal pain, and somnolence 5. These are often transient and can be minimized by appropriate dose titration 7.
Administration Details
- May be taken with or without food
- Can be discontinued without tapering
- Capsules should be taken whole, not opened 1