From the Guidelines
Atomoxetine can be a suitable option for treating ADHD in patients with bipolar disorder, but it should be used with caution and careful monitoring, as evidenced by recent studies 1. When considering medication for patients with both conditions, atomoxetine may be preferred over stimulants because it has a lower risk of triggering manic episodes.
Key Considerations
- The typical adult dosage starts at 40mg daily for at least 3 days, then increases to 80mg daily, with a maximum of 100mg daily if needed, as recommended by the manufacturer 1.
- For children, dosing is weight-based, usually starting at 0.5mg/kg/day and gradually increasing, with a maximum recommended dosage of 1.4 mg/kg/day or 100 mg/day, whichever is lower 1.
- Treatment should always occur in the context of mood stabilization, meaning the bipolar disorder should be well-controlled with appropriate mood stabilizers before initiating atomoxetine.
- Close monitoring is essential, particularly during the first few weeks of treatment, as there is still some risk of mood destabilization, and patients should be monitored closely for suicidality, clinical worsening, and unusual changes of behavior 1.
Mechanism and Side Effects
- Atomoxetine works by inhibiting norepinephrine reuptake rather than affecting dopamine like stimulants do, which explains its potentially safer profile in bipolar patients 1.
- However, it may take 2-4 weeks to see full benefits, unlike the immediate effects of stimulants.
- Side effects can include nausea, decreased appetite, fatigue, and rarely, liver problems or suicidal thoughts, which require additional vigilance in bipolar patients, and warnings exist for preexisting cardiovascular diseases, emergent psychotic or manic symptoms, and aggressive behavior or hostility 1.
Clinical Evidence
- Analyses of twelve placebo-controlled trials in children and adolescents showed a greater risk of suicidal ideation during treatment in those participants receiving atomoxetine, which has led to special warnings by federal agencies and regulatory bodies 1.
- The most common adverse effects of atomoxetine in child and adolescent clinical trials were nausea, vomiting, fatigue, decreased appetite, abdominal pain, and somnolence, and seven percent of the population have been estimated to be poor metabolizers of atomoxetine, with significantly higher plasma levels and longer half-lives 1.
From the FDA Drug Label
Atomoxetine capsules may not be right for you or your child Before starting atomoxetine capsules tell your doctor or your child’s doctor about all health conditions (or a family history of) including: have or had suicide thoughts or actions heart problems, heart defects, irregular heart beat, high blood pressure, or low blood pressure mental problems, psychosis, mania, bipolar illness, or depression Tell your child or teenager’s doctor if your child or teenager (or there is a family history of): has bipolar illness (manic-depressive illness)
Atomoxetine is not explicitly contraindicated in patients with bipolar disorder. However, patients with bipolar illness should be closely monitored due to the potential increased risk of suicidal thoughts and actions.
- The decision to use atomoxetine in patients with ADHD and bipolar disorder should be made on a case-by-case basis, considering the potential benefits and risks.
- Patients should be closely monitored for signs of suicidal thoughts and actions, mania, and other mental problems.
- The use of atomoxetine in patients with bipolar disorder requires careful evaluation and monitoring by a healthcare professional 2.
From the Research
Atomoxetine for ADHD in Bipolar Disorder
- Atomoxetine is a non-stimulant medication that has shown efficacy in treating Attention Deficit Hyperactivity Disorder (ADHD) in adults, including those with comorbid bipolar disorder 3, 4.
- Studies have demonstrated that atomoxetine can be effective in reducing ADHD symptoms in patients with bipolar disorder, with a modestly increased risk of (hypo)manic switches and destabilization of the mood disorder when utilized in association with mood stabilizers 3.
- A review of clinical studies found that the presence of comorbidity, including bipolar disorder, did not adversely impact the efficacy of atomoxetine in treating ADHD symptoms in adults 4.
- Atomoxetine may be a valuable treatment option for adults with ADHD and comorbid bipolar disorder, particularly in patients who are at risk for substance abuse or who do not wish to take a controlled substance 5, 6.
Key Findings
- Atomoxetine has been shown to be effective in reducing ADHD symptoms in adults with comorbid bipolar disorder, with significant improvements in investigator- and patient-rated scores 5, 3.
- The medication has a different subjective-effects profile compared to stimulants and is not associated with abuse or diversion, making it a useful option for patients with substance abuse concerns 5.
- Atomoxetine can be administered once or twice daily and has a generally well-tolerated safety profile, with common adverse events including nausea, dry mouth, and insomnia 5, 6.
Considerations for Treatment
- A hierarchical approach to treatment is desirable, with mood stabilization preceding the treatment of ADHD symptoms in patients with comorbid bipolar disorder 3.
- Atomoxetine may be considered as a treatment option for adults with ADHD and comorbid bipolar disorder, particularly in patients who have not responded to stimulant therapy or have concerns about substance abuse 3, 4.