Who Should Not Take Atomoxetine (Strattera)
Atomoxetine should not be taken by individuals with hypersensitivity to the medication, those taking MAOIs within the past 14 days, patients with narrow-angle glaucoma, or those with pheochromocytoma. 1 Several other patient populations require careful consideration before using this medication due to significant risks.
Absolute Contraindications
- Hypersensitivity to atomoxetine or any components of the formulation 1
- Current or recent (within 14 days) use of monoamine oxidase inhibitors (MAOIs) such as phenelzine, tranylcypromine, or selegiline 1
- Narrow-angle glaucoma 1, 2
- Pheochromocytoma (rare tumor that can cause severe hypertension) 1
Patients Requiring Special Caution or Monitoring
Cardiovascular Conditions
- Pre-existing cardiovascular disease or abnormalities 3, 1
- History of heart problems, heart defects, irregular heartbeat 1
- Hypertension - atomoxetine can increase blood pressure and heart rate 3, 4
- Patients with these conditions require:
- Baseline ECG evaluation
- Regular blood pressure and heart rate monitoring
- Possible cardiology referral if ECG abnormalities are present 3
Mental Health Conditions
- Suicidal ideation risk - FDA black box warning for increased risk in children and adolescents 3, 1
- Monitor closely for suicidality, especially during first few months of treatment or dose changes
- Risk is approximately 4 per 1,000 patients 1
- Bipolar disorder - may precipitate manic episodes 3, 1
- History of psychosis - may worsen symptoms 3, 1
- Aggressive behavior or hostility - may be exacerbated 3, 1
Liver Conditions
- Hepatic insufficiency - increases atomoxetine exposure 5
- History of liver disease - rare cases of severe liver injury have been reported 3, 1
- Monitor for signs of liver problems (jaundice, dark urine, right upper quadrant pain, unexplained flu-like symptoms) 1
Other Conditions
- Seizure disorders - may lower seizure threshold 2
- Tourette's syndrome - requires careful monitoring 2
- Urinary outflow obstruction - may worsen symptoms 3, 2
- Pregnancy - limited safety data available 3, 1
- Breastfeeding - likely present in breast milk; effects on nursing infant unknown 3, 1
Drug Interactions
- CYP2D6 inhibitors (e.g., paroxetine, fluoxetine) - can significantly increase atomoxetine levels 3, 5
- Poor CYP2D6 metabolizers (approximately 7% of population) - have higher plasma levels and slower elimination of atomoxetine, increasing risk of adverse effects 5
Clinical Pearls and Caveats
Before initiating atomoxetine, obtain a thorough personal and family cardiac history, particularly focusing on sudden death, cardiovascular symptoms, Wolff-Parkinson-White syndrome, hypertrophic cardiomyopathy, and long QT syndrome 3
Atomoxetine should be tapered rather than abruptly discontinued to minimize withdrawal effects 3
Monitor growth in children, as atomoxetine has been linked to growth delays in the first 1-2 years of treatment, particularly in children who are taller or heavier than average before treatment 3
For pregnant patients, consider registering with the National Pregnancy Registry of ADHD Medications if atomoxetine treatment is necessary 1
While atomoxetine is not a controlled substance and has negligible abuse potential (unlike stimulants), it generally has a slower onset of action and may be less effective than stimulant medications for ADHD symptoms 5, 6
By carefully screening for these contraindications and risk factors before prescribing atomoxetine, clinicians can minimize adverse outcomes and optimize treatment safety.