What is the recommended dosage and treatment plan for Attention Deficit Hyperactivity Disorder (ADHD) using Strattera (atomoxetine)?

Strattera (Atomoxetine) Dosage and Treatment Plan for ADHD

For the treatment of ADHD, Strattera (atomoxetine) should be initiated at 40 mg daily and titrated to a target dose of 80 mg daily (or 1.2 mg/kg/day for those under 70 kg), with a maximum dose of 100 mg daily or 1.4 mg/kg/day. 1

Dosing Guidelines

Initial Dosing

• Children and adolescents up to 70 kg: Start with 0.5 mg/kg/day
• Children and adolescents over 70 kg and adults: Start with 40 mg/day 1
• Dose can be administered once daily in the morning or divided into two doses (morning and late afternoon) 1, 2

Titration

• Increase dose every 7-14 days 3
• Target dose progression: 40 mg → 60 mg → 80 mg 3

Target and Maximum Doses

• Target dose:
  • Children and adolescents up to 70 kg: 1.2 mg/kg/day
  • Children and adolescents over 70 kg and adults: 80 mg/day 1
• Maximum dose:
  • Children and adolescents up to 70 kg: 1.4 mg/kg/day
  • Children and adolescents over 70 kg and adults: 100 mg/day 1

Administration Considerations

• Can be administered as a single daily dose in the morning or divided into two evenly distributed doses 1, 2
• Once-daily dosing has been shown to be effective and convenient 4
• Twice-daily dosing may reduce the incidence of nausea (16.4% vs 32.4% with once-daily dosing) 2
• Can be taken with or without food 1
• No need for drug holidays (unlike stimulants) due to 24-hour coverage of symptoms 4

Special Populations

CYP2D6 Poor Metabolizers

• Approximately 7% of the population are poor CYP2D6 metabolizers 5
• These individuals may require lower doses due to slower clearance of atomoxetine 6
• Plasma concentrations can be approximately 10-fold higher in poor metabolizers 6

Hepatic Impairment

• Dose adjustment required in moderate to severe hepatic impairment 1
• Monitor for signs of liver injury (jaundice, dark urine, right upper quadrant pain) 1

Patients with Substance Use Disorder

• Atomoxetine is recommended as first-line treatment for ADHD in patients with substance use disorder due to minimal abuse potential 5
• Not a controlled substance, making it suitable for patients with history of substance abuse 7

Monitoring and Follow-up

• Initial titration phase: Weekly contact (can be by telephone) 3
• Maintenance phase: Monthly appointments until symptoms stabilize 3
• Monitor for:
  • Suicidal ideation (especially in children and adolescents during first few months) 1
  • Blood pressure and heart rate (atomoxetine can cause increases) 1
  • Growth in pediatric patients (height and weight) 1
  • Emergence of psychotic or manic symptoms 1

Efficacy and Duration of Treatment

• Efficacy has been demonstrated in multiple randomized, double-blind, placebo-controlled trials 4
• Effects persist throughout waking hours and into the next morning with a single morning dose 4
• Long-term efficacy has been demonstrated for up to 18 months 4
• Atomoxetine improves core ADHD symptoms as well as quality of life measures and self-esteem 4

Common Side Effects

• Gastrointestinal disorders (nausea, dry mouth)
• Decreased appetite
• Insomnia
• Dizziness
• Sweating
• Sexual problems
• Modest increases in heart rate and blood pressure 7

Important Precautions

• Boxed warning: Increased risk of suicidal ideation in children and adolescents 1
• Cardiovascular: Not recommended in patients with serious structural cardiac abnormalities or other serious cardiac problems 1
• Liver: Discontinue if jaundice or laboratory evidence of liver injury occurs 1
• Urinary: May cause urinary hesitancy or retention 1
• Priapism: Requires prompt medical attention if suspected 1

Atomoxetine is a valuable non-stimulant option for ADHD treatment with the advantage of once-daily dosing, 24-hour symptom coverage, and no abuse potential, making it particularly suitable for patients with substance abuse concerns or those who prefer not to take controlled substances.