Is there a correlation between tics and the use of Strattera (atomoxetine)?

Correlation Between Tics and Strattera (Atomoxetine)

Yes, there is evidence that Strattera (atomoxetine) can exacerbate existing tics or precipitate new tics in some patients, particularly in children with ADHD who have a history of tics or Tourette's syndrome.

Evidence on Atomoxetine and Tics

Clinical Evidence

• Multiple case reports have documented tic exacerbation or precipitation following atomoxetine administration:
  • A case with an ABAB design showed clear on-off control of tics with atomoxetine administration and discontinuation 1
  • Two children with ADHD experienced tic exacerbation and precipitation at relatively low doses of atomoxetine 2
  • A 13-year-old male developed tics following a single dose of atomoxetine despite having no prior history of movement disorders 3

Timing and Presentation

• The time from starting atomoxetine to tic symptoms appearing is approximately 19 days, though it can occur much sooner 1
• Common tic presentations include:
  • Eye blinking
  • Vocal tics
  • Throat clearing
  • Neck movements/twitches 1, 2

Resolution

• In most cases, tic symptoms resolve after discontinuing atomoxetine without requiring further pharmacotherapy 1
• However, some patients may experience persistent tics that require additional treatment, such as atypical neuroleptics 2

Clinical Considerations

Risk Factors

• Male gender appears to be a predominant risk factor in reported cases 1
• Previous history of tics increases the risk of tic exacerbation with atomoxetine 1
• Even patients without prior tic history can develop tics on atomoxetine 3

Clinical Guidelines Perspective

• While earlier guidelines suggested atomoxetine as a safer alternative for ADHD patients with tics, more recent evidence challenges this assumption
• The American Academy of Child and Adolescent Psychiatry practice parameters noted that controlled studies had not found methylphenidate to worsen motor tics in Tourette's syndrome, contradicting previous assumptions about stimulants being more problematic than non-stimulants for tic disorders 4

Monitoring Recommendations

• Careful monitoring for the emergence or worsening of tics is essential when initiating atomoxetine
• Regular assessment during dose adjustments is particularly important, as some cases report tic precipitation following dose increases 2
• If tics develop or worsen, consider:
  1. Reducing the dose
  2. Discontinuing atomoxetine
  3. Switching to alternative ADHD medications

Management Options for ADHD with Tics

Alternative Medications

• Extended-release guanfacine (Intuniv) or extended-release clonidine (Kapvay) may be considered as non-stimulant alternatives for patients with ADHD and tics 4
• Some stimulant formulations with potentially lower abuse potential may be options in certain cases, such as lisdexamfetamine (Vyvanse), dermal methylphenidate (Daytrana), or OROS methylphenidate (Concerta) 4

Dosing Considerations

• If atomoxetine is used in patients with risk factors for tics, consider:
  • Starting at lower doses
  • More gradual titration
  • Close monitoring for tic emergence or exacerbation

Conclusion

While atomoxetine was initially thought to be a safer option for ADHD patients with comorbid tic disorders, emerging evidence indicates that it can both exacerbate existing tics and precipitate new tics in some patients. Clinicians should maintain vigilance for the development of tics when prescribing atomoxetine, particularly in male patients and those with a history of tics or Tourette's syndrome.