Can Strattera (atomoxetine) and Qelbree (viloxazine) be cross-tapered?

Cross-Tapering Strattera (Atomoxetine) and Qelbree (Viloxazine)

Yes, Strattera (atomoxetine) and Qelbree (viloxazine) can be cross-tapered, with gradual dose adjustments of both medications to minimize withdrawal effects and optimize symptom control during the transition.

Cross-Tapering Approach

Step 1: Preparation

• Review patient's current atomoxetine dose and response
• Ensure no contraindications to viloxazine
• Establish baseline vital signs (blood pressure, heart rate)

Step 2: Initiation and Cross-Tapering Schedule

1. Week 1: Start viloxazine 200 mg once daily while maintaining full atomoxetine dose 1
2. Week 2: Increase viloxazine to 400 mg once daily; reduce atomoxetine by 25-50%
3. Week 3: If needed, increase viloxazine to 600 mg (maximum dose); reduce atomoxetine by another 25-50%
4. Week 4: Discontinue atomoxetine completely if patient is stable on viloxazine

Step 3: Monitoring During Cross-Tapering

• Monitor for:
  • Blood pressure and heart rate changes
  • Emergence of side effects
  • ADHD symptom control
  • Sleep disturbances
  • Mood changes

Clinical Considerations

Pharmacological Rationale

Both medications are non-stimulant options for ADHD with similar mechanisms:

• Atomoxetine: Selective norepinephrine reuptake inhibitor 2
• Viloxazine: Selective norepinephrine reuptake inhibitor with serotonergic activity 3

Benefits of Cross-Tapering

• Prevents withdrawal symptoms from abrupt atomoxetine discontinuation 4
• Maintains continuous ADHD symptom control during transition
• Allows assessment of tolerability to the new medication before complete switch

Potential Challenges

• Both medications can affect blood pressure and heart rate, requiring monitoring
• Overlapping side effect profiles may temporarily increase adverse effects
• Limited published data on specific cross-tapering between these two medications

Evidence for Switching Between Non-Stimulants

While specific protocols for cross-tapering atomoxetine and viloxazine are not well-established in guidelines, evidence supports:

1. Gradual tapering of psychotropic medications is generally recommended to avoid withdrawal symptoms 4
2. Cross-tapering is an established approach when switching between medications for the same condition 5
3. Research shows that patients who had suboptimal response to atomoxetine often benefit from switching to viloxazine 6

Special Considerations

Timing of Doses

• Both medications are typically administered once daily in the morning
• During cross-tapering, consider separating doses (e.g., atomoxetine in morning, viloxazine in evening) if side effects occur

Duration of Cross-Tapering

• Standard approach is 3-4 weeks
• May need to extend to 6-8 weeks in patients who are sensitive to medication changes 5
• A minimum 6-8 week trial of viloxazine is recommended before final evaluation of efficacy 5

Common Pitfalls to Avoid

• Rushing the transition: Too rapid discontinuation of atomoxetine may lead to rebound symptoms
• Inadequate monitoring: Both medications require monitoring for cardiovascular effects
• Premature efficacy assessment: Full therapeutic effect of viloxazine may take several weeks 6
• Overlooking drug interactions: Both medications are metabolized by CYP450 enzymes

Comparative Efficacy

Recent research suggests that some patients who respond inadequately to atomoxetine may show improved response with viloxazine, with 96% of patients in one study preferring viloxazine over atomoxetine 6. This supports the rationale for switching in appropriate cases.