Atomoxetine (Strattera) Dosing for ADHD
For ADHD treatment, atomoxetine (Strattera) should be initiated at 0.5 mg/kg/day and titrated to a target dose of 1.2 mg/kg/day for optimal symptom control, with a maximum recommended dose of 100 mg daily for most patients. 1
Dosing by Age Group and Weight
Children and Adolescents (≤70 kg)
- Starting dose: 0.5 mg/kg/day 2, 1
- Target dose: 1.2 mg/kg/day 2, 1
- Maximum dose: 1.4-1.8 mg/kg/day or 100 mg daily (whichever is less) 3
- Titration: Increase dose after 7-14 days if needed 3
Adults and Children >70 kg
- Starting dose: 40 mg daily 2
- Titration: Increase to 60 mg, then 80 mg daily at 7-14 day intervals 3
- Target dose: 80 mg daily 1
- Maximum dose: 100 mg daily 3
Administration Options
Once Daily Dosing
- Can be administered as a single morning dose 1
- Mean final dose in clinical trials with once-daily dosing was approximately 1.3 mg/kg/day 1
- May have higher incidence of nausea (32.4%) compared to twice-daily dosing 4
Twice Daily Dosing
- Can be administered as divided doses in the morning and late afternoon/evening 1
- Lower incidence of nausea (16.4%) compared to once-daily dosing 4
- May provide slightly better efficacy than once-daily dosing 4
Efficacy Considerations
- Atomoxetine has an effect size of approximately 0.7 compared to 1.0 for stimulants 2
- The 1.8 mg/kg/day dose does not provide additional benefit over the 1.2 mg/kg/day dose 1
- The 0.5 mg/kg/day dose was not superior to placebo in acute treatment 1
- However, for maintenance treatment after robust initial response, a lower dose of 0.5 mg/kg/day may be effective 5
Monitoring and Side Effect Management
- Onset of action: Unlike stimulants, atomoxetine may take 6-12 weeks for full effect 2
- Common side effects: Dry mouth, insomnia, nausea, decreased appetite, constipation, dizziness, sweating 6
- Vital signs: Monitor for modest increases in heart rate and blood pressure 6
- Resolution of side effects: Most common side effects appear within the first week of treatment and have median resolution times of 3-53 days 7
Special Considerations
- Atomoxetine does not require dose adjustment in patients with end-stage renal disease 1
- No dose adjustment needed based on gender or ethnic origin 1
- For patients with comorbid anxiety disorders, atomoxetine does not worsen anxiety symptoms 1
- Unlike stimulants, atomoxetine is not a controlled substance and has negligible risk of abuse 6
Clinical Pearls
- Atomoxetine provides "around-the-clock" symptom control compared to the intermittent coverage of stimulants 2
- Patients should be informed about the delayed onset of action to prevent premature discontinuation
- For patients who experience a robust response to initial treatment, consider reducing to 0.5 mg/kg/day for maintenance to minimize side effects while maintaining efficacy 5
- Atomoxetine is particularly useful for patients with substance use disorders or those who cannot take controlled substances 2, 6