What is the recommended titration schedule for increasing Strattera (atomoxetine) from 40mg to 80mg?

Atomoxetine (Strattera) Titration from 40 mg to 80 mg

For adults titrating atomoxetine from 40 mg to 80 mg daily, increase the dose after a minimum of 3 days at 40 mg to the target dose of 80 mg, which can be administered either as a single daily dose in the morning or as evenly divided doses in the morning and late afternoon/early evening. 1

Recommended Titration Schedule

The FDA-approved titration schedule for atomoxetine is straightforward:

1. Starting dose: 40 mg daily (current dose)
2. Minimum duration at starting dose: 3 days
3. Target dose: 80 mg daily
4. Administration options:
   • Single daily dose in the morning, OR
   • Divided into two doses (40 mg in morning and 40 mg in late afternoon/early evening)

Important Clinical Considerations

Dosing Adjustments for Special Populations

• CYP2D6 poor metabolizers: If you are taking strong CYP2D6 inhibitors (e.g., paroxetine, fluoxetine, quinidine) or are a known CYP2D6 poor metabolizer, maintain the 40 mg dose for 4 weeks before increasing to 80 mg, and only increase if symptoms don't improve and the initial dose is well tolerated 1

• Hepatic impairment:

  • Moderate impairment (Child-Pugh Class B): Reduce target dose to 50% of normal
  • Severe impairment (Child-Pugh Class C): Reduce target dose to 25% of normal 1

Administration Guidelines

• Atomoxetine can be taken with or without food 1
• Capsules should be taken whole, not opened 1
• No tapering is required when discontinuing 1

Monitoring During Titration

During the titration period, monitor for:

• Cardiovascular effects: Check blood pressure and heart rate regularly, as atomoxetine can cause modest increases in both 2, 3
• Common side effects: Dry mouth, insomnia, nausea, decreased appetite, constipation, dizziness, sweating 2, 3
• Less common side effects: Dysuria, sexual problems, palpitations 2, 3

Efficacy and Safety Considerations

• The maximum recommended daily dose is 100 mg, though no additional benefit has been demonstrated for doses higher than 80 mg in adults 1
• Safety of single doses over 120 mg and total daily doses above 150 mg have not been systematically evaluated 1
• The plasma half-life of atomoxetine varies significantly between CYP2D6 extensive metabolizers (5.2 hours) and poor metabolizers (21.6 hours), which affects steady-state concentrations 4

Common Pitfalls to Avoid

1. Rushing the titration: Always wait at least 3 days before increasing the dose
2. Ignoring metabolizer status: CYP2D6 poor metabolizers require slower titration
3. Missing hepatic impairment: Dose adjustments are necessary for patients with liver issues
4. Overlooking drug interactions: Strong CYP2D6 inhibitors significantly affect atomoxetine metabolism

By following this titration schedule and monitoring appropriately, you can optimize the therapeutic benefit of atomoxetine while minimizing adverse effects.