What is the recommended treatment protocol for Attention Deficit Hyperactivity Disorder (ADHD) using Atomoxetine?

Atomoxetine Treatment Protocol for ADHD

Atomoxetine is recommended as first-line treatment for ADHD in patients with substance use disorders, risk of stimulant abuse, tic disorders, or Tourette's syndrome, with a starting dose of 0.5 mg/kg/day and target dose of 1.2 mg/kg/day. 1

Dosing Protocol

Initial Dosing

• Children and adolescents up to 70 kg:

  • Starting dose: 0.5 mg/kg/day
  • Target dose: 1.2 mg/kg/day
  • Maximum dose: 1.4 mg/kg/day (not to exceed 100 mg/day)

• Children and adolescents over 70 kg and adults:

  • Starting dose: 40 mg/day
  • Target dose: 80 mg/day
  • Maximum dose: 100 mg/day 2

Administration Schedule

• Can be administered as a single daily morning dose or divided into two evenly split doses 1, 2
• Dose adjustments should be made every 7-14 days to allow for proper assessment of efficacy and tolerability 1

Special Populations Requiring Dose Adjustments

• Hepatic impairment: Reduce dosage in patients with moderate to severe hepatic impairment 2
• CYP2D6 poor metabolizers: Reduce dosage as these patients have greater exposure to atomoxetine 2
• Patients taking strong CYP2D6 inhibitors: Dose adjustment may be necessary 2

Monitoring Requirements

1. Cardiovascular monitoring:

   • Measure blood pressure and heart rate at baseline and regularly during treatment
   • Use with caution in patients with hypertension, tachycardia, or cardiovascular disease 1, 2

2. Mental health monitoring:

   • Screen for bipolar disorder before initiating treatment
   • Monitor for emergence of suicidal ideation, particularly during the first few months (black box warning)
   • Watch for new psychotic or manic symptoms 2

3. Growth monitoring:

   • Regular monitoring of height and weight in pediatric patients 1

4. Hepatic function:

   • Monitor for signs of liver injury (jaundice, dark urine, right upper quadrant tenderness) 2

Side Effect Management

• Insomnia: Consider earlier dosing in the day
• Appetite suppression: Encourage meals when medication effect is lowest; provide high-calorie snacks in evening
• Nausea/dyspepsia: Take with food
• Dry mouth: Ensure adequate hydration
• Urinary hesitancy/retention: Monitor for symptoms and consider dose reduction if severe 1, 2

Indications for Preferential Use

Atomoxetine is particularly beneficial for patients with:

• Substance use disorders or risk of stimulant abuse
• Comorbid anxiety disorders
• Tic disorders or Tourette's syndrome
• Patients who do not wish to take controlled substances 1

Contraindications

• Hypersensitivity to atomoxetine
• Use within 2 weeks of MAOI use
• Narrow-angle glaucoma
• Pheochromocytoma or history of pheochromocytoma
• Severe cardiovascular disorders 2

Treatment Duration and Follow-up

• Schedule follow-up within 2-4 weeks after initiating treatment
• Regular monitoring visits to assess efficacy, side effects, and need for dose adjustments
• Long-term treatment requires ongoing assessment of continued benefit versus risks 1

Comprehensive Treatment Approach

Atomoxetine should be used as part of a comprehensive treatment program that includes:

• Behavioral interventions
• Educational accommodations (IEP or 504 plan for students)
• Psychoeducation about ADHD
• Consideration of cognitive behavioral therapy, particularly for adults with ADHD 1

Remember that while atomoxetine is effective for ADHD, it may be less effective than extended-release stimulant formulations but offers advantages in specific patient populations where stimulants are contraindicated or problematic.