Can a teenager with a history of myoclonic seizure take Strattera (atomoxetine)?

Atomoxetine (Strattera) Use in Teenagers with History of Myoclonic Seizures

Atomoxetine should be avoided in teenagers with a history of myoclonic seizures due to potential seizure risk, and alternative ADHD treatments should be considered instead. 1

Seizure Risk with Atomoxetine

Atomoxetine has been associated with seizure risk in certain populations:

• A documented case report showed atomoxetine overdose resulting in tonic-clonic seizure and mild cardiac toxicity 2
• Patients with a history of seizures represent a high-risk population that requires special consideration when prescribing medications that may affect seizure threshold

The risk is particularly concerning for patients with myoclonic seizures because:

• Myoclonic seizures can be exacerbated by certain medications
• Guidelines specifically state that medications that exacerbate myoclonic seizures should be avoided 1

Specific Concerns for Myoclonic Seizures

Myoclonic seizures require particular caution with medication selection:

• Vigabatrin specifically "exacerbates typical absence and myoclonic seizures and should therefore not be prescribed in the idiopathic generalised epilepsies" 1
• While atomoxetine is not explicitly contraindicated, the clinical approach to myoclonic seizures emphasizes avoiding medications that may lower seizure threshold or exacerbate seizure activity

Evidence on Atomoxetine and Seizure Risk

The evidence regarding atomoxetine and seizure risk shows mixed findings:

• One study suggests that the crude incidence rates of seizure adverse events with atomoxetine were between 0.1 and 0.2%, not significantly different from placebo 3
• However, case reports of seizures with atomoxetine exist 2, suggesting caution is warranted in high-risk populations

Alternative ADHD Treatments for Patients with Seizure History

For teenagers with a history of myoclonic seizures who need ADHD treatment:

1. Buspirone may be considered as it:

   • Does not lower the seizure threshold
   • Has not been associated with increased seizure activity in clinical practice 4

2. Non-pharmacological approaches should be prioritized:

   • Behavioral therapy
   • Educational interventions
   • Parent training

Monitoring Recommendations if Atomoxetine Must Be Used

If alternative treatments are ineffective and atomoxetine must be considered:

• Start with a lower dose than typically recommended
• Monitor closely for any signs of seizure activity
• Ensure concurrent antiepileptic medication is optimized
• Consider EEG monitoring during initial treatment phase
• Educate the patient and family about potential warning signs of seizure activity

Treatment of Myoclonic Seizures

If the patient continues to have myoclonic seizures, preferred treatments include:

• Valproate, levetiracetam, and benzodiazepines are widely used and effective for myoclonic seizures 5
• Zonisamide may also be effective 6

Key Pitfalls to Avoid

1. Never combine medications that lower seizure threshold - this can significantly increase risk
2. Don't ignore early warning signs of increased seizure activity
3. Avoid assuming that ADHD must be treated pharmacologically in all cases
4. Don't overlook the importance of optimizing antiepileptic therapy before adding ADHD medications

Given the history of myoclonic seizures and the potential risks, the safest approach is to avoid atomoxetine and consider alternative treatments for ADHD in this teenage patient.