What is the recommended dosage and treatment guidelines for Atomoxetine (Strattera) in patients with Attention Deficit Hyperactivity Disorder (ADHD)?

Atomoxetine (Strattera) Dosage and Treatment Guidelines for ADHD

The recommended dosage for atomoxetine (Strattera) in ADHD treatment is an initial dose of 0.5 mg/kg/day with a target dose of 1.2 mg/kg/day for children and adolescents up to 70 kg, and an initial dose of 40 mg/day with a target dose of 80 mg/day for individuals over 70 kg and adults. 1, 2

Dosing Recommendations

Weight-Based Dosing Schedule

• Children and adolescents up to 70 kg:

  • Initial dose: 0.5 mg/kg/day
  • Target dose: 1.2 mg/kg/day
  • Maximum dose: 1.4 mg/kg/day 1

• Children and adolescents over 70 kg and adults:

  • Initial dose: 40 mg/day
  • Target dose: 80 mg/day
  • Maximum dose: 100 mg/day 1

Titration Schedule

• Start with a lower dose and gradually increase to minimize side effects
• A slow titration schedule with divided doses is recommended during the first several weeks of treatment 3
• Allow 6-8 weeks (or longer) before fully evaluating efficacy and tolerability 3

Special Populations and Dosing Adjustments

Hepatic Impairment

• Dosage adjustment required for patients with hepatic impairment 1

CYP2D6 Considerations

• Dose adjustments needed for patients taking strong CYP2D6 inhibitors
• Dose adjustments needed for patients who are known CYP2D6 poor metabolizers 1

Monitoring and Safety Considerations

Cardiovascular Monitoring

• Regular monitoring of blood pressure and heart rate is essential
• Use with caution in patients with hypertension, tachycardia, or cardiovascular disease 1
• Atomoxetine should generally not be used in children or adolescents with known serious structural cardiac abnormalities 1

Psychiatric Monitoring

• WARNING: Increased risk of suicidal ideation in children and adolescents
• Monitor closely for emergence of suicidal thoughts, especially during initial treatment 1
• Screen for bipolar disorder prior to starting treatment 1
• Monitor for emergence of psychotic or manic symptoms 1
• Watch for aggressive behavior or hostility 1

Growth Monitoring

• Height and weight should be regularly monitored in pediatric patients 1

Contraindications

Atomoxetine is contraindicated in patients with:

• Hypersensitivity to atomoxetine or other constituents of the product
• Use within 2 weeks after discontinuing MAOIs
• Narrow-angle glaucoma
• Pheochromocytoma or history of pheochromocytoma
• Severe cardiovascular disorders 1

Clinical Considerations

Efficacy

• Atomoxetine 1.2 mg/kg/day and 1.8 mg/kg/day show superior outcomes compared to placebo, with 1.2 mg/kg/day being as effective as 1.8 mg/kg/day for most patients 4
• Approximately 50% of non-responders to methylphenidate will respond to atomoxetine therapy 3

When to Consider Atomoxetine

• For patients unresponsive or incompletely responsive to stimulant treatment
• For patients with comorbid conditions (e.g., tics, anxiety, depression)
• For patients with sleep disturbances or eating problems
• When stimulants are poorly tolerated
• In situations where there is potential for drug abuse or diversion 3

Common Side Effects

• Gastrointestinal symptoms (most common)
• Decreased appetite
• Potential for aggression or hostility
• Urinary hesitancy and retention 1, 5

Multimodal Treatment Approach

For optimal outcomes, atomoxetine should be combined with:

• Parent training in behavior management for children and adolescents
• Cognitive Behavioral Therapy (CBT) for older adolescents and adults 2

This combined approach of medication with behavioral interventions offers the best chance for symptom improvement and functional gains in academic and social domains 2.