Dosage and Treatment Guidelines for Strattera (Atomoxetine) in ADHD
For patients with ADHD, Strattera (atomoxetine) should be dosed at 0.5 mg/kg/day initially, then titrated to a target dose of 1.2 mg/kg/day, with a maximum of 1.4 mg/kg/day in children and adolescents up to 70 kg, or 40 mg initially with a target of 80 mg and maximum of 100 mg daily for those over 70 kg and adults. 1
Dosing Recommendations by Age Group
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
- Administration can be once daily in the morning or divided into two doses (morning and late afternoon) 1
Adolescents (over 70 kg) and Adults
- Initial dose: 40 mg/day
- Target dose: 80 mg/day
- Maximum dose: 100 mg/day
- Administration can be once daily or divided into two doses 1
Special Dosing Considerations
Hepatic Impairment
- Dose adjustment required:
- Moderate hepatic impairment (Child-Pugh Class B): Reduce to 50% of normal dose
- Severe hepatic impairment (Child-Pugh Class C): Reduce to 25% of normal dose 1
CYP2D6 Poor Metabolizers
- Dose adjustment required for patients known to be CYP2D6 poor metabolizers
- Consider lower doses and slower titration 1
Concomitant Use with Strong CYP2D6 Inhibitors
- Dose adjustment required when used with medications like paroxetine
- Similar adjustments as for CYP2D6 poor metabolizers 1
Treatment Guidelines by Age
Elementary and Middle School-Aged Children (6-12 years)
- Atomoxetine is FDA-approved and recommended as a treatment option
- Evidence is particularly strong for stimulant medications, while sufficient but less strong for atomoxetine 2
- Should be combined with parent training in behavior management and/or behavioral classroom interventions 2
Adolescents (12-18 years)
- Atomoxetine is recommended with the adolescent's assent
- Should be combined with evidence-based training interventions and/or behavioral interventions if available 2
Monitoring and Follow-up
Initial Titration
- Titrate doses to achieve maximum benefit with minimum adverse effects 2
- Allow at least 6-8 weeks to evaluate the overall tolerability and efficacy 3
- Monitor for:
Long-term Management
- ADHD should be recognized as a chronic condition requiring ongoing management 2
- Regular assessment of symptoms using standardized scales
- Follow-up within 2-4 weeks after medication initiation 4
Safety Considerations
Boxed Warning
- Increased risk of suicidal ideation in children and adolescents
- Patients started on therapy should be monitored closely 1
Cardiovascular Effects
- Monitor for increases in blood pressure and heart rate
- Use with caution in patients with hypertension, tachycardia, or cardiovascular disease
- Contraindicated in severe cardiovascular disorders 1
Liver Effects
- Discontinue and do not restart in patients with jaundice or laboratory evidence of liver injury 1
Clinical Advantages of Atomoxetine
- Non-stimulant medication with negligible risk of abuse or misuse 5, 6
- Not a controlled substance, allowing for more convenient prescription processing 7
- Can be administered once daily or divided into two doses 5
- Particularly useful for patients:
Common Side Effects
- Headache, abdominal pain, decreased appetite, vomiting, somnolence, and nausea 5
- Dry mouth, insomnia, constipation, dizziness, sweating, dysuria, sexual problems, and palpitations in adults 7
- Gastrointestinal effects, aggression/hostility, and increased hyperactivity in younger children 8
Atomoxetine provides an effective non-stimulant option for ADHD treatment with a different side effect profile than stimulants. While it may be less effective than extended-release stimulant formulations, it offers important advantages for specific patient populations and clinical scenarios.