Strattera (Atomoxetine) Treatment for ADHD
For children and adolescents with ADHD, Strattera (atomoxetine) should be initiated at 0.5 mg/kg/day and titrated after a minimum of 3 days to a target dose of 1.2 mg/kg/day, with a maximum recommended dose of 1.4 mg/kg/day or 100 mg daily, whichever is less. 1
Dosage Recommendations
- Atomoxetine is administered orally and is available in capsules containing 10,18,25,40,60,80, or 100 mg of atomoxetine hydrochloride, as well as in an oral solution (4 mg/ml) 2
- For children and adolescents up to 70 kg: Start with 0.5 mg/kg/day, target 1.2 mg/kg/day, maximum 1.4 mg/kg/day 1, 3
- For children and adolescents over 70 kg and adults: Start with 40 mg/day, target 80 mg/day, maximum 100 mg/day 3
- Atomoxetine can be administered either as a single daily dose or split into two evenly divided doses 4
- Dose titration should follow a sequential, weight-based approach 2
Age-Specific Recommendations
- For preschool-aged children (4-5 years): Atomoxetine is not recommended as it has not received sufficient rigorous study in this population 1
- For elementary school-aged children (6-11 years): Atomoxetine is FDA-approved, with evidence being sufficient but less strong than for stimulant medications 2
- For adolescents (12-18 years): Atomoxetine is recommended with the adolescent's assent 2
- Atomoxetine may be particularly useful for adolescents at risk of substance abuse, as it has negligible abuse potential and is not a controlled substance 2, 4
Safety Monitoring and Precautions
- Atomoxetine carries an FDA black box warning for increased risk of suicidal ideation in children and adolescents 1, 3
- Monitor closely for suicidality, clinical worsening, and unusual behavior changes, especially during the first few months of treatment or with dose changes 1, 3
- Common adverse effects include:
- Perform cardiac evaluation if risk factors are present before starting treatment 1
- Monitor growth as atomoxetine has been linked to growth delays in the first 1-2 years of treatment 1
- Monitor for hepatic effects, as atomoxetine has been associated with rare cases of severe liver injury 3
Special Considerations
- Atomoxetine is metabolized through the CYP2D6 pathway; dosage adjustments may be needed for poor metabolizers or when used with CYP2D6 inhibitors 2, 3
- For patients with comorbid anxiety, tics, or substance use concerns, atomoxetine may be preferable to stimulants 2, 5
- Atomoxetine may be less likely than stimulants to exacerbate sleep disorders 4
- The duration of action extends throughout waking hours with effects persisting to the next morning with a single morning dose 6
Comparative Efficacy
- Atomoxetine is significantly more effective than placebo for treating ADHD symptoms 4, 5
- Atomoxetine is comparable to immediate-release methylphenidate but less effective than extended-release methylphenidate formulations and extended-release mixed amphetamine salts 4, 5
- In patients who respond favorably to initial treatment, atomoxetine has been shown to be superior to placebo in maintaining long-term response (up to 18 months) 6
Common Pitfalls to Avoid
- Failing to monitor for suicidal ideation, especially during the first few months of treatment 1, 3
- Not accounting for CYP2D6 metabolism status, which can significantly affect drug levels 2, 3
- Starting at too high a dose; always begin at 0.5 mg/kg/day and titrate gradually 1
- Not allowing sufficient time for full therapeutic effect, as atomoxetine may take longer than stimulants to show maximum benefit 6
- Overlooking potential drug interactions, particularly with selective serotonin reuptake inhibitors which can elevate serum atomoxetine levels 2
Atomoxetine represents an important non-stimulant option for ADHD treatment, particularly valuable for patients with concerns about stimulant abuse potential or those with comorbid anxiety or tic disorders 2, 5.