Can a young teen take Strattera (atomoxetine) and Concerta (methylphenidate) together?

Combining Strattera and Concerta in Young Teens with ADHD

Young teens can take Strattera (atomoxetine) and Concerta (methylphenidate) together, but this combination should only be used when monotherapy with either medication has proven inadequate for symptom control. 1, 2

Efficacy and Safety Considerations

• Concerta (methylphenidate) is a stimulant medication with robust efficacy for ADHD symptoms, while Strattera (atomoxetine) is a non-stimulant selective norepinephrine reuptake inhibitor with moderate efficacy 2, 3
• Studies show that osmotically released methylphenidate (Concerta) demonstrates superior efficacy compared to atomoxetine, with response rates of 56% versus 45% respectively 3
• Both medications target different neurotransmitter systems - methylphenidate primarily affects dopamine, while atomoxetine primarily affects norepinephrine, which provides a theoretical basis for their combined use 2
• When used individually, both medications are generally well-tolerated with different side effect profiles - stimulants more commonly cause insomnia while atomoxetine more commonly causes somnolence 2

Specific Considerations for Young Teens

• Adolescents present unique challenges for ADHD medication management, including concerns about compliance, privacy at school, and potential for medication diversion 1
• Concerta is particularly well-suited for adolescents as it is a long-acting preparation that is resistant to diversion (cannot be ground up or snorted) 1
• Atomoxetine has negligible risk of abuse or misuse and is not a controlled substance, making it particularly useful for patients at risk of substance abuse 2
• For adolescents, special attention should be given to providing medication coverage for symptom control while driving, as ADHD symptoms can impair driving safety 1

Potential Benefits of Combination Therapy

• Some patients who do not respond adequately to one medication may respond to the other - studies show that 43% of non-responders to methylphenidate subsequently responded to atomoxetine, and 42% of non-responders to atomoxetine had previously responded to methylphenidate 3
• The different side effect profiles may allow for better overall tolerability when doses of each medication are optimized in combination 2, 4

Potential Risks and Monitoring

• Both medications can affect cardiovascular parameters, so monitoring of heart rate and blood pressure is essential 2
• The combination may potentially increase the risk of side effects common to both medications, such as decreased appetite 2, 4
• If a teen is taking multiple medications for ADHD, careful consideration should be given to which medication to adjust or discontinue first if side effects occur 1

Clinical Approach to Combination Therapy

• Start with monotherapy of either medication before considering combination therapy 1
• If monotherapy is inadequate, the American Academy of Child and Adolescent Psychiatry suggests that the second medication should be started at a low dose and increased slowly while monitoring for side effects 1
• For adolescents specifically, a common approach is to use Concerta once in the morning at home and potentially add atomoxetine if needed for additional symptom control 1
• Regular monitoring of height, weight, blood pressure, heart rate, and mental status is essential 2

Common Pitfalls to Avoid

• Failing to assess for substance abuse before initiating stimulant therapy in adolescents 1
• Not monitoring for potential diversion of stimulant medication, which is a special concern among adolescents 1
• Overlooking the different pharmacokinetic profiles - atomoxetine may be affected by CYP2D6 inhibitors, potentially leading to increased atomoxetine levels 2
• Discontinuing medications abruptly rather than tapering, which may lead to rebound worsening of symptoms 1