How to transition a patient from Strattera (atomoxetine) 40mg to Concerta (methylphenidate)?

Transitioning from Strattera 40mg to Concerta in a 13-Year-Old

The most effective approach to transition a 13-year-old from Strattera (atomoxetine) 40mg to Concerta (methylphenidate) is to discontinue Strattera abruptly and start Concerta at 18mg daily the following day, then titrate upward based on clinical response.

Discontinuation of Strattera

• Atomoxetine can be safely discontinued abruptly without tapering, as it does not produce withdrawal symptoms or rebound effects 1
• Studies show that discontinuation of atomoxetine is well tolerated and does not result in the development of an acute discontinuation syndrome 1
• While ADHD symptoms may worsen slightly following discontinuation, they typically do not return to pre-treatment levels 1

Initial Dosing of Concerta

• Start with Concerta 18mg once daily in the morning, which is approximately equivalent to methylphenidate immediate-release 5mg given three times daily 2
• Concerta utilizes an osmotically released, timed drug-delivery system (OROS) that produces an ascending plasma drug level throughout the day with effects lasting for a full 12-hour period 3
• Morning administration is recommended to minimize potential sleep disturbances 3

Titration Schedule

• After starting with 18mg, assess clinical response after 1 week
• If needed, increase to 36mg once daily, then potentially to 54mg once daily based on clinical response 3
• Clinical efficacy should guide dosing rather than weight or plasma concentrations, as plasma levels of methylphenidate do not correlate well with clinical response 2

Monitoring During Transition

• Monitor for common side effects of Concerta, including:
  • Insomnia (more common with stimulants than with atomoxetine) 4
  • Decreased appetite 5
  • Potential changes in heart rate and blood pressure 5
• Watch for emergence of tics, which can occur with stimulant medications 6

Managing Potential Side Effects

• For appetite loss: administer Concerta with meals and provide a high-calorie snack in the evening when stimulant effects have worn off 5
• For difficulty falling asleep: ensure morning administration of Concerta and consider implementing a bedtime routine 5
• For irritability: evaluate when it occurs (peak effect vs. rebound) and adjust dosing accordingly 5

Special Considerations

• Concerta has several advantages over immediate-release methylphenidate:

  • Eliminates the midday "trough" in medication levels 2
  • Lower potential for abuse compared to immediate-release formulations 2
  • Once-daily dosing improves compliance, particularly important for adolescents 3

• If oral tics develop while on Concerta, consider:

  • Adjusting the dose of Concerta 6
  • Adding an alpha-agonist such as clonidine or guanfacine as a first-line option for managing tics 6

Efficacy Expectations

• Be aware that atomoxetine is generally considered less effective than extended-release methylphenidate formulations like Concerta 4, 7
• Approximately 75% of responders to atomoxetine will also respond to methylphenidate 8
• Allow at least 1-2 weeks to evaluate the initial response to Concerta 3

Follow-up Recommendations

• Schedule a follow-up appointment 1-2 weeks after initiating Concerta to assess efficacy and side effects
• Discontinuation rates for ADHD medications have decreased with the availability of long-acting formulations like Concerta 9
• If Concerta is not effective or poorly tolerated after adequate trial, consider other treatment options