Can a teenager take Lexapro (escitalopram) 5mg and Strattera (atomoxetine) 18mg?

Can a Teenager Take Lexapro 5mg and Strattera 18mg Together?

Yes, a teenager can take Lexapro (escitalopram) 5mg and Strattera (atomoxetine) 18mg together, but this combination requires careful monitoring for serotonin syndrome and cardiovascular effects, particularly during the first 24-48 hours after initiation or dose changes.

Rationale for Combination Therapy

Both medications are FDA-approved for use in adolescents and can be appropriately combined when treating co-occurring conditions:

• Escitalopram is FDA-approved for adolescents aged 12 years and older for depression and anxiety disorders 1
• Atomoxetine is FDA-approved for ADHD in children, adolescents, and adults 1, 2, 3
• The combination addresses different neurotransmitter systems: atomoxetine primarily affects norepinephrine with minimal serotonin effects, while escitalopram is a selective serotonin reuptake inhibitor 4, 2

Critical Monitoring Requirements

Serotonin Syndrome Risk

Caution is required when combining two serotonergic medications, even though atomoxetine has minimal serotonergic activity 1:

• Monitor closely for symptoms within the first 24-48 hours after starting or changing doses 1
• Watch for mental status changes (confusion, agitation, anxiety), neuromuscular hyperactivity (tremors, clonus, hyperreflexia), and autonomic hyperactivity (hypertension, tachycardia, diaphoresis) 1
• The risk is lower with this combination compared to combining two SSRIs or an SSRI with an MAOI, but vigilance remains essential 1

Cardiovascular Monitoring

Both medications can affect cardiovascular parameters and require baseline and ongoing monitoring 1, 5:

• Obtain personal and family cardiac history before initiating treatment, specifically asking about sudden death, Wolff-Parkinson-White syndrome, hypertrophic cardiomyopathy, and long QT syndrome 1
• Atomoxetine may increase heart rate and blood pressure in 5-15% of patients 1, 5
• Escitalopram has the least effect on CYP450 enzymes among SSRIs, reducing drug-drug interaction concerns 1
• Monitor vital signs regularly, particularly during dose titration 1

Dosing Considerations

Escitalopram 5mg

• This is below the typical starting dose of 10mg for adolescents 1
• The effective dose range is 10-20mg daily, with a maximum of 20mg 1
• Starting at 5mg may be appropriate for initial tolerability assessment

Atomoxetine 18mg

• This represents a low starting dose for adolescents 1, 2
• Atomoxetine demonstrates dose-proportional pharmacokinetics and should be titrated to achieve maximum benefit with minimum adverse effects 1, 2
• The medication can be given once daily or split into two divided doses 2

Pharmacokinetic Interactions

The combination has a favorable interaction profile 1, 6:

• Escitalopram (citalopram/escitalopram) has minimal effect on CYP450 isoenzymes compared to other SSRIs 1
• Atomoxetine is primarily metabolized by CYP2D6 6
• Since escitalopram is not a significant CYP2D6 inhibitor, it should not substantially affect atomoxetine metabolism 1, 6

Adverse Effects to Monitor

Common Side Effects

• Atomoxetine: Decreased appetite, abdominal pain, nausea, somnolence, initial gastrointestinal symptoms 1, 2
• Escitalopram: Sexual dysfunction (in adolescents), gastrointestinal symptoms, activation symptoms 1

Serious but Rare Concerns

• Atomoxetine: Black box warning for suicidal ideation; rare hepatotoxicity requiring liver function monitoring 1, 2
• Escitalopram: Increased suicidal thinking (FDA black box warning for all antidepressants in youth); abnormal bleeding risk 1
• Both medications require close monitoring, especially during the first few months and after dose changes 1

Monitoring Schedule

Implement frequent contact during initial treatment phase 1:

• Contact (in-person or telephone) within the first week after initiation 1
• Monitor closely for clinical worsening, suicidality, and unusual behavioral changes 1
• Telephone monitoring has been shown to be as effective as face-to-face visits for monitoring adverse events in adolescents 1
• Continue regular monitoring throughout treatment, particularly after any dose adjustments 1

Common Pitfalls to Avoid

• Do not combine with MAOIs: Both medications are contraindicated with monoamine oxidase inhibitors 1, 4
• Avoid abrupt discontinuation: Escitalopram requires slow tapering to prevent discontinuation syndrome 1
• Do not assume all symptoms require medication adjustment: Distinguish between medication side effects, underlying psychiatric symptoms, and psychosocial stressors that may require behavioral interventions rather than medication changes 1
• Monitor growth parameters: Atomoxetine may cause initial decreases in expected height and weight, though these typically normalize over 2-3 years 1, 2

When This Combination is Particularly Appropriate

This medication combination is well-suited for adolescents with:

• Co-occurring ADHD and anxiety or depression requiring treatment of both conditions 1
• Concerns about stimulant abuse potential (atomoxetine is not a controlled substance) 2
• Co-morbid anxiety or tics where atomoxetine may be preferred over stimulants 2