Is it safe to prescribe atomoxetine (Strattera) for Attention Deficit Hyperactivity Disorder (ADHD) and anxiety in a patient with a history of an eating disorder?

Atomoxetine Use in ADHD with Comorbid Anxiety and Eating Disorder History

Atomoxetine can be prescribed for ADHD and anxiety in patients with a history of eating disorders, but requires careful monitoring for appetite suppression, weight loss, and gastrointestinal symptoms that could exacerbate eating disorder behaviors.

Key Safety Considerations

Eating Disorder-Specific Risks

The primary concern with atomoxetine in patients with eating disorder history relates to its appetite-suppressing effects:

• Decreased appetite is a common adverse effect of atomoxetine, occurring frequently enough to warrant FDA labeling 1
• Weight loss and gastrointestinal symptoms (nausea, vomiting, abdominal pain) are well-documented side effects that could trigger eating disorder relapse 2, 3
• Growth delays have been observed in the first 1-2 years of treatment, though these typically normalize after 2-3 years 1

Critical Contraindication from Obesity Guidelines

Naltrexone/bupropion combination is explicitly contraindicated in patients with anorexia or bulimia nervosa due to seizure risk from abrupt discontinuation behaviors associated with eating disorders 1. While this doesn't directly address atomoxetine, it establishes that eating disorder history requires medication-specific risk assessment.

Advantages of Atomoxetine in This Clinical Scenario

Benefits for Comorbid Anxiety

• Atomoxetine may be beneficial for comorbid anxiety disorders, with evidence supporting its use in ADHD patients with anxiety 1, 4
• Unlike stimulants, atomoxetine does not typically exacerbate anxiety symptoms 4
• The 2019 AAP guidelines note that children with comorbid anxiety disorder can improve on ADHD medications 1

Non-Stimulant Profile

• No abuse potential, making it safer than stimulants in patients with complex psychiatric histories 2, 3
• Not a controlled substance, reducing concerns about misuse behaviors that might overlap with eating disorder pathology 2
• Less likely to cause insomnia compared to stimulants, which is important for overall mental health stability 2

Monitoring Protocol

Essential Pre-Treatment Assessment

Before initiating atomoxetine in a patient with eating disorder history:

• Obtain baseline weight, height, and BMI to establish growth trajectory 1
• Assess current eating patterns including any restrictive eating, binge eating, or compensatory behaviors 1
• Evaluate cardiovascular status with ECG if there is history of purging or current restrictive eating, as these patients may have electrolyte abnormalities and cardiac complications 1
• Screen for suicidal ideation, as atomoxetine carries an FDA black box warning for increased suicidal thoughts 1

Ongoing Monitoring Requirements

• Monitor weight and vital signs regularly throughout treatment, as atomoxetine can increase heart rate and blood pressure 1
• Slow dose titration to minimize gastrointestinal side effects that could trigger eating disorder behaviors 1
• Watch for decreased appetite and weight loss, particularly in the first few months of treatment 2, 3
• Assess for hepatotoxicity with liver function tests if symptoms develop, as atomoxetine has rare association with hepatitis 1

Dosing Strategy

Conservative Approach

• Start at 40 mg daily and titrate slowly every 7-14 days to minimize GI side effects 1
• Consider evening dosing to reduce daytime appetite suppression, though this may increase somnolence 1
• Maximum dose should not exceed 1.4 mg/kg/day or 100 mg/day 1

Alternative Considerations

When Atomoxetine May Not Be Appropriate

If the eating disorder history includes:

• Active anorexia nervosa with significant malnutrition - the appetite-suppressing effects could worsen nutritional status
• Recent severe purging behaviors - cardiovascular monitoring becomes more critical and complex
• Current hepatic dysfunction - atomoxetine exposure increases with liver impairment 2

Other ADHD Medication Options

• Guanfacine or clonidine may be considered as they do not suppress appetite and may actually cause weight gain, though they have different efficacy profiles 1
• Stimulants are not absolutely contraindicated in eating disorder history, but require similar careful monitoring for appetite and weight effects 1

Multidisciplinary Coordination

Coordinate care with the patient's eating disorder treatment team (if active) or mental health provider to ensure:

• Unified monitoring of weight and eating behaviors
• Early identification of eating disorder symptom recurrence
• Integrated treatment planning that addresses both ADHD and eating disorder recovery 1

Clinical Bottom Line

Atomoxetine is a reasonable choice for ADHD and anxiety in patients with eating disorder history, particularly if the eating disorder is in remission. Its non-stimulant profile and potential benefits for anxiety outweigh risks in most cases, provided there is close monitoring of appetite, weight, and eating behaviors. The key is slow titration, regular weight monitoring, and coordination with eating disorder treatment providers to catch any relapse early.