Is it safe to take Strattera (atomoxetine) before undergoing gastric sleeve surgery?

Strattera (Atomoxetine) and Gastric Sleeve Surgery

Strattera can be safely continued through the perioperative period for gastric sleeve surgery, as it does not delay gastric emptying, increase bleeding risk, or compromise anastomotic healing—the primary concerns that necessitate holding other medications before bariatric procedures.

Mechanism and Safety Profile

Atomoxetine is a selective norepinephrine reuptake inhibitor that does not affect gastrointestinal motility or platelet function 1, 2. Unlike medications that require perioperative cessation (such as GLP-1 receptor agonists which delay gastric emptying, or NSAIDs which compromise healing), atomoxetine lacks these problematic mechanisms 3.

Key Perioperative Considerations

Cardiovascular Effects

• Atomoxetine causes statistically but not clinically significant increases in heart rate and blood pressure 1
• These modest hemodynamic changes are well tolerated and do not contraindicate surgery 2
• Standard preoperative cardiac risk assessment should proceed as usual 3

No Gastric Emptying Concerns

• Unlike drugs that must be held before gastric sleeve surgery (proton pump inhibitors, opioids, tricyclic antidepressants, GLP-1 agonists), atomoxetine does not delay gastric emptying 3
• There is no need to apply the "three half-life" holding period recommended for medications affecting gastric motility 3

No Bleeding Risk

• Atomoxetine does not affect platelet aggregation or coagulation, unlike NSAIDs which are associated with higher anastomotic dehiscence rates 4
• The medication does not require discontinuation for bleeding prevention 3

Postoperative Management

Medication Administration

• Capsules should be opened when appropriate to improve absorption in the altered gastrointestinal tract after sleeve gastrectomy 5
• Atomoxetine can be administered once or twice daily, allowing flexibility in the immediate postoperative period when oral intake is limited 1, 2

Monitoring Requirements

• Continue standard postoperative bariatric follow-up at 1-2 weeks, then 1,3,6,9, and 12 months 6
• No additional monitoring specific to atomoxetine is required beyond routine vital signs 1

Drug Interactions

• Be aware that CYP2D6 inhibitors (such as paroxetine) can increase atomoxetine exposure 1
• This is relevant if antidepressants are being considered for postoperative mood management 1

Common Pitfalls to Avoid

• Do not confuse atomoxetine with stimulants: Unlike methylphenidate or amphetamines, atomoxetine is not a controlled substance and carries negligible abuse risk 1, 2
• Do not unnecessarily discontinue: There is no evidence-based reason to hold atomoxetine preoperatively, and doing so may destabilize ADHD symptoms during an already stressful perioperative period 1
• Do not overlook absorption issues: In the early postoperative period when patients are on liquid diets, consider opening capsules or temporarily adjusting timing to optimize absorption 5

Special Populations

Patients with Hepatic Insufficiency

• Atomoxetine exposure increases in hepatic insufficiency 1
• If significant liver disease is present (uncommon in bariatric candidates), dose adjustment may be needed 1

Poor CYP2D6 Metabolizers

• Approximately 7-10% of the population are poor metabolizers who have greater atomoxetine exposure and slower elimination 1
• These patients may experience more adverse effects but can still safely undergo surgery 1

Postoperative Adverse Event Management

• Common atomoxetine side effects (nausea, decreased appetite, abdominal discomfort) overlap with expected postoperative symptoms after sleeve gastrectomy 5, 1
• If nausea is problematic, use multimodal antiemetic therapy with ondansetron, dexamethasone, or metoclopramide as recommended for high-risk bariatric patients 3
• Early satiety and decreased appetite from atomoxetine may actually facilitate adherence to small, frequent meals required after sleeve gastrectomy 5, 1

Long-Term Considerations

• Atomoxetine does not interfere with the nutritional supplementation regimen required after sleeve gastrectomy (multivitamins, thiamine, vitamin B12, iron, calcium, vitamin D) 5, 6
• Continue lifelong multidisciplinary follow-up as recommended for all bariatric patients, with no additional requirements specific to atomoxetine 6