Is Strattera (atomoxetine) a suitable alternative for a patient currently on Vyvanse (lisdexamfetamine) 70mg, considering a switch to a non-stimulant medication for Attention Deficit Hyperactivity Disorder (ADHD)?

Switching from Vyvanse to Strattera (Atomoxetine)

Strattera (atomoxetine) is a reasonable alternative to Vyvanse, but you should counsel the mother that it will likely be less effective and take 2-4 weeks to show benefit, compared to the robust response her child currently has on Vyvanse 70mg. 1

Evidence-Based Treatment Hierarchy

Stimulants remain first-line therapy for ADHD, with non-stimulants like atomoxetine recommended as second-line options. 1 The evidence strongly supports this hierarchy:

• Stimulants demonstrate 65-75% response rates versus only 5-30% for placebo, representing the largest body of treatment literature for any childhood psychiatric disorder 1
• Atomoxetine is significantly less effective than extended-release stimulants like Vyvanse (lisdexamfetamine) 2, 3
• In a direct head-to-head trial, patients switching from methylphenidate to either Vyvanse or atomoxetine showed median time to clinical response of 12 days for Vyvanse versus 21 days for atomoxetine (p=0.001), with 81.7% response rate for Vyvanse versus 63.6% for atomoxetine by week 9 3

When Atomoxetine Is Particularly Appropriate

Consider atomoxetine preferentially if the child has:

• Active substance use concerns or high risk of medication diversion (atomoxetine is not a controlled substance) 1, 2
• Comorbid anxiety disorders or tics/Tourette's disorder 1, 2
• Intolerable stimulant side effects (severe insomnia, appetite suppression, or cardiovascular concerns) 1, 2
• Family preference to avoid controlled substances after informed discussion 1

Critical Counseling Points for the Mother

Set realistic expectations about the transition:

• Atomoxetine requires daily compliance and may take several weeks to achieve full therapeutic effect, unlike the immediate action of Vyvanse 4
• The child will likely experience a period of reduced symptom control during the switch 3
• Effect size for atomoxetine is smaller than stimulants across all ADHD symptom domains 3

Practical Switching Strategy

Initiate atomoxetine at 0.5 mg/kg/day for children under 70kg, titrating to 1.2 mg/kg/day (maximum 1.4 mg/kg/day) over several weeks 5:

• Start atomoxetine while continuing Vyvanse at reduced dose initially if abrupt symptom worsening is a concern 1
• Gradually taper Vyvanse as atomoxetine is titrated up over 2-3 weeks 1
• Monitor for initial somnolence and gastrointestinal symptoms, particularly if dose is increased too rapidly 1

Safety Monitoring Requirements

Monitor the following parameters closely:

• Suicidal ideation (FDA black box warning) - atomoxetine increases risk of suicidal thoughts in children/adolescents (0.4% vs 0% placebo) 5
• Heart rate and blood pressure at each visit 1
• Height and weight every 3 months (atomoxetine causes growth delays in first 1-2 years, though catch-up occurs by years 2-3) 1
• Liver function if any signs of jaundice or hepatic symptoms (rare but serious risk) 1, 2

Common Pitfalls to Avoid

• Do not switch without exploring the mother's specific concerns about stimulants - address misconceptions about addiction, long-term safety, or side effects that may be manageable 1
• Do not expect equivalent efficacy - atomoxetine works well for some patients but has smaller effect sizes than Vyvanse 2, 3
• Do not discontinue abruptly without a transition plan - the child is on a high dose (70mg) of a highly effective medication 1

Alternative Consideration

If the concern is specifically about controlled substance status or abuse potential rather than stimulant class effects, consider other non-amphetamine options like extended-release guanfacine or clonidine as adjunctive therapy rather than complete replacement 1, though these also have lower efficacy than stimulants as monotherapy 1.