Atomoxetine is NOT Contraindicated During TMS
Atomoxetine can be safely used during TMS treatment, as there is no evidence that standard TMS safety guidelines need to be specifically adjusted for patients taking this medication. 1
Safety Framework for TMS
The primary safety concern with TMS is seizure risk, and TMS safety guidelines are largely based around minimizing this risk. 1 The key principle is that any factor that independently increases seizure risk can theoretically increase brain sensitivity to TMS-induced seizures. 1
Atomoxetine-Specific Considerations
Seizure Risk Profile
- Atomoxetine does not increase seizure risk compared to stimulant medications used for ADHD treatment. 2
- A large cohort study of pediatric patients found atomoxetine was associated with a non-statistically significant 28% lower risk of seizure compared to stimulant therapy (RR 0.72; 95%CI 0.37,1.38). 2
- The overall risk of seizure with atomoxetine therapy is not significantly different from stimulants. 2
Mechanism and Safety
- Atomoxetine is a selective norepinephrine reuptake inhibitor that acts almost exclusively on the noradrenergic pathway, with little or no affinity for various neurotransmitter receptors. 3
- The medication should be used with caution in patients with hypertension or significant cardiovascular disorders, but this relates to blood pressure effects, not seizure risk. 4, 5
Medications That DO Require Caution with TMS
The 2019 consensus guidelines specifically identify medications that warrant increased vigilance during TMS due to seizure risk: 1
- Bupropion (lowers seizure threshold)
- Tramadol (increases seizure risk)
- Benzodiazepine/barbiturate withdrawal
- Cocaine use
- Alcohol withdrawal
Atomoxetine is notably absent from this list of concerning medications. 1
Clinical Monitoring Recommendations
While atomoxetine is not contraindicated, standard TMS safety monitoring should include: 1, 5
- Blood pressure monitoring throughout treatment (atomoxetine can increase blood pressure in a significant percentage of patients)
- Avoidance in patients with known cardiovascular problems
- Standard TMS seizure precautions that apply to all patients
Common Pitfalls to Avoid
- Do not confuse atomoxetine with stimulant medications - while both treat ADHD, atomoxetine is a non-stimulant with a different safety profile and is not a controlled substance. 3, 4
- Do not assume all ADHD medications carry the same TMS risks - the evidence shows atomoxetine does not increase seizure risk. 2
- The overall risk of TMS-related seizures is <1%, and this rate is comparable to most psychotropic medications. 6