Strattera (Atomoxetine) Dosage for ADHD
Start atomoxetine at 40 mg orally once daily, then titrate every 7-14 days to 60 mg and then 80 mg daily, with a maximum dose of 1.4 mg/kg/day or 100 mg/day, whichever is less. 1
Initial Dosing
- Begin with 40 mg orally once daily as the standard starting dose 1
- Atomoxetine can be administered as either a single daily dose or split into two evenly divided doses throughout the day 2, 3
- A single morning dose provides symptom control extending throughout waking hours and into the next morning 4
Titration Schedule
- Adjust the dose every 7-14 days based on clinical response and tolerability 1
- Progress from 40 mg daily to 60 mg daily, then to 80 mg daily 1
- The target therapeutic dose is approximately 1.2 mg/kg/day 4
- Maximum dose is the lesser of 1.4 mg/kg/day or 100 mg/day 1
Monitoring During Titration
- Maintain weekly contact (by telephone is acceptable) during initial titration and dose adjustments 5
- Titration typically requires 2-4 weeks to reach optimal dosing 5
- Systematically assess for specific side effects including insomnia, anorexia, headaches, decreased appetite, nausea, abdominal pain, and somnolence at each adjustment 5, 2
- Monitor weight regularly as weight loss is common with atomoxetine 5
- Check heart rate and blood pressure, as modest increases may occur but are generally well tolerated 2, 3
Onset of Effect and Long-Term Management
- Allow 6-12 weeks for full therapeutic effects to be observed, as atomoxetine has a slower onset compared to stimulants 1
- After dose stabilization, schedule follow-up appointments at least monthly 5
- If adequate symptom control is not achieved at maximum dose, consider alternative treatments or adding non-stimulant medications 5
Special Populations
Adults with ADHD
- Use the same dosing strategy: 60,90, or 120 mg/day in divided or single doses 6, 3
- Adult trials demonstrated efficacy at these doses with good tolerability 6, 3
Poor CYP2D6 Metabolizers
- Patients who are poor CYP2D6 metabolizers have greater drug exposure and slower elimination 2
- These patients may require lower doses and experience more adverse effects 2
- CYP2D6 inhibitors (such as paroxetine) produce similar pharmacokinetic changes 2
Clinical Context
- Atomoxetine is generally used as second-line therapy after stimulants in most guidelines, though it may be first-line in specific circumstances 1
- Consider atomoxetine as first-line in patients with comorbid substance use disorders, tic/Tourette's disorder, anxiety, or those who prefer a non-controlled substance 1, 2, 7
- Atomoxetine has negligible abuse potential and is not a controlled substance 2, 6, 3
Common Pitfalls to Avoid
- Do not start at too high a dose, as this increases unnecessary side effects and decreases adherence 5
- Do not expect immediate results—unlike stimulants, atomoxetine requires 6-12 weeks for full effect 1
- Do not discontinue abruptly without assessment, though atomoxetine is not associated with rebound symptoms or acute discontinuation syndrome 2, 4
- Be aware of the black-box warning for suicidal ideation, particularly during initial treatment 2
- Monitor for rare but serious liver injury, though this is uncommon 2