Starting Dose of Strattera (Atomoxetine) for Adults
For adults, Strattera should be initiated at 40 mg once daily, then increased after a minimum of 3 days to a target dose of 80 mg daily, administered either as a single morning dose or divided into morning and late afternoon/evening doses. 1
Initial Dosing Protocol
- Start at 40 mg daily for all adults and adolescents weighing over 70 kg 1
- Maintain this initial dose for at least 3 days before any increase 1
- The 40 mg can be taken as a single dose or split into two divided doses (morning and late afternoon/evening) 1
Titration Schedule
- After 3 days minimum, increase to the target dose of 80 mg daily 1
- If optimal response is not achieved after 2-4 additional weeks at 80 mg, may increase to maximum of 100 mg daily 1
- Maximum recommended dose is 100 mg/day for adults 1
- No data support increased effectiveness at doses higher than 100 mg 1
Important Timing Considerations
- Full therapeutic effect requires 6-12 weeks, unlike stimulants which work within hours 2
- Set appropriate patient expectations about this delayed response timeline 2
- Slow titration (increasing dose gradually at 1-2 week intervals) is generally better tolerated and helps avoid exceeding the optimal dose 2
Special Dosing Adjustments
For CYP2D6 Poor Metabolizers or Strong CYP2D6 Inhibitor Use
- Start at 40 mg/day 1
- Only increase to 80 mg/day if symptoms fail to improve after 4 weeks AND the initial dose is well tolerated 1
- Strong CYP2D6 inhibitors include paroxetine, fluoxetine, and quinidine 1
For Hepatic Impairment
- Moderate hepatic impairment (Child-Pugh Class B): Reduce initial and target doses to 50% of normal (start at 20 mg, target 40 mg) 1
- Severe hepatic impairment (Child-Pugh Class C): Reduce initial and target doses to 25% of normal (start at 10 mg, target 20 mg) 1
Administration Details
- May be taken with or without food 1
- Capsules must be swallowed whole, not opened 1
- Can be discontinued without tapering 1
Critical Safety Monitoring
- Screen for bipolar disorder (personal or family history of bipolar disorder, mania, or hypomania) before initiating treatment 1
- Monitor closely for suicidality, clinical worsening, and unusual behavior changes, especially during the first few months or at dose changes 2
- Watch for behavioral activation/agitation (motor or mental restlessness, insomnia, impulsiveness, aggression) early in treatment or with dose increases 2
Common Adverse Effects to Anticipate
- Dry mouth, insomnia, nausea, decreased appetite, constipation, dizziness, sweating, dysuria, sexual problems, and palpitations occur more frequently than with placebo 3, 4
- Gastrointestinal effects (nausea, vomiting, abdominal pain) and decreased appetite are common 2
- Modest increases in heart rate (1-2 beats per minute) and blood pressure (1-4 mm Hg) are typical 5
Key Clinical Pitfalls to Avoid
- Do not increase dose too rapidly - behavioral activation and agitation are more likely with rapid escalation 2
- Do not expect immediate results - unlike stimulants, atomoxetine requires 6-12 weeks for full effect 2
- Do not forget CYP2D6 status - poor metabolizers have 10-fold higher plasma concentrations and require slower titration 6
- Do not skip hepatic function assessment - dose adjustments are essential in hepatic impairment 1