Is Strattera (atomoxetine) contraindicated in Graves' disease?

Is Strattera Contraindicated in Graves' Disease?

Strattera (atomoxetine) is not contraindicated in Graves' disease, but requires careful monitoring if the hyperthyroidism is uncontrolled or severe.

Key Considerations for Atomoxetine Use

Cardiovascular Effects and Thyroid Status

• Atomoxetine can increase heart rate and blood pressure, which may be problematic in patients with active hyperthyroidism from Graves' disease 1
• The primary concern is the additive cardiovascular stimulation when combining atomoxetine with the already elevated sympathetic tone present in untreated or poorly controlled hyperthyroidism
• Beta-blockers (such as propranolol or atenolol) are routinely used to manage hyperthyroid symptoms and could theoretically help mitigate atomoxetine's cardiovascular effects 1

Clinical Approach Algorithm

Step 1: Assess thyroid control status

• If Graves' disease is well-controlled on antithyroid medications (methimazole or propylthiouracil) with normal free T4 and TSH levels, atomoxetine can be initiated with standard monitoring 2, 3
• Monitor thyroid function every 2-4 months during interferon-based treatments, though this specific frequency applies to hepatitis C treatment contexts 1

Step 2: If hyperthyroidism is active or severe

• Prioritize achieving euthyroid status first before initiating atomoxetine 2, 3
• Use thioamides (methimazole preferred, or propylthiouracil in specific situations) to normalize thyroid hormone levels 1
• Consider beta-blocker therapy for symptomatic relief during the stabilization period 1

Step 3: Monitor for complications

• Watch for worsening tachycardia, hypertension, or cardiac symptoms after atomoxetine initiation 1
• Be alert for mood destabilization (agitation, irritability, restlessness) especially in the first 24-48 hours after starting or dose changes 4

Important Caveats

• Thyroid storm is an absolute contraindication to starting atomoxetine until the crisis is resolved, given the extreme hypermetabolic state and cardiovascular instability 1
• There is no direct pharmacologic interaction between atomoxetine and thyroid hormones or antithyroid medications 5
• Atomoxetine does not affect peripheral endocrine glands directly 5

Pregnancy Considerations

• If the patient is pregnant with Graves' disease, atomoxetine does not appear to cause major congenital malformations, though data are limited 1, 5
• Pregnant women with Graves' disease require specialized monitoring regardless of ADHD medication use 1