What is the recommended dosing for Strattera (atomoxetine)?

Strattera (Atomoxetine) Dosing

Start atomoxetine at 40 mg once daily in adults and patients over 70 kg, or 0.5 mg/kg/day in children and adolescents up to 70 kg, then increase after a minimum of 3 days to a target dose of 80 mg daily (or 1.2 mg/kg/day), with a maximum of 100 mg daily. 1

Initial Dosing

Children and Adolescents ≤70 kg

• Starting dose: 0.5 mg/kg/day 1
• Target dose: 1.2 mg/kg/day after minimum 3 days 1
• Maximum dose: 1.4 mg/kg/day or 100 mg daily, whichever is less 1
• Can be given as single morning dose or divided into morning and late afternoon/evening doses 1

Children and Adolescents >70 kg and Adults

• Starting dose: 40 mg once daily 1
• Target dose: 80 mg daily after minimum 3 days 1
• Maximum dose: 100 mg daily after 2-4 additional weeks if optimal response not achieved 1
• No data support increased effectiveness at doses higher than the target 1

Titration Guidelines

Increase doses slowly at 1-2 week intervals using the smallest available increments to minimize behavioral activation and optimize tolerability. 2

• Maintain initial dose for at least 1-2 weeks before increasing 2
• Increase by small increments (typically 10-25 mg) no more frequently than every 1-2 weeks 2
• Rapid dose escalation can cause behavioral activation, agitation, motor restlessness, insomnia, impulsiveness, and aggression, particularly in younger patients 2
• If side effects occur, return to the previous well-tolerated dose 2

Special Populations

Hepatic Impairment

• Moderate hepatic insufficiency (Child-Pugh Class B): Reduce initial and target doses to 50% of normal 1
• Severe hepatic insufficiency (Child-Pugh Class C): Reduce initial and target doses to 25% of normal 1

CYP2D6 Poor Metabolizers or Concurrent Strong CYP2D6 Inhibitors

When using strong CYP2D6 inhibitors (paroxetine, fluoxetine, quinidine) or in known CYP2D6 poor metabolizers:

• Children/adolescents ≤70 kg: Start at 0.5 mg/kg/day, increase to 1.2 mg/kg/day only if symptoms fail to improve after 4 weeks and initial dose is well tolerated 1
• Children/adolescents >70 kg and adults: Start at 40 mg/day, increase to 80 mg/day only if symptoms fail to improve after 4 weeks and initial dose is well tolerated 1

Administration Details

• Can be taken with or without food 1
• Capsules must be swallowed whole, not opened 1
• Can be discontinued without tapering 1
• Single doses over 120 mg and total daily doses above 150 mg have not been systematically evaluated 1

Timeline for Response

Set appropriate expectations: atomoxetine requires 6-12 weeks to achieve full therapeutic effect, unlike stimulants which work within hours. 2

• This delayed response timeline is critical for patient adherence 2
• Symptoms typically return upon discontinuation 2

Safety Monitoring

• Screen for personal or family history of bipolar disorder, mania, or hypomania before initiating 1
• Monitor closely for suicidality, clinical worsening, and unusual behavioral changes, especially during the first few months or with dose changes 2
• Monitor blood pressure and heart rate at baseline, 1 week, and with each dose adjustment 3
• Common adverse effects include nausea, vomiting, fatigue, decreased appetite, abdominal pain, and somnolence 2