Strattera (Atomoxetine) Dose Titration Timeline for ADHD
For patients on Strattera 40mg daily, the dose should be increased after a minimum of 3 days to the target dose of 80mg daily, with further increases to 100mg possible after an additional 2-4 weeks if optimal response is not achieved. 1
Initial Titration Schedule
The FDA-approved dosing for patients over 70 kg (and adults) specifies:
- Start at 40mg daily
- Increase after a minimum of 3 days to target dose of 80mg daily 1
- Administer as either a single morning dose or divided into morning and late afternoon/evening doses 1
Secondary Titration Phase
If optimal response is not achieved at 80mg daily:
- Wait an additional 2-4 weeks at the 80mg dose 1
- May then increase to maximum of 100mg daily in patients without optimal response 1
- No data support increased effectiveness at doses higher than 100mg 1
Key Differences from Stimulant Medications
Atomoxetine requires substantially longer to demonstrate full therapeutic effect compared to stimulants:
- Initial improvement may be seen as early as 1 week, but full effect takes longer 2
- Median time to response (25% symptom improvement) is 3.7 weeks 2
- Probability of symptom improvement may continue increasing up to 52 weeks 2
- This contrasts sharply with stimulants, which show effects within 30 minutes and are typically titrated weekly 3
Monitoring During Titration
Assessment should include:
- Standardized ADHD rating scales (ADHD-RS or CAARS) from parents/teachers for children, or from patient/significant other for adults 3, 4
- Blood pressure, pulse, height, and weight at each visit 4
- Side effect monitoring, particularly gastrointestinal symptoms, decreased appetite, and cardiovascular parameters 5, 6
Important Clinical Considerations
Common pitfalls to avoid:
- Do not increase too rapidly - The minimum 3-day interval exists because atomoxetine's therapeutic effects are not immediate like stimulants 1
- Do not expect immediate response - Unlike stimulants that work within hours, atomoxetine's onset of action extends over weeks 3, 2
- Do not exceed 100mg total daily dose - This is the maximum recommended dose with no evidence of additional benefit at higher doses 1
Special populations requiring dose adjustment:
- Patients taking strong CYP2D6 inhibitors (paroxetine, fluoxetine, quinidine): Initiate at 40mg and only increase to 80mg after 4 weeks if symptoms fail to improve and initial dose is well tolerated 1
- Known CYP2D6 poor metabolizers: Same cautious approach as above 1
- Moderate hepatic impairment: Reduce doses to 50% of normal 1
- Severe hepatic impairment: Reduce doses to 25% of normal 1
Discontinuation
Atomoxetine can be discontinued without tapering - there is no evidence of rebound symptoms or acute discontinuation syndrome 1, 6