What is the recommended dosing for Strattera (atomoxetine) in the treatment of Attention Deficit Hyperactivity Disorder (ADHD)?

Strattera (Atomoxetine) Dosing for ADHD

Start atomoxetine at 40 mg orally once daily, then titrate every 7-14 days to 60 mg and subsequently to 80 mg daily, with a maximum dose of 1.4 mg/kg/day or 100 mg/day, whichever is less. 1

Initial Dosing Strategy

• Begin with 40 mg orally once daily as the standard starting dose for both children and adults 1
• Atomoxetine can be administered either as a single daily dose or split into two evenly divided doses throughout the day 2, 3
• The target therapeutic dose is approximately 1.2 mg/kg/day 4

Titration Schedule

• Increase the dose every 7-14 days based on clinical response and tolerability 1
• Progress systematically: 40 mg daily → 60 mg daily → 80 mg daily 1
• Maximum dose is the lesser of 1.4 mg/kg/day or 100 mg/day 1
• For preschool-aged children (4-5 years), start with lower doses and increase in smaller increments due to slower metabolism rates 5

Monitoring Requirements

• Maintain weekly contact during initial titration and systematically assess for specific side effects at each dose adjustment 1
• Allow 6-12 weeks for full therapeutic effects to manifest, as atomoxetine has a slower onset of action compared to stimulant medications 1
• After dose stabilization, schedule follow-up appointments at least monthly 1
• Monitor heart rate and blood pressure, as atomoxetine causes statistically (though not clinically) significant increases in both parameters 2
• Screen for suicidal ideation, particularly during initial treatment, given the black-box warning for increased suicidal thoughts 2

Clinical Context and When to Use Atomoxetine

• Atomoxetine is generally second-line therapy after stimulants have been tried, though it may be first-line in specific circumstances 1
• Consider atomoxetine as first-line in patients with:
  • Comorbid substance use disorders or risk of substance abuse 5, 1
  • Comorbid tic disorders or Tourette's syndrome 1, 2
  • Comorbid anxiety disorders 2, 3
  • Preference for non-controlled substances 1, 6
  • Concerns about stimulant diversion, particularly in adolescents 5

Special Populations

Adolescents

• Assess for substance abuse symptoms before initiating treatment 5
• Monitor prescription-refill requests for signs of misuse or diversion 5
• Consider longer-acting coverage for symptom control while driving 5

Adults

• Effective doses in adults range from 60-120 mg/day 7, 6
• Adult dosing follows similar titration principles with demonstrated efficacy at these higher doses 7, 6

Important Caveats

• If no adequate symptom control is achieved at maximum dose after 6-12 weeks, consider alternative treatments or adding other non-stimulant medications 1
• Common adverse events include headache, abdominal pain, decreased appetite, nausea, vomiting, and somnolence (more common than with stimulants) 2, 4
• Initial weight and height loss may occur but typically returns to normal with long-term treatment 2
• Atomoxetine has negligible abuse potential and is not a controlled substance, making it advantageous for long-term prescription management 2, 3, 6
• Rare but serious liver injury has been reported; monitor for signs of hepatic dysfunction 2
• No symptom rebound or acute discontinuation syndrome occurs when stopping atomoxetine 2, 4