Can a 21-year-old take Depakote (valproate) and Strattera (atomoxetine) together?

Can a 21-Year-Old Take Depakote and Strattera Together?

Yes, a 21-year-old can safely take Depakote (valproate) and Strattera (atomoxetine) together, as there are no clinically significant drug interactions between these medications. 1, 2, 3

No Pharmacokinetic Interactions

• Atomoxetine does not inhibit or induce the clearance of other drugs metabolized by cytochrome P450 enzymes, meaning it will not affect valproate metabolism 2
• Valproate is metabolized primarily through glucuronide conjugation, mitochondrial beta-oxidation, and cytochrome P450-dependent oxidation pathways that do not overlap with atomoxetine's metabolism 4
• In vitro and in vivo studies confirm that atomoxetine administration with other medications does not result in clinically significant drug interactions 3

Rationale for Combination Therapy

This combination may be clinically appropriate when treating co-occurring conditions, such as ADHD with bipolar disorder or seizure disorder. 5

• The American Academy of Child and Adolescent Psychiatry supports medication combinations used to treat multiple disorders in the same patient (e.g., a stimulant or non-stimulant for ADHD combined with a mood stabilizer for bipolar disorder) 5
• Valproate is a first-choice agent for bipolar disorder maintenance treatment and should continue for at least 2 years after the last episode 5
• Atomoxetine is particularly useful for patients with ADHD who have co-morbid conditions, as it does not exacerbate anxiety or tics and carries negligible risk of abuse 1, 6

Monitoring Requirements

Regular monitoring is essential when using this combination, with specific attention to both medications' side effect profiles. 7

For Valproate:

• Baseline and routine laboratory monitoring including liver function tests, complete blood count with platelets, and ammonia levels if encephalopathy symptoms develop 5, 4
• Monitor for gastrointestinal disturbances, tremor, weight gain, and signs of liver toxicity 4
• Women of childbearing potential require counseling about teratogenicity risk, including 1-3% risk of neural tube defects 4

For Atomoxetine:

• Monitor heart rate and blood pressure, as atomoxetine causes modest increases that are generally well tolerated 1, 6
• Watch for common adverse effects including decreased appetite, nausea, dry mouth, insomnia, and somnolence 1
• Be aware of the black-box warning for suicidal ideation, particularly during treatment initiation 1

Dosing Considerations

• Atomoxetine can be administered once or twice daily, with typical adult doses ranging from 60-120 mg/day 6
• Atomoxetine reaches steady-state plasma concentrations within 3-4 days in extensive CYP2D6 metabolizers and requires dose adjustment in poor metabolizers 2
• Valproate dosing should be individualized based on seizure control or mood stabilization needs, with therapeutic monitoring of serum levels 4

Important Caveats

The prescriber must have a clear rationale for using this medication combination and should develop a comprehensive treatment and monitoring plan. 5

• Document the specific indications for each medication (e.g., ADHD requiring atomoxetine, bipolar disorder or seizures requiring valproate) 5
• Educate the patient about both medications, their expected benefits, potential side effects, and the importance of adherence 7
• Schedule regular follow-up appointments to assess efficacy, monitor for adverse effects, and adjust treatment as needed 7
• Avoid the pitfall of using medications to address all symptom fluctuations; some behavioral changes may require psychosocial interventions rather than medication adjustments 5