Does atomoxetine (Strattera) need to be held on the day of surgery or anesthesia in a patient with Attention Deficit Hyperactivity Disorder (ADHD)?

Atomoxetine Does Not Need to Be Held on the Day of Surgery

Atomoxetine can be safely continued through the day of surgery and does not require preoperative discontinuation. Unlike sympathomimetic medications such as phentermine that require specific washout periods before anesthesia, atomoxetine's mechanism as a selective norepinephrine reuptake inhibitor does not pose the same perioperative cardiovascular risks.

Key Distinction from Sympathomimetic Agents

• Phentermine and similar sympathomimetic drugs must be discontinued at least 4 days before procedures requiring anesthesia due to risks of hyperadrenergic effects and paradoxical refractory hypotension from catecholamine depletion 1
• Atomoxetine operates through a different mechanism as a highly selective norepinephrine reuptake inhibitor without the direct sympathomimetic properties that create perioperative hazards 2, 3
• The drug selectively inhibits presynaptic norepinephrine reuptake in the prefrontal cortex and has little to no affinity for various neurotransmitter receptors, distinguishing it from direct-acting sympathomimetics 2

Cardiovascular Profile During Anesthesia

• Atomoxetine causes only modest, clinically insignificant increases in heart rate and blood pressure that are generally well tolerated and gradually decrease on cessation of treatment 3, 4
• The drug is not associated with QT interval prolongation, reducing concerns about cardiac arrhythmias during anesthesia 3, 4
• Unlike amphetamines that can cause catecholamine depletion, atomoxetine does not create the same risk of blunted response to intraoperative hypotension 5

Perioperative Medication Management Principles

• Psychiatric medications including antidepressants should be continued perioperatively to avoid withdrawal, with monitoring for drug interactions 6
• Long-acting sedative premedication should be avoided within 12 hours of surgery as it impairs immediate postoperative recovery, mobility, and oral intake 7
• Atomoxetine does not fall into the category of medications requiring discontinuation, as it lacks abuse potential and is not a controlled substance 2, 3

Clinical Considerations

• Abrupt discontinuation of chronic medications can be more harmful than continuation in most cases, particularly for psychiatric medications 6
• The risk-benefit analysis favors continuation, as atomoxetine withdrawal could destabilize ADHD symptoms without providing meaningful reduction in anesthetic risk 2
• Standard anesthetic monitoring and techniques are appropriate for patients taking atomoxetine, with no special precautions required beyond routine cardiovascular monitoring 7

Common Pitfall to Avoid

• Do not confuse atomoxetine with stimulant medications or sympathomimetic appetite suppressants that do require preoperative discontinuation 1
• The key distinction is that atomoxetine is a selective norepinephrine reuptake inhibitor, not a direct sympathomimetic agent or stimulant 2, 8