What is the recommended dosing for Strattera (atomoxetine) in a patient with 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 then 80 mg daily, with a maximum dose of 1.4 mg/kg/day or 100 mg/day, whichever is less. 1

Initial Dosing

• Begin with 40 mg orally once daily as the standard starting dose for most patients with ADHD 1
• This can be administered as a single morning dose or split into two divided doses (early morning and late afternoon/early evening) 2
• Single morning dosing is effective throughout the waking hours and extends into the evening 3, 4

Titration Schedule

• Adjust the dose every 7-14 days based on clinical response and tolerability 1
• Progress from 40 mg daily → 60 mg daily → 80 mg daily 1
• The target therapeutic dose is approximately 1.2 mg/kg/day 3
• Maximum dose is the lesser of 1.4 mg/kg/day or 100 mg/day 1

Monitoring During Titration

• Maintain weekly contact (by telephone or in-person) during initial titration and dose adjustments 1
• Systematically assess for specific side effects at each adjustment, including insomnia, anorexia, headaches, gastrointestinal symptoms, and weight loss 1
• Monitor weight regularly as decreased appetite is common 3, 4

Timeline for Therapeutic Effect

• Allow 6-12 weeks for full therapeutic effects to be observed, as atomoxetine has a slower onset compared to stimulants 1
• This is a critical pitfall to avoid—patients and families need to understand that atomoxetine does not work immediately like stimulants 1
• After dose stabilization, schedule follow-up appointments at least monthly 1

Special Populations

Preschool-Aged Children (4-5 years)

• Start with lower doses and increase in smaller increments due to slower metabolism rates 1

Adolescents

• Assess for substance abuse symptoms before initiating treatment 1
• Monitor prescription-refill requests for signs of misuse or diversion 1
• Consider longer-acting coverage for symptom control while driving 1

Clinical Context

• Atomoxetine is generally second-line therapy after stimulants, but may be first-line in specific circumstances 1:
  • Patients with comorbid substance use disorders or risk of substance abuse 1, 4
  • Patients with comorbid tic disorders or Tourette's disorder 1, 3
  • Patients who prefer a non-controlled substance 1
  • Patients with comorbid anxiety 4, 5

Treatment Failure

• If adequate symptom control is not achieved at maximum dose after 6-12 weeks, consider alternative treatments or adding non-stimulant medications 1

Key Advantages

• Negligible abuse potential and not a controlled substance 1, 4, 6
• Can be administered once or twice daily 4, 7
• No evidence of symptom rebound or acute discontinuation syndrome 3, 4
• Effective throughout the day with single morning dosing 3, 4