Switching from Strattera to Qelbree in Children and Adolescents with ADHD
Strattera (atomoxetine) can be stopped abruptly without tapering when switching to Qelbree (viloxazine), as neither medication requires gradual discontinuation—unlike alpha-2 agonists which must be tapered to avoid rebound hypertension. 1
Direct Switching Protocol
Stop Strattera and start Qelbree the next day without any washout period or overlap. This approach is safe because:
- Atomoxetine does not cause withdrawal symptoms or rebound effects upon cessation 2, 3
- Viloxazine does not require tapering when discontinued 1
- Both medications work through norepinephrine mechanisms, making direct switching pharmacologically reasonable 4, 5
Qelbree Initiation Strategy
Start viloxazine at the FDA-approved initial dose based on weight:
- 100 mg once daily for patients weighing <40 kg 4
- 200 mg once daily for patients weighing ≥40 kg 4
- Administer in the morning with or without food 5
Titrate weekly by 100 mg increments based on response and tolerability, up to maximum doses of 400-600 mg daily depending on weight 4, 5
Critical Timeline Expectations
Counsel families that viloxazine requires 2-4 weeks before clinical benefits become apparent, unlike stimulants which work immediately 1. This delayed onset is similar to atomoxetine's median response time of 3.7 weeks 6, so patients switching from Strattera should already understand this concept.
Monitor ADHD symptoms systematically at each dose adjustment using standardized parent and teacher rating scales 7
Efficacy Comparison
Both medications are nonstimulants with effect sizes around 0.7, which is lower than stimulants (effect size ~1.0) but clinically meaningful 8, 4. Viloxazine demonstrated efficacy in placebo-controlled trials in children and adolescents before its adult approval 5, while atomoxetine has decades of pediatric data 2, 3.
Monitoring Parameters During Transition
Check the following at baseline and after each dose adjustment:
- ADHD symptom severity using validated rating scales 7
- Cardiovascular parameters (blood pressure and heart rate), though viloxazine does not cause the hypotension/bradycardia seen with alpha-2 agonists 1
- Appetite and weight, as both medications can cause decreased appetite 3, 5
- Sleep patterns and somnolence 3, 5
Common Adverse Effects to Anticipate
Viloxazine's adverse event profile includes:
- Somnolence/fatigue (similar to atomoxetine) 3, 5
- Decreased appetite and potential weight loss 5
- Gastrointestinal symptoms (nausea, abdominal pain) 3, 5
- Headache 3, 5
These side effects are generally mild to moderate and often transient 2, 3
When to Consider This Switch
Appropriate clinical scenarios for switching from Strattera to Qelbree include:
- Inadequate symptom control despite optimal atomoxetine dosing (1.2 mg/kg) 2
- Intolerable side effects from atomoxetine 3, 6
- Patient/family preference for a newer nonstimulant option 4
- Continued need to avoid stimulants due to substance abuse risk, comorbid tics, or severe anxiety 8, 6
Critical Pitfalls to Avoid
Do not taper atomoxetine unnecessarily—this only delays the switch without providing clinical benefit, as atomoxetine lacks discontinuation syndrome 2, 3
Do not expect immediate improvement—both the family and prescriber must understand that nonstimulants require weeks to months for full therapeutic effect 6, 5
Do not abandon nonstimulants prematurely if response is suboptimal—consider combination therapy with stimulants, as atomoxetine has been shown safe and effective when combined with stimulants 6, and both guanfacine and clonidine are FDA-approved for adjunctive use 8, 7
If viloxazine proves inadequate after 4-6 weeks at optimal dosing, strongly consider trial of stimulant medications, as they remain first-line treatment with superior effect sizes 8, 4