What are the effects of taking 200mg of Strattera (Atomoxetine) on the body of an adult or child with Attention Deficit Hyperactivity Disorder (ADHD), particularly with regards to potential adverse effects such as nausea, headache, insomnia, tachycardia, and hypertension?

Effects of Taking 200mg Strattera (Atomoxetine)

Taking 200mg of Strattera (atomoxetine) represents a dose that is double the maximum recommended daily dose and poses significant risks for serious adverse effects, particularly cardiovascular complications, severe liver injury, and psychiatric symptoms including suicidal ideation. 1

Critical Safety Concern: Dose Exceeds Maximum

• The maximum recommended dose of atomoxetine is 100 mg/day or 1.4 mg/kg/day, whichever is lower 2, 1
• A 200mg dose represents a 100% overdose above the FDA-approved maximum 1
• Poor metabolizers of CYP2D6 (approximately 7% of the population) would experience significantly higher plasma levels and prolonged half-life at this dose, dramatically increasing adverse effect risk 2, 1

Cardiovascular Effects at Supratherapeutic Doses

At 200mg, expect substantially elevated cardiovascular risks beyond the modest increases seen at therapeutic doses:

• At therapeutic doses, atomoxetine increases heart rate and blood pressure, with average increases of 1-4 mm Hg for blood pressure 2
• At double the maximum dose, cardiovascular effects would be amplified, particularly in the 5-15% of patients who already experience substantial increases at normal doses 2
• Atomoxetine should be used with extreme caution in patients with hypertension, tachycardia, cardiovascular or cerebrovascular disease, and is contraindicated in severe cardiac or vascular disorders 1
• Risk of serious cardiovascular events including sudden death, stroke, and myocardial infarction exists even at therapeutic doses in vulnerable patients 1

Severe Liver Injury Risk

Atomoxetine carries a significant risk of severe hepatotoxicity that would be amplified at supratherapeutic doses:

• Postmarketing reports document rare cases of severe liver injury, including liver failure requiring transplantation 1
• Liver injury typically occurs within 120 days of initiation, with some patients presenting with liver enzymes >20 times the upper limit of normal and bilirubin >2 times the upper limit of normal 1
• At 200mg daily, the risk of hepatotoxicity would be substantially elevated beyond the already concerning baseline risk 1
• Immediate discontinuation is required if jaundice or laboratory evidence of liver injury develops 1

Psychiatric and Suicidal Ideation Risk

The FDA black box warning for suicidal ideation becomes particularly concerning at double the maximum dose:

• Meta-analysis of 12 placebo-controlled trials showed significantly higher incidence of suicidal ideation in children and adolescents receiving atomoxetine versus placebo 2, 1
• All patients on atomoxetine require close monitoring for suicidality, clinical worsening, and unusual behavioral changes, especially during initial treatment or dose changes 2, 1
• At 200mg, risk of agitation, irritability, hostility, impulsivity, restlessness, or mania would be substantially elevated 3, 1
• Emergent psychotic or manic symptoms are a documented risk even at therapeutic doses 2

Gastrointestinal and Systemic Effects

Common adverse effects would be significantly amplified at 200mg:

• Most common adverse effects at therapeutic doses include nausea, vomiting, decreased appetite, abdominal pain, fatigue, and somnolence 2, 1
• At double the maximum dose, expect severe nausea, vomiting, and gastrointestinal distress 2, 4, 5
• Decreased appetite and weight loss would be markedly pronounced 2, 6
• Somnolence and fatigue would likely be severe and functionally impairing 2, 6

Additional Serious Adverse Effects at Supratherapeutic Doses

• Dry mouth, insomnia, constipation, dizziness, sweating, dysuria, sexual dysfunction, and palpitations would all be amplified 4, 5
• Headaches and abdominal pain would likely be severe 2, 6
• Risk of priapism, though rare, exists and would be elevated at higher doses 2
• Allergic reactions and effects on urinary outflow are documented concerns 2

Immediate Management Recommendations

If a patient has taken or is considering taking 200mg of atomoxetine:

• Immediately discontinue the medication and do not restart at this dose 1
• Monitor vital signs closely, particularly heart rate and blood pressure 2, 1
• Obtain baseline liver function tests and monitor for signs of hepatotoxicity including pruritus, dark urine, jaundice, right upper quadrant tenderness, or unexplained flu-like symptoms 1
• Assess for cardiac symptoms including chest pain, syncope, palpitations, or other signs of cardiac disease 1
• Monitor closely for emergence of suicidal ideation, agitation, irritability, or unusual behavioral changes 1
• If therapeutic atomoxetine treatment is indicated, restart at appropriate weight-based dosing: initial dose of 40 mg daily, titrating every 7-14 days to maximum of 100 mg/day or 1.4 mg/kg/day, whichever is lower 2, 3

Common Pitfall to Avoid

• Never assume that doubling the dose will simply double the therapeutic effect—atomoxetine has a narrow therapeutic window, and doses above the maximum carry disproportionately elevated risks of serious adverse events including liver failure, cardiovascular complications, and psychiatric emergencies 1