What is the recommended adult dose of Strattera (Atomoxetine) for treating Attention Deficit Hyperactivity Disorder (ADHD)?

Adult Dosing of Strattera (Atomoxetine)

For adults with ADHD, start Strattera at 40 mg once daily, increase after a minimum of 3 days to a target dose of 80 mg daily (either as a single morning dose or divided into morning and late afternoon/evening doses), and after 2-4 additional weeks, may increase to a maximum of 100 mg daily if optimal response is not achieved. 1

Initial Dosing

• Begin with 40 mg once daily in adults and adolescents over 70 kg body weight 1
• This starting dose applies regardless of whether you choose once-daily or twice-daily administration 1
• Atomoxetine may be taken with or without food 1

Titration Schedule

• After a minimum of 3 days, increase to the target dose of 80 mg daily 1
• Administer either as a single morning dose or as evenly divided doses in the morning and late afternoon/early evening 1
• After 2-4 additional weeks at 80 mg, may increase to 100 mg daily maximum in patients who have not achieved optimal response 1

Maximum Dosing

• The maximum recommended total daily dose is 100 mg 1
• No data support increased effectiveness at doses higher than 100 mg 1
• Single doses over 120 mg and total daily doses above 150 mg have not been systematically evaluated for safety 1

Dosing Flexibility: Once vs. Twice Daily

• Both once-daily (80 mg QD) and twice-daily (40 mg BID) dosing at the target dose are safe, well-tolerated, and efficacious 2
• Twice-daily dosing (40 mg BID) results in significantly lower nausea rates (16.4%) compared to once-daily dosing (32.4%), which may improve tolerability 2
• Once-daily morning dosing eliminates the need for workplace administration, maintaining privacy and improving adherence 3

Special Population Adjustments

Patients Taking Strong CYP2D6 Inhibitors or Known Poor Metabolizers

• Start at 40 mg/day 1
• Only increase to the usual target of 80 mg/day if symptoms fail to improve after 4 weeks AND the initial dose is well tolerated 1
• Strong CYP2D6 inhibitors include paroxetine, fluoxetine, and quinidine 1

Hepatically Impaired Patients

• Moderate hepatic impairment (Child-Pugh Class B): Reduce initial and target doses to 50% of normal 1
• Severe hepatic impairment (Child-Pugh Class C): Reduce initial and target doses to 25% of normal 1

Clinical Efficacy Data

• In two large 10-week controlled trials, atomoxetine at doses of 60-120 mg/day produced mean reductions in ADHD symptom scores of 28.3-30.1% versus 18.1-19.6% with placebo 4, 5
• Continued efficacy was demonstrated in a 34-week extension phase 4, 5
• The duration of action extends throughout waking hours, with drug effects persisting until the next morning with a single morning dose 6

Common Pitfalls to Avoid

• Do not exceed 100 mg daily as there is no evidence of increased effectiveness at higher doses 1
• Screen for bipolar disorder, mania, or hypomania (personal or family history) prior to initiating treatment 1
• Do not open capsules—they must be taken whole 1
• Atomoxetine can be discontinued without tapering 1

Monitoring Considerations

• Most common adverse events include dry mouth, insomnia, nausea, decreased appetite, constipation, dizziness, sweating, dysuria, sexual problems, and palpitations 4, 5
• Modest increases in heart rate and blood pressure occur but are generally well tolerated and gradually decrease on cessation 4, 5
• Withdrawal rates due to adverse events in clinical trials ranged from 7.8-9.3% versus 2.4-4.3% with placebo 4, 5

Key Advantages

• Atomoxetine is a nonstimulant with negligible abuse potential and is not a controlled substance, making it particularly useful in patients at risk for substance abuse 4, 5
• No evidence of rebound symptoms or acute discontinuation syndrome when stopping treatment 6
• No QT interval prolongation 4, 5