Can Strattera Be Prescribed for ADHD in a Patient with Seizure History on Keppra?
Yes, a healthcare provider can prescribe Strattera (atomoxetine) for ADHD in a patient with a history of seizures who is on Keppra (levetiracetam), but this requires careful monitoring and informed consent about the seizure risk.
Seizure Risk with Atomoxetine
The FDA label for atomoxetine explicitly acknowledges seizure risk. Seizures have been reported in postmarketing surveillance, including in patients with pre-existing seizure disorders, those with identified risk factors for seizures, and patients with neither history nor risk factors 1. The exact relationship between atomoxetine and seizures remains difficult to evaluate due to uncertainty about baseline seizure risk in ADHD patients 1.
Case reports document serious seizure-related adverse events with atomoxetine:
- A 17-year-old experienced a tonic-clonic seizure after atomoxetine overdose (2840 mg), though this was a supratherapeutic dose 2
- An 18-year-old on therapeutic atomoxetine (60 mg/day) developed complex partial seizures with focal EEG abnormalities and regional hypoperfusion that resolved within 48 hours of discontinuation 3
Clinical Decision Framework
When Atomoxetine May Be Appropriate
Atomoxetine is particularly useful for ADHD patients at risk of substance abuse, those with comorbid anxiety or tics, or who prefer a non-controlled substance 4. For your patient with controlled epilepsy on levetiracetam, atomoxetine can be considered if:
- Seizures are well-controlled on current antiepileptic therapy (levetiracetam) 5
- The patient has failed or cannot tolerate stimulant medications 4
- There are contraindications to stimulants (e.g., substance abuse risk, cardiovascular concerns) 4
Monitoring Requirements
If prescribing atomoxetine to this patient:
- Start at the lower end of the dosing range: 40 mg PO daily, titrating every 7-14 days to 60-80 mg/day (maximum 1.4 mg/kg/day or 100 mg/day) 6
- Ensure levetiracetam levels are therapeutic and seizures remain controlled 5
- Monitor closely for any seizure activity, particularly during dose titration 1
- Educate the patient to report immediately any new neurological symptoms (headache, sensory changes, confusion) 3
- Consider baseline and follow-up EEG if clinically indicated 3
Alternative Considerations
Stimulant medications (methylphenidate) remain first-line for ADHD and do not provoke seizures in most patients with epilepsy, though seizure frequency may increase in children with active epilepsy 7. However, atomoxetine offers advantages as a non-controlled substance with negligible abuse potential 4.
Drug Interaction Assessment
There are no significant pharmacokinetic interactions between atomoxetine and levetiracetam 1. Atomoxetine does not cause clinically important inhibition or induction of cytochrome P450 enzymes 1, and levetiracetam has minimal drug-drug interactions 5. This combination is pharmacologically compatible.
Common Pitfalls to Avoid
- Do not use atomoxetine with MAOIs or within 14 days of MAOI discontinuation due to risk of serious reactions including hyperthermia, rigidity, and autonomic instability 1
- Monitor blood pressure and heart rate, as atomoxetine causes statistically significant (though not clinically significant) increases in both parameters 4
- Be aware that CYP2D6 poor metabolizers (5-10% of population) have 6-8 fold higher atomoxetine exposure and experience more adverse effects 1, 4
- Discontinue atomoxetine immediately if seizures occur and do not rechallenge 3