Managing Alcohol Withdrawal in Patients Taking Strattera (Atomoxetine)
Continue atomoxetine during alcohol withdrawal management and treat the withdrawal syndrome with benzodiazepines as first-line therapy, using short-acting agents (lorazepam or oxazepam) if liver dysfunction is present. There is no contraindication to continuing atomoxetine during alcohol withdrawal, and benzodiazepines remain the gold standard treatment regardless of concurrent ADHD medications 1, 2.
Acute Withdrawal Management
First-Line Treatment: Benzodiazepines
Benzodiazepines are the gold standard for alcohol withdrawal syndrome because they prevent the most serious complications including seizures and delirium tremens 3, 1, 2.
For patients without liver disease, use long-acting benzodiazepines (diazepam or chlordiazepoxide) as they provide superior protection against seizures through gradual self-tapering 1, 2.
For patients with hepatic dysfunction, advanced age, or severe medical comorbidities, switch to short or intermediate-acting benzodiazepines (lorazepam or oxazepam) to prevent drug accumulation 3, 1, 2. Note that while short-acting agents are traditionally recommended for liver disease, controlled trials have not validated their superiority, and all benzodiazepines are affected by hepatic insufficiency 3.
Dosing Strategy
Use symptom-triggered dosing rather than fixed-dose schedules to prevent drug accumulation while ensuring adequate symptom control 3, 1.
Monitor withdrawal severity using the Clinical Institute Withdrawal Assessment for Alcohol (CIWA-Ar) scale: scores >8 indicate moderate withdrawal requiring pharmacological intervention, and scores ≥15 indicate severe withdrawal requiring aggressive treatment 1, 2.
Limit benzodiazepine treatment to 7-14 days maximum to minimize dependence risk, which is particularly important in patients with alcohol use disorder who are at higher risk of benzodiazepine abuse 1, 2.
Essential Adjunctive Treatment
- Administer thiamine (vitamin B1) prophylactically to all patients undergoing alcohol withdrawal to prevent Wernicke's encephalopathy, as 30-80% of alcohol-dependent individuals show signs of thiamine deficiency 3, 2.
Atomoxetine Considerations During Withdrawal
Safety Profile
Atomoxetine can be safely continued during alcohol withdrawal as it is a selective norepinephrine reuptake inhibitor with no significant interaction with benzodiazepines 4.
Atomoxetine is particularly appropriate for patients with substance use disorders because it has negligible abuse potential and is not a controlled substance 4.
Monitor cardiovascular parameters as atomoxetine causes statistically (though not clinically) significant increases in heart rate and blood pressure, which could be additive with withdrawal-related tachycardia and hypertension 4.
Hepatic Considerations
- If the patient has alcoholic liver disease, atomoxetine exposure will be increased due to hepatic insufficiency affecting its extensive biotransformation 4. However, this does not contraindicate its use—simply monitor for increased side effects.
Setting Determination
Treat as outpatient if: mild-to-moderate withdrawal (CIWA-Ar <15), stable medical/psychiatric status, adequate social support, and reliable supervision 1, 5, 6.
Admit to inpatient setting if: risk of severe withdrawal complications, concurrent serious physical or psychiatric disorders, inadequate social support, history of seizures or delirium tremens, or lack of reliable supervision 1, 5, 6.
Monitor outpatients daily for up to 5 days after the last drink to verify symptom improvement and evaluate need for additional treatment 6.
Critical Pitfalls to Avoid
Do not use naltrexone or disulfiram if the patient has alcoholic liver disease or cirrhosis due to hepatotoxicity risk; use acamprosate or baclofen instead for long-term relapse prevention 1.
Do not extend benzodiazepine prescriptions beyond 7-14 days as this increases dependence risk in patients already vulnerable to substance abuse 1, 2.
Do not delay thiamine administration in high-risk patients or those with suspected Wernicke's encephalopathy, as this can lead to irreversible neurological damage 1.
Do not discontinue atomoxetine abruptly as this may destabilize ADHD symptoms during an already stressful withdrawal period; atomoxetine discontinuation is generally well tolerated with low incidence of discontinuation-emergent adverse events 4.
Long-Term Management After Withdrawal
Once acute withdrawal resolves (typically 5-7 days), initiate pharmacotherapy for relapse prevention: naltrexone 50 mg daily is first-line (unless liver disease present), or acamprosate 666 mg three times daily as an alternative with no hepatotoxicity 3, 1.
For patients with cirrhosis, use baclofen 30-60 mg/day instead of naltrexone to reduce alcohol craving and maintain abstinence 3, 1.
Continue atomoxetine for ADHD management as part of comprehensive care, recognizing that untreated ADHD may increase relapse risk 4.