Strattera and History of Anorexia/Bulimia
Strattera (atomoxetine) is not absolutely contraindicated in patients with a history of anorexia nervosa or bulimia nervosa, but naltrexone-bupropion combination therapy is explicitly contraindicated in these patients due to seizure risk. 1
Key Contraindication Evidence
Naltrexone/bupropion (Contrave) carries a specific contraindication for patients with a history of anorexia or bulimia nervosa because these conditions predispose to seizures, and bupropion lowers the seizure threshold. 1 This contraindication applies to:
- Current anorexia or bulimia nervosa
- History of these disorders
- Abrupt discontinuation of alcohol, benzodiazepines, barbiturates, or antiepileptic drugs 1
Strattera-Specific Considerations
No explicit contraindication exists in guidelines or research for atomoxetine use in patients with eating disorder history. 2 However, several clinical factors warrant careful consideration:
Cardiovascular Monitoring Required
- Atomoxetine causes statistically significant increases in heart rate and blood pressure in pediatric patients 2
- Patients with bulimia nervosa are at risk for hypokalemia and hypochloremic alkalosis from purging, which can cause cardiac complications 1, 3
- ECG monitoring is recommended in patients with restrictive eating disorders or severe purging behavior 1
Weight and Appetite Effects
- Atomoxetine commonly causes decreased appetite, nausea, vomiting, and abdominal pain 2
- Initial weight loss occurs with atomoxetine treatment, though this eventually normalizes long-term 2
- In patients with active or recent anorexia nervosa, atomoxetine's appetite-suppressing effects could worsen nutritional status 1
Clinical Decision Algorithm
For patients with REMOTE history (>1 year remission) of anorexia/bulimia:
- Atomoxetine may be used with close monitoring 2
- Obtain baseline ECG, vital signs, and weight 1
- Monitor weight, appetite, heart rate, and blood pressure at each visit 2
For patients with RECENT history (<1 year) or active symptoms:
- Prioritize weight restoration and eating disorder treatment first 1
- Defer ADHD pharmacotherapy until nutritional rehabilitation is achieved 1
- If ADHD treatment is urgent, consider non-stimulant alternatives that don't suppress appetite 2
For patients with current purging behaviors:
- Check electrolytes (potassium, chloride) before initiating atomoxetine 1, 3
- Obtain baseline and follow-up ECG due to combined cardiac risks 1, 3
- Monitor electrolytes monthly if purging continues 3
Critical Safety Monitoring
Required assessments before and during atomoxetine treatment in this population:
- Baseline: ECG, vital signs with orthostatic measurements, weight, BMI, electrolytes 1, 3
- Weekly initially: Weight, vital signs, eating behaviors, purging frequency 3
- Monthly: Electrolytes if any purging behavior present 3
- Ongoing: Screen for suicidal ideation (black box warning for atomoxetine) 2
Red flags requiring immediate discontinuation: