Abrupt Cessation of Strattera (Atomoxetine)
Atomoxetine can be discontinued abruptly without requiring a gradual taper, as it does not cause a discontinuation syndrome or symptom rebound. 1
Evidence for Abrupt Discontinuation Safety
The most definitive evidence comes from a prospective, placebo-controlled study specifically designed to assess discontinuation effects in both children and adults with ADHD. This study demonstrated that:
- Abrupt discontinuation of atomoxetine after 9-10 weeks of continuous therapy did not result in an acute discontinuation syndrome 1
- The incidence of discontinuation-emergent adverse events was low, with no statistically significant differences between patients abruptly stopping atomoxetine versus those continuing on placebo 1
- ADHD symptoms worsened following discontinuation but did not return to pretreatment levels (no rebound effect) 1
- Tapering of doses is not necessary when atomoxetine is discontinued 1
Contrast with Other Psychotropic Medications
This safety profile distinguishes atomoxetine from other psychotropic medications that require gradual tapering:
- SSRIs (particularly paroxetine, fluvoxamine, and sertraline) are associated with discontinuation syndrome characterized by dizziness, fatigue, nausea, insomnia, anxiety, and irritability 2
- Benzodiazepines require gradual tapering to avoid withdrawal symptoms 2
- Antipsychotics should be tapered to avoid rebound worsening of symptoms 2
Practical Clinical Considerations
Despite the evidence supporting abrupt discontinuation, some clinical guidelines recommend a more conservative approach:
- The American Academy of Child and Adolescent Psychiatry recommends gradual tapering over 1-2 weeks rather than abrupt cessation 3
- The American Academy of Pediatrics suggests that prescribers are generally encouraged to taper medication slowly, even when not strictly required 2
This conservative recommendation exists because:
- A thoughtful monitoring plan is critical to detect return of ADHD symptoms, which may take hours to days for hyperactivity symptoms but weeks to months for inattentive symptoms 2
- Gradual tapering may be prudent if it is unclear whether the current medication is having a beneficial effect 2
Cardiovascular Monitoring During Discontinuation
While atomoxetine discontinuation is safe from a withdrawal perspective, cardiovascular parameters should still be monitored:
- Heart rate and blood pressure should be monitored during the discontinuation period, as atomoxetine causes modest increases in these parameters that gradually decrease upon cessation 4, 5
- Document baseline vital signs before discontinuation 3
Common Pitfalls to Avoid
- Do not assume tapering is required based on experience with other medications – atomoxetine's unique pharmacology does not produce dependence or withdrawal 1
- Do not confuse symptom recurrence with withdrawal syndrome – ADHD symptoms may return but this represents the underlying condition, not a discontinuation reaction 1
- Do not initiate a new ADHD medication immediately without an appropriate washout period – allow at least 1 week before starting another non-stimulant 3
Algorithm for Discontinuation Decision
If discontinuing due to side effects or lack of efficacy:
- Atomoxetine may be stopped abruptly without taper 1
- Monitor cardiovascular parameters (heart rate, blood pressure) at discontinuation and 1-2 weeks after 3
- Monitor for return of ADHD symptoms over the following weeks to months 2
If discontinuing due to symptom remission:
- Consider gradual taper over 1-2 weeks to allow careful monitoring of symptom return 3
- This approach is more conservative but allows better assessment of whether continued treatment is needed 2
If patient is on multiple medications: