How to safely discontinue atomoxetine in a patient with ADHD?

How to Safely Discontinue Atomoxetine

Atomoxetine can be discontinued abruptly without tapering, as it does not cause rebound symptoms or a discontinuation syndrome. 1, 2

Evidence for Abrupt Discontinuation

• The FDA label explicitly states that "Atomoxetine capsules can be discontinued without being tapered," providing the highest level of regulatory guidance for this practice 1
• Prospective, placebo-controlled studies in both children and adults demonstrated that abrupt discontinuation after 9-10 weeks of continuous therapy did not result in statistically significant differences in discontinuation-emergent adverse events compared to placebo 2
• ADHD symptoms worsened following drug discontinuation but did not return to pretreatment levels, indicating no symptom rebound effect 2

Key Differences from Alpha-2 Agonists

This stands in stark contrast to guanfacine and clonidine, which must be tapered to avoid rebound hypertension. 3, 4

• The Pediatrics guideline society specifically warns that "rebound hypertension after abrupt guanfacine and clonidine discontinuation has been observed, these medications should be tapered off rather than suddenly discontinued" 3
• When discontinuing guanfacine, taper by 1mg every 3-7 days to prevent cardiovascular complications 4

Practical Implementation

• Simply stop atomoxetine on the chosen discontinuation date without dose reduction 1, 2
• Patients may miss occasional doses during treatment without experiencing rebound effects or discontinuation syndrome 5
• No special monitoring is required during the discontinuation period beyond standard clinical follow-up 2

What to Expect After Discontinuation

• ADHD symptoms will gradually return but typically remain below pretreatment severity levels initially 2
• The incidence of new adverse events emerging specifically from discontinuation is low and comparable to placebo 2
• Common adverse effects during treatment (decreased appetite, nausea, somnolence) will resolve after stopping the medication 3, 4

Clinical Context for Discontinuation Decisions

• If discontinuing due to inadequate response, allow 6-12 weeks for full therapeutic effect before making this determination, as atomoxetine has a delayed onset of action 4
• If switching to a stimulant medication, atomoxetine may be co-administered with methylphenidate during the transition period without undue concern for adverse events, though blood pressure and heart rate monitoring is necessary 5
• Consider alternative ADHD medications if atomoxetine is being discontinued due to tolerability issues: stimulants (methylphenidate or amphetamines) remain first-line with 70-80% response rates, or alpha-2 agonists (guanfacine or clonidine) for specific comorbidities 4, 6