What is the recommended starting dose of Strattera (atomoxetine) for a 19-year-old patient with Attention Deficit Hyperactivity Disorder (ADHD)?

Strattera (Atomoxetine) Dosing for a 19-Year-Old New Patient with ADHD

Start atomoxetine at 40 mg orally once daily in the morning, then titrate to 60 mg after 7-14 days, and subsequently to 80 mg daily after another 7-14 days, with a maximum dose of 100 mg/day. 1

Initial Dosing Protocol

• Begin with 40 mg once daily as the standard starting dose for adults and patients over 70 kg 1, 2
• Administer as a single morning dose, though splitting into morning and evening doses is an option if tolerability issues arise 1
• The 40 mg starting dose applies specifically to your 19-year-old patient, as they fall into the adult weight category (>70 kg) 2

Titration Schedule

Follow this specific titration algorithm:

• Week 1-2: Maintain 40 mg daily to assess tolerability 1, 2
• Week 3-4: Increase to 60 mg daily if well-tolerated 1
• Week 5-6: Increase to 80 mg daily (target dose) if needed 1
• Maximum dose: 100 mg/day or 1.4 mg/kg/day, whichever is less 1, 2

The American Academy of Child and Adolescent Psychiatry emphasizes increasing doses in the smallest available increments at approximately 1-2 week intervals, as slow titration is generally better tolerated and helps avoid exceeding the optimal dose 2. This gradual approach is critical because behavioral activation, agitation, motor restlessness, and impulsiveness can occur early in treatment or with rapid dose increases 2.

Critical Timeline Expectations

Set realistic expectations with your patient from the outset:

• Atomoxetine requires 6-12 weeks to achieve full therapeutic effect, unlike stimulants which work within hours 2
• This delayed response timeline is essential to communicate upfront to prevent premature discontinuation 2
• Allow the full 6-12 week period at target dose (80 mg) before judging efficacy 2
• Real-world data show that underdosing (averaging ~60 mg/day instead of the recommended 80 mg target) is common and associated with poor outcomes 3

Monitoring Requirements

Establish this monitoring protocol:

• Weekly contact during initial titration and dose adjustments 1
• Systematically assess for specific side effects at each adjustment, including nausea, vomiting, fatigue, decreased appetite, abdominal pain, and somnolence 2
• Monitor closely for suicidality, clinical worsening, and unusual behavioral changes, especially during the first few months or at times of dose changes, due to the FDA black box warning for increased suicidal ideation risk 2
• Obtain baseline and monitor blood pressure, heart rate, height, and weight at follow-up visits 2
• After dose stabilization, schedule follow-up appointments at least monthly 1

Common Pitfalls to Avoid

Do not make these mistakes:

• Do not stop at 40-60 mg daily thinking this is adequate—the target dose is 80 mg for most adults, and suboptimal dosing (averaging 60 mg in real-world practice) leads to treatment failure 3
• Do not judge efficacy before 6-12 weeks at target dose—this is the most common reason for premature treatment discontinuation 2
• Do not increase doses more frequently than every 7-14 days—rapid escalation increases risk of behavioral activation and agitation, particularly in younger patients 2
• Do not assume immediate effects—unlike stimulants that work within days, atomoxetine has a fundamentally different pharmacological timeline 2

Clinical Context for This Patient

Atomoxetine positioning in treatment algorithm:

• Atomoxetine is generally second-line therapy after stimulants for ADHD, though it may be first-line in specific circumstances 1
• Consider atomoxetine as first-line if your patient has comorbid substance use disorders, tic/Tourette's disorder, prefers a non-controlled substance, or has concerns about stimulant abuse potential 1
• Atomoxetine has negligible abuse potential and is not a controlled substance, making prescription refills more convenient during long-term treatment 4, 5
• If adequate symptom control is not achieved at maximum dose (100 mg) after 6-12 weeks, consider alternative treatments or adding other medications 1

Dosing Flexibility

• Once-daily dosing in the morning is standard, but twice-daily dosing (split morning and evening) can reduce adverse effects if needed 4, 5
• Evening-only dosing is also an option if daytime side effects are problematic 1
• The medication provides "around-the-clock" symptom coverage with once-daily dosing, with effects persisting through waking hours and into the next morning 6