Can a patient with hypertension on sertraline start Strattera (atomoxetine) at 20mg?

Can You Start Strattera at 20mg in a Patient with Hypertension on Sertraline?

Yes, you can start Strattera (atomoxetine) at 20mg in a patient with controlled hypertension on sertraline, but only after confirming blood pressure is well-controlled (target <130/80 mmHg) and establishing baseline cardiovascular parameters including blood pressure and heart rate. 1

Prerequisites Before Starting Atomoxetine

Blood pressure must be optimally controlled before initiating atomoxetine. The target is <130/80 mmHg for adults under 65 years. 2, 1 If blood pressure is not at goal, optimize antihypertensive therapy first using:

• ACE inhibitors, ARBs, calcium channel blockers, or thiazide/thiazide-like diuretics as first-line agents 2
• Combination therapy is recommended for most patients with confirmed hypertension (BP ≥140/90 mmHg) 2

Establish baseline measurements before starting atomoxetine: 1

• Blood pressure and heart rate (mandatory)
• Height and weight (to monitor for appetite/weight changes)
• Document any history of cardiovascular disease, arrhythmias, or seizures

Why Atomoxetine is Appropriate for This Patient

Atomoxetine is specifically recommended as a first-choice non-stimulant option for patients with controlled hypertension because it has minimal impact on blood pressure compared to stimulants. 1 This makes it safer than methylphenidate or amphetamine-based medications, which can worsen blood pressure control. 1

Key advantages in hypertensive patients:

• Atomoxetine causes only statistically (not clinically) significant increases in blood pressure and heart rate 3
• It provides 24-hour symptom control with once-daily dosing 1
• No abuse potential and not a controlled substance 3, 4

Dosing Strategy

Starting at 20mg daily is below the typical initial dose but may be appropriate for cautious initiation. Standard dosing recommendations are:

• Adults: Initial dose typically 40mg/day for 3 days, then increase to target of 80mg/day 4
• Can be given as single morning dose or divided into two doses 3, 4
• Maximum dose: 100mg/day in adults 4

Starting at 20mg allows you to assess tolerability before reaching therapeutic doses, which is reasonable given the patient's hypertension.

Monitoring Requirements

Check blood pressure and heart rate at each dose adjustment. 1 Specifically:

• Recheck BP after at least 2 weeks of any dose change 1
• Ensure BP remains <130/80 mmHg during atomoxetine therapy 1
• Monitor for modest increases in heart rate (typically 1-2 bpm) and blood pressure (1-4 mmHg) 3

Managing Blood Pressure Elevations if They Occur

If blood pressure rises above target while on atomoxetine: 1

1. First, optimize antihypertensive therapy by adding a second agent (calcium channel blocker or thiazide diuretic) rather than discontinuing atomoxetine 1
2. If on single agent, advance to combination therapy with RAS blocker + CCB or thiazide diuretic 2
3. If already on two drugs, advance to three-drug combination (RAS blocker + CCB + thiazide diuretic) 2

Drug Interaction Considerations with Sertraline

Sertraline is a moderate CYP2D6 inhibitor, which will increase atomoxetine exposure. 5 This interaction is important because:

• Atomoxetine is primarily metabolized by CYP2D6 5
• CYP2D6 inhibitors like sertraline reduce atomoxetine clearance, similar to effects seen in poor CYP2D6 metabolizers 5
• This results in approximately 10-fold higher steady-state plasma concentrations 5

Practical implications:

• The 20mg starting dose is actually appropriate given the sertraline interaction, as it accounts for reduced atomoxetine clearance
• Titrate more slowly than usual due to increased atomoxetine exposure
• Monitor more closely for adverse effects (nausea, dry mouth, constipation, urinary retention) 4, 6
• The frequency and severity of adverse events are similar regardless of CYP2D6 phenotype, so this interaction is manageable 5

Critical Precautions

Atomoxetine should be used with caution in patients with hypertension or any significant cardiovascular disorder. 6 Specifically:

• Do not use in patients with uncontrolled hypertension 7
• Monitor blood pressure throughout treatment, not just at initiation 7
• Avoid in patients with narrow-angle glaucoma, urinary outflow obstruction, or severe cardiovascular disease 7, 6

Do not combine multiple RAS blockers (e.g., adding another ACE inhibitor or ARB to existing therapy), as dual renin-angiotensin system blockade provides no benefit and increases adverse events. 2, 1

Common Pitfalls to Avoid

• Do not start atomoxetine if blood pressure is uncontrolled (≥140/90 mmHg or above individualized target). Optimize antihypertensive therapy first. 1
• Do not ignore the sertraline-atomoxetine interaction. The reduced clearance means lower doses may be therapeutic, and side effects may be more pronounced. 5
• Do not discontinue antihypertensive therapy when starting atomoxetine. Maintain current blood pressure medications and adjust only if BP becomes too low or too high. 1
• Do not assume stimulants are equivalent alternatives. Stimulants (methylphenidate, amphetamines) cause more pronounced blood pressure increases and are explicitly listed as medications that elevate blood pressure. 1, 8