What are the considerations for treating with Strattera (Atomoxetine) and stimulants concurrently?

From the Guidelines

The concurrent use of Strattera (atomoxetine) and stimulants is generally not recommended due to the potential increased risk of adverse cardiovascular effects and elevated blood pressure 1.

Key Considerations

• Cardiovascular Risks: The combination of Strattera and stimulants may increase the risk of cardiovascular events, such as elevated heart rate and blood pressure, although the overall risk is still considered low 1.
• Monitoring: Close medical supervision and regular monitoring of blood pressure, heart rate, and other vital signs are essential when considering concurrent use 1.
• Dosing: Treatment duration and dosing should be individualized and carefully titrated to minimize risks and optimize therapeutic benefits.
• Alternative Options: Non-stimulant medications like Strattera may be considered as first-line treatment options in certain cases, such as disruptive behavior disorders, tic disorder, Tourette's syndrome, and substance use disorders 1.

Special Populations

• Children and Adolescents: The use of Strattera and stimulants in children and adolescents requires careful consideration of the potential risks and benefits, including the potential for growth delays and cardiovascular effects 1.
• Comorbidities: The presence of comorbidities, such as anxiety or autism spectrum disorder, may influence the decision to use Strattera and stimulants concurrently 1.

Important Warnings

• Black Box Warning: Strattera has a black box warning for increased risk of suicidal thoughts in children and adolescents 1.
• Cardiovascular Monitoring: Clinicians should obtain a personal and family cardiac history and perform additional evaluation if risk factors are present before starting non-stimulant medications like Strattera 1.

From the FDA Drug Label

7.7 Methylphenidate Coadministration of methylphenidate with atomoxetine hydrochloride did not increase cardiovascular effects beyond those seen with methylphenidate alone. The main consideration for treating with Strattera (Atomoxetine) and stimulants (such as methylphenidate) concurrently is that coadministration did not increase cardiovascular effects beyond those seen with the stimulant alone 2.

• Key points to consider:
  • No increased cardiovascular effects were observed with concurrent use.
  • This information is based on studies with methylphenidate, a specific type of stimulant.
• Clinical decision: Strattera (Atomoxetine) can be used concurrently with stimulants like methylphenidate, but caution is still advised due to the potential for increased effects on heart rate and blood pressure.

From the Research

Considerations for Treating with Strattera (Atomoxetine) and Stimulants Concurrently

• The use of atomoxetine and stimulants concurrently is considered off-label, and the evidence for its effectiveness and safety is limited 3.
• The main reason for prescribing combination therapy is inadequate response to previous treatment, and most patients who receive combination therapy are children or adolescents with a combined ADHD subtype 3.
• Methylphenidate is most often used in combination with atomoxetine for treatment augmentation or switch, and ADHD symptom control is improved in some, but not all, patients 3.
• There are no serious adverse events reported in the studies of patients with ADHD who received combination therapy, but the evidence is limited due to the small number of publications and heterogeneous study designs 3.

Cardiovascular Effects

• Atomoxetine and stimulants have been associated with small but statistically significant increases in blood pressure and heart rate in children and adolescents with ADHD 4, 5.
• The risk of serious cardiovascular adverse events, including statistically or clinically significant increases in QTc, and sudden cardiac death associated with stimulants, atomoxetine, or α(2)-adrenergic agonists prescribed for ADHD is extremely low 4.
• However, great caution is advised when considering stimulant and non-stimulant medications for patients of any age with a diagnosis of ADHD and a personal or family history or other known risk factors for cardiovascular disease 4.

Safety and Tolerability

• Atomoxetine and stimulants have been associated with adverse events such as headache, abdominal pain, decreased appetite, vomiting, somnolence, and nausea, but most of these events are mild or moderate 6, 7.
• The majority of adverse events are not serious, and few patients discontinue treatment due to adverse events 6, 7.
• However, atomoxetine has been associated with a higher incidence of suicidal ideation than placebo, and rare cases of serious liver injury have been reported 6.