What starting dose of atomoxetine (Strattera) is recommended for a 42‑year‑old man with ADHD, how should it be ordered, and what baseline vital signs and laboratory tests are needed before initiating therapy?

Starting Atomoxetine (Strattera) for a 42-Year-Old Man with ADHD

For a 42-year-old man with ADHD, start atomoxetine at 40 mg once daily in the morning, increase to 60 mg after 7–14 days, then to 80 mg if needed, with a maximum of 100 mg/day; measure baseline blood pressure, pulse, height, and weight before initiating therapy. 1

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Initial Dosing and Titration Protocol

• Begin with 40 mg orally once daily in the morning for adults weighing >70 kg (which applies to most adult men). 2
• Maintain this initial dose for at least 7–14 days before increasing to assess tolerability and avoid behavioral activation or agitation that can occur with rapid dose escalation. 2
• After 7–14 days, increase to 60 mg daily, then after another 7–14 days increase to 80 mg daily if ADHD symptoms remain inadequately controlled. 2, 3
• The target therapeutic dose is 60–100 mg daily (approximately 1.2 mg/kg/day), which is necessary for optimal efficacy in most adults. 1
• The absolute maximum dose is 100 mg/day or 1.4 mg/kg/day, whichever is lower—doses above this threshold do not improve efficacy and increase adverse-effect risk. 2, 4

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How to Order the Prescription

• Write the prescription as: "Atomoxetine 40 mg capsules, take one capsule by mouth once daily in the morning. Dispense #30. Refills: 1."
• After the first 7–14 days, adjust to: "Atomoxetine 60 mg capsules, take one capsule by mouth once daily in the morning."
• If further titration is needed after another 7–14 days: "Atomoxetine 80 mg capsules, take one capsule by mouth once daily in the morning."
• Atomoxetine can be administered as a single morning dose or split into morning and evening doses to reduce adverse effects if needed, though once-daily dosing is preferred for adherence. 1, 4
• Atomoxetine is not a controlled substance, so repeat prescriptions can be processed more conveniently than stimulants. 5, 4

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Baseline Laboratory Tests and Vital Signs

Required Baseline Measurements

• Blood pressure and pulse (both seated and standing if the patient has any history of orthostatic symptoms or cardiovascular concerns). 1, 2
• Height and weight to establish baseline growth parameters and monitor for appetite suppression over time. 1, 2

No Routine Laboratory Tests Required

• No baseline laboratory tests (e.g., CBC, metabolic panel, liver function tests) are routinely required before starting atomoxetine unless clinically indicated by the patient's medical history. 1
• However, if the patient has pre-existing liver disease or takes medications that affect hepatic metabolism, consider baseline liver function tests.

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Ongoing Monitoring Requirements

• At each follow-up visit, measure blood pressure, pulse, height, and weight to detect cardiovascular effects and monitor for appetite suppression. 1, 2
• Screen systematically for suicidal ideation, clinical worsening, and unusual behavioral changes, especially during the first few months of treatment or after dose adjustments, as atomoxetine carries an FDA black-box warning for increased suicidal ideation risk in children and adolescents (though this risk is less well-established in adults, vigilance is still warranted). 1, 2
• Monitor for common adverse effects including nausea, decreased appetite, dry mouth, fatigue, abdominal pain, insomnia, dizziness, sweating, dysuria, sexual problems, and palpitations. 2, 5, 4
• Schedule follow-up visits at 2 weeks, 4 weeks, and then monthly until symptom control stabilizes, allowing timely dose adjustments. 1

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Critical Timeline Expectations

• Atomoxetine requires 6–12 weeks to achieve full therapeutic effect, unlike stimulants which work within days—set appropriate expectations with the patient about this delayed response timeline. 1, 2
• Some symptom improvement may be observed as early as the first week, but maximal benefit typically emerges after 6–12 weeks at the target dose. 1, 6
• If ADHD symptoms have not improved adequately after 6–12 weeks at 80–100 mg daily, consider switching to a stimulant medication (methylphenidate or amphetamine-based agents), as stimulants have larger effect sizes (≈1.0 vs. ≈0.7 for atomoxetine) and 70–80% response rates. 1

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Common Pitfalls to Avoid

• Do not increase the dose more frequently than every 7–14 days, as rapid titration increases the risk of behavioral activation, agitation, insomnia, and gastrointestinal side effects. 2
• Do not exceed 100 mg/day or 1.4 mg/kg/day, as higher doses do not improve efficacy and significantly increase adverse effects. 2, 4
• Do not assume atomoxetine will work as quickly as stimulants—counsel the patient that full benefit may take 6–12 weeks, and premature discontinuation due to perceived lack of efficacy is a common mistake. 1, 2
• Do not use atomoxetine as first-line therapy if the patient has no contraindications to stimulants, as stimulants are more effective (70–80% response rate, effect size ≈1.0) and work within days. 1 Atomoxetine is best reserved for patients who fail or cannot tolerate stimulants, have active substance abuse concerns, or prefer a non-controlled medication. 1, 5, 4

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Special Considerations for This Patient

• If the patient has comorbid anxiety or depression, atomoxetine may be particularly useful, as it has evidence supporting efficacy in ADHD with comorbid anxiety and does not exacerbate anxiety like stimulants might. 1
• If the patient has a history of substance abuse, atomoxetine is an excellent choice because it has negligible abuse potential and is not a controlled substance. 1, 5, 4
• If the patient has cardiovascular concerns (e.g., hypertension, tachycardia), atomoxetine causes modest increases in heart rate and blood pressure that are generally well tolerated, but close monitoring is essential. 5, 4