Strattera

(atomoxetine)

Forms/Strengths

•  Capsules: 10 mg, 18 mg, 25 mg, 40 mg, 60 mg, 80 mg, 100 mg

Dosing

• Age: ≥ 6
• Onset: ~ 60 min
• Considerations: Take the first dose on awakening. Additional doses may be given at intervals of 4-6 hours. 
• Initial Dose:
  • ≤70 kg: 0.5 mg/kg/day (1 or 2 divided doses)
  • >70 kg: 40 mg daily
    
• Titration:
  • ≤70 kg: After at least 3 days at the initial dose, increase to approximately 1.2 mg/kg/day.
  • >70 kg: After at least 3 days at 40 mg/day, increase to 80 mg/day. If no improvement after 2-4 weeks, may increase up to 100 mg/day.
    
• Max Dose:
  • ≤70 kg: lesser of 1.4 mg/kg/day or 100 mg/day
  • >70 kg: 100 mg/day

Quick Facts

• Selective norepinephrine reuptake inhibitor; increases synaptic NE and indirectly boosts dopamine in the prefrontal cortex
• Non-stimulant ADHD option; improves focus, attention, and impulse control
• Oral capsule; weight-based, typically once-daily dosing
• Common side effects: decreased appetite, nausea, dry mouth, fatigue, mood swings
• Monitor for suicidal ideation in pediatric patients; consider liver function checks

Indications

•  ADHD (ICD-10: F90.0)

Off-Label Uses

• Coexisting Anxiety or Tic Disorders: Used off-label in patients with ADHD who may have anxiety or tic disorders, as an alternative to stimulants.
• Oppositional Defiant Disorder (ODD): May help reduce irritability and impulsiveness when comorbid with ADHD.
• Autism Spectrum Disorder (ASD)-associated ADHD symptoms: Sometimes considered when stimulants are not tolerated.
• Substance Use Disorder in ADHD patients: Considered when stimulant misuse is a concern.

How to Take

• Take once or twice daily, with the first dose in the morning; if a second dose is needed, take it in the late afternoon.
• Can be taken with or without food; taking with food may help reduce nausea.
• Swallow the capsule whole; do not crush, chew, or open.
• If a dose is missed, take it as soon as possible unless it is close to the next dose—do not double up.
• Do not abruptly stop taking; consult a healthcare provider before discontinuation. 

Side Effects

•  Common: Somnolence, gastrointestinal symptoms, decreased appetite.
• Serious: Increased heart rate and blood pressure, suicidal thoughts (black box warning), rare cases of hepatitis

Monitoring / Labs

• Cardiovascular: Baseline and routine monitoring of heart rate and blood pressure.
• Growth in Pediatrics: Regular monitoring of height and weight to detect growth suppression.
• Psychiatric Symptoms: Observe for mood changes, anxiety, or psychosis.
• Abuse Potential: Monitor for misuse or diversion.

Education

• When to Call the Doctor:

  • Severe mood changes, aggression, or suicidal thoughts.
  • Symptoms of liver dysfunction (yellowing of the skin/eyes, dark urine, persistent nausea).
  • Unusual bruising or bleeding.
  • Severe dizziness, fainting, or difficulty urinating.
  • Chest pain, rapid heartbeat, shortness of breath (cardiovascular concerns).

• Safety Tips:

  • Monitor blood pressure and heart rate, as Strattera may cause increases.
  • Use caution in patients with a history of depression, bipolar disorder, or suicidal thoughts.
  • Avoid alcohol, as it may increase drowsiness and liver toxicity risk.
  • May cause drowsiness; use caution when driving or operating heavy machinery.
  • Tapering may be needed when discontinuing to prevent withdrawal effects.

• Parent Tips for Pediatric Patients:

  • Monitor for behavioral changes, increased agitation, or suicidal thoughts, particularly in the first few weeks.
  • May cause drowsiness or fatigue—observe how the child responds to the medication.
  • Encourage hydration and balanced meals to minimize side effects.
  • If taken for ADHD, track progress with teachers and caregivers to assess effectiveness.

Additional Information

• Contraindications:

  • Hypersensitivity to atomoxetine or formulation components.
  • Use within 14 days of MAOI therapy (risk of hypertensive crisis).
  • Severe cardiovascular disease, including history of stroke or arrhythmia.
  • Narrow-angle glaucoma.

• Pregnancy:

  • Category C; use only if benefits outweigh risks.
  • Limited human data; animal studies suggest potential fetal harm.

• Lactation:

  • Unknown if excreted in breast milk; use with caution.

• Drug Interactions:

  • CYP2D6 inhibitors (e.g., fluoxetine, paroxetine) may increase atomoxetine levels.
  • Serotonergic drugs (e.g., SSRIs, SNRIs, MAOIs) increase serotonin syndrome risk.
  • Albuterol and other stimulants may enhance cardiovascular side effects.
  • Antihypertensive medications may lead to excessive blood pressure lowering.