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# Atomoxetine (Strattera)
## Overview
Atomoxetine is a non-stimulant, selective norepinephrine reuptake inhibitor (SNRI) used primarily for the management of ADHD. Unlike stimulants, it is non-habit forming and has no potential for abuse.
## Primary Indications
Attention-Deficit/Hyperactivity Disorder (ADHD) in children, adolescents, and adults.
## Adult Dosing
Initiate at 40 mg/day for 7 days. Increase to a target maintenance dose of 80 mg/day (given once daily in the morning or as divided doses BID). Maximum dose is 100 mg/day.
## Pediatric Dosing
Patients $\leq$ 70 kg: Initiate at 0.5 mg/kg/day for 7 days. Increase to target of 1.2 mg/kg/day. Maximum 80 mg/day.
Patients > 70 kg: Follow adult dosing schedule.
## Dose Adjustments
* **Hepatic Impairment:** Reduce starting and target doses by 50% in patients with moderate impairment (Child-Pugh Class B) and by 75% in patients with severe impairment (Child-Pugh Class C).
* **Potent CYP2D6 Inhibitors (e.g., fluoxetine, paroxetine):** In patients stably dosed on atomoxetine, reduce dose if inhibitors are started. If starting atomoxetine in patients already on these inhibitors, consider a lower starting dose and monitor clinical response closely.
## Contraindications
Hypersensitivity; concurrent use or use within 14 days of a Monoamine Oxidase Inhibitor (MAOI); narrow-angle glaucoma; history of pheochromocytoma; severe cardiovascular disorders (e.g., severe hypertension, tachycardia, or structural heart disease where increases in BP/HR would be dangerous).
## Adverse Effects
* **Common:** Dry mouth, insomnia, nausea, decreased appetite, constipation, fatigue, erectile dysfunction, urinary hesitancy.
* **Serious:** Severe liver injury (rare), suicidal ideation (especially in children/adolescents), orthostatic hypotension, tachycardia, and priapism.
## Key Drug Interactions
* **MAOIs:** Risk of hypertensive crisis.
* **CYP2D6 Inhibitors:** Significantly increase atomoxetine plasma concentrations.
* **Beta-agonists (e.g., albuterol):** May increase cardiovascular effects (tachycardia/BP elevation).
* **Antihypertensives:** Potential for antagonizing blood pressure-lowering effects.
## Monitoring
* Monitor blood pressure and heart rate periodically.
* Monitor for signs of suicidal ideation or unusual behavioral changes.
* Monitor height and weight in pediatric patients.
* Assess for jaundice or RUQ pain (rare hepatotoxicity).
## Clinical Pearls
* **Onset:** Therapeutic effects may take 2–4 weeks; full clinical response can take up to 6–8 weeks of consistent dosing.
* **Administration:** Can be taken with or without food. Do not open capsules; the powder is a severe ocular irritant.
* **Non-stimulant:** Preferred in patients with a history of substance use disorder or significant stimulant-induced anxiety/tics.
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**Educational Disclaimer:** This information is for educational purposes. Clinical guidelines, local protocols, and individual patient variables must be considered. Always consult the most current official prescribing information (e.g., FDA package insert) or local clinical pharmacist/formulary resources before prescribing or administering medication.
