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Figure 1: Atomoxetine hydrochloride. References 1 Elia, J. Author information Affiliations Decision Resources Inc. View author publications. Rights and permissions Reprints and Permissions. Paroxetine increased the maximum concentration of atomoxetine by 3. There was no change in paroxetine level with the addition of atomoxetine Belle et al It is recommended to begin treatment at standard doses but pursue further dose increases with caution.

Inducers of this system include dexamethasone and rifampin. No studies were found that examine the interaction between atomoxetine and 2D6 inducers. Atomoxetine has not been shown to have an effect on the metabolism of other medications metabolized through 2D6. Administration with a monoamine oxidase inhibitor or within 2 weeks of administration of this agent is contraindicated because of the risk of a hypertensive crisis Eli Lilly Administration with methylphenidate does not appear to increase the risk of cardiovascular problems more than can occur with methylphenidate alone, but there is limited research on this combination.

A case report reviewed 4 cases in which patients received a combination of atomoxetine with a stimulant medication 3 patients on a mixed amphetamine salt and 1 patient on OROS methylphenidate.

In 2 cases the atomoxetine was added to the stimulant medication when the patient had difficulty with complete coverage of ADHD symptoms throughout the day. In the other 2 cases a stimulant medication was added to atomoxetine when a partial benefit was observed at a maximum dose of atomoxetine. In all 4 cases, improvement in functioning was reported with no evidence of significant adverse events Brown A randomized, double-blind, placebo study was conducted on patients ages 7—17 with ADHD and concomitant anxiety or depression.

Patients received fluoxetine or placebo for 8 weeks in conjunction with atomoxetine the last 5 weeks. Reductions in ADHD, depressive symptoms, and anxiety symptoms were marked in both treatment groups.

Overall, the combination of fluoxetine and atomoxetine was well tolerated, although this group had greater increases in blood pressure and pulse compared with the atomoxetine-only group Kratochvil et al Atomoxetine is given at a target dose of 1.

It is recommended to begin at 0. Medication effect may take up to 4 weeks to occur. Patients should be monitored for medication effect via rating scales completed initially at 4 weeks. Weight, height for growing children and adolescents , blood pressure, and pulse should be monitored at every visit.

Liver function tests are indicated if there is report of fatigue, jaundice, right upper quadrant pain, or flu-like illness. If the patient has pre-existing hypertension, tachycardia, or cardiovascular disease additional caution is advised, as atomoxetine has not been studied in patients with these conditions and the medication is known to slightly increase blood pressure and pulse.

The medication should not be administered in conjunction with a monoamine oxidase inhibitor. While there are no specific recommendations when atomoxetine is given with albuterol or stimulant medication, careful monitoring of cardiovascular function is recommended. Because of concerns about mydriasis, atomoxetine is contraindicated in patients with narrow-angle glaucoma.

There have been no controlled studies on the use of atomoxetine in pregnancy. Atomoxetine is currently a category C medication for use in pregnancy.

In a randomized, double-blind, placebo-controlled trial of children with ADHD, morning vs evening dosing of atomoxetine for 6 weeks was evaluated. Both groups responded significantly better than those on placebo. At this time, the importance of timing of dose, if any, is not clear. In contrast, a second study that analyzed response to morning vs evening dosing of atomoxetine, found the evening dose was reported as better tolerated.

Both groups demonstrated a positive response to medication Kelsey et al While plasma levels of atomoxetine are not currently used to direct dosing, a recent study found a correlation between atomoxetine level and response to medication. It was noted that in 1 patient, this required a daily dose of 2.

In a prospective, placebo-controlled trial of atomoxetine in children and adults, patients were monitored for changes in symptoms and adverse events after discontinuation of atomoxetine. There was no evidence of a discontinuation syndrome.

Symptoms of ADHD were noted to worsen but not return to pretreatment levels of severity Wernicke et al Atomoxetine is a novel compound that has clinical utility both for children and adults with ADHD.

It is unclear at this time whether atomoxetine is also effective in the treatment of anxiety or depression. Data are also mixed as to whether children with comorbid ODD demonstrate improvement of oppositional behaviors secondary to a medication trial. Further research is needed on efficacy of atomoxetine in special populations with attentional problems such as patients with epilepsy or autism spectrum disorders.

Benefits specific to atomoxetine include the once-daily dosing, sustained medication effect, and lack of risk for abuse. It is generally well tolerated, with the most common side-effects including appetite suppression, mild weight loss, and nausea. Serious but rare potential side-effects may include agitation, irritability, elevated liver enzymes, rash, tics, and suicidal ideation.

Further research into the pharmacodynamics and safety of the medication is indicated. Additional data on the safety of long term use are not currently available. Atomoxetine is a useful addition to nonstimulant treatment options for patients with ADHD who have not responded to stimulant medication or are unable to tolerate problematic side-effects.

Atomoxetine should also be considered an alternative in patients with ADHD and a history of substance abuse. Disclosures The author has no conflicts of interest to disclose. National Center for Biotechnology Information , U. Journal List Neuropsychiatr Dis Treat v. Neuropsychiatr Dis Treat. Marcialee Ledbetter. Author information Copyright and License information Disclaimer.

All rights reserved. This article has been cited by other articles in PMC. Abstract Attention deficit hyperactivity disorder ADHD is a common chronic condition with childhood onset that can continue into adulthood. Keywords: atomoxetine, ADHD, review, nonstimulants. Pharmacology Pharmacokinetics Atomoxetine is absorbed through the gastrointestinal tract with peak levels in 1. Future research will establish if CYP2D6 genotyping will be a useful tool for determining appropriate dosing schedules for patients taking atomoxetine deLeon et al The pharmacokinetics of atomoxetine in the child and adolescent population were studied in 21 patients aged 7—14 identified as extensive metabolizers of CYP2D6.

Pharmacodynamics The noradrenergic system is important for sustained attention, learning, memory, and adaptive response. Efficacy studies The drug development of atomoxetine for the treatment of ADHD in adults, adolescents, and children proceeded methodically, with the initial trials in adults followed by open-label safety trials in children.

Open trials An open-label trial with 10 male subjects, ages 9—14 was conducted over 10 weeks. Controlled trials Adults A double-blind, placebo-controlled crossover study of atomoxetine was completed in 22 adults with a diagnosis of ADHD. Children and adolescents The earliest controlled studies in patients under age 18 were completed in with proof-of-concept studies. Very slight but statistically significant increases in diastolic blood pressure and pulse were noted Spencer, Heiligenstein, et al A double-blind, placebo study was completed with children and adolescents, ages 6—16 years.

Safety Atomoxetine has been shown to be a well-tolerated and safe medication alternative to the stimulants for the treatment of ADHD. Side-effects The most common side-effects include headache, abdominal pain, nausea, vomiting, decreased appetite, weight loss, irritability, insomnia, and sedation. Overdose There is at least 1 report of significant complications from atomoxetine overdose.

Drug interactions Because atomoxetine is metabolized through the CYP2D6 system, interactions can occur with medications that are inhibitors of this system such as paroxetine, fluoxetine, and quinidine. Dosage—administration Atomoxetine is given at a target dose of 1. Conclusion Atomoxetine is a novel compound that has clinical utility both for children and adults with ADHD.

Open in a separate window. Footnotes Disclosures The author has no conflicts of interest to disclose. J Clin Psychiatry.

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In the clinical trials for atomoxetine in children and adolescents, the most common side effects reported were upset stomach, decreased appetite, nausea or vomiting, dizziness, tiredness, and mood swings. In the clinical trials in adults, the most common side effects reported were constipation, dry mouth, nausea, decreased appetite, dizziness, sexual side effects, and problems passing urine. Atomoxetine must be dispensed with a patient Medication Guide that describes the drug's uses and warnings.

This medication has a boxed warning for the increased risk of suicidal ideation in children and adolescents.