Strattera for ADHD

Strattera is the brand name for atomoxetine, a selective norepinephrine reuptake inhibitor used to treat ADHD. This means that which means it increase the amount of norepinephrine available for cell singling, especially in the prefrontal cortex, which is the part of the brain that often has deficits in those with ADHD. It can also help treat anxiety. Strattera is FDA approved for use in individuals ages 6 and older with ADHD. It has a similar mechanism of action to the recently released viloxazine (brand name Qelbree), also approved to treat ADHD.

What are the downsides to Strattera compared to stimulants when treating ADHD?
-Takes weeks to know if it will help ADHD (up to 10 weeks). 
-Helps with ADHD in 30-50% of patients who try it, whereas stimulants help in > 70% of patients who try them. 
-Has to be taken daily whereas stimulants can be taken as needed and skipped whenever you want. 

What are the upsides to Strattera compared to stimulants when treating ADHD? 
‍-It helps focus 24 hours per day (it doesn’t stop working midway through the day, as stimulants often do), 
-It usually doesn’t interfere with sleep (it does inly in 10% of cases) It helps to treat anxiety as well as ADHD (as opposed to stimulants which can sometimes worsen anxiety) 
-It tends to be a less of a problem in terms of irritability (for some, stimulants can cause irritability when taken or when they wear off) 
-It has a much lower chance of causing tics than stimulants do 
-It has little to no abuse potential, as it does not increase dopamine in the striatum, as stimulants do. For this reason it is often considered 1st line treatment for those who have abused stimulants in the past but need something for ADHD. 

What aspects of ADHD can Strattera help? 
-Distractability
-Impulsivity
-Hyperactivity
-Inattentiveness
-Poor Focus

How does Strattera work?
‍Strattera works in the prefrontal cortex of the brain. The Prefrontal cortex is located at the front of the frontal lobe, and it helps with a variety of complex behaviors including planning, behavior regulation, thought, emotion, and even personality development. The prefrontal cortex keeps your brain from wandering into distractions, rushing in on impulse, or getting stuck in compulsions – two things that don’t work well in untreated ADHD. 

Can it help anxiety too?
‍Yes, it definitely does. Multiple studies have shown it can benefit anxiety, including social anxiety. 

How long will it take to work?
‍Symptom reduction can occur in just days but more commonly it takes weeks. In some cases it takes up to 12 weeks to really know if it's effective or not. The final dose of Strattera is determined through titration (slowly increasing the dose and weighing benefits against side effects) and a thorough re-assessment of the symptoms your provider was initially aiming to treat. Strattera is available from 10mg up to a maximum dose of 100mg. Dosing in children is determined by weight. This medication can be taken once daily in the morning or it can be divided into 2x per day dosing if there is too much stomach upset on a higher dose. If it causes fatigue it can even be given at night.

What are the potential side effects? 
decreased appetite
increased heart rate
increased blood pressure
dizziness
fatigue (1/20 risk)
insomnia
Extremely rare but possible based off of case reports: Urinary retention, Seizures, Liver enzyme elevation— not enough to warrant monitoring liver enzymes, Tics, Glaucoma 
There is a black box warning about suicidal ideation because of some theoretical increased suicidal thinking in the 1st study that led to its approval. However other studies that have come after didn't show that risk. But we still need to watch for it.

How is Strattera dosed in adults? 
To start: 25mg/day x 10 days then 50mg/day x 10 days. Follow up on Spruce before running out and then IF NEEDED we can increase to 80mg per day for one month. Typically, we feel that it is best to meet for a session after being on that dose for one month and discuss whether or not to remain at 80mg vs increase to the maximum dose of 100mg.

How is Strattera dosed in children 14 and under?
‍It is weight based and to start: 0.23mg/pound per day. Usually we aim for a dose that works but we often increase to 0.55mg/pound per day. The maximum dosing for children/adolescents is 0.64mg/pound per day

Can Strattera be combined with stimulants? 
Yes, that is sometimes done and can help with tough to treat cases or where you need some ADHD treatment in the evenings, when stimulants have stopped working, or the mornings, before stimulants kick in. It also can lead to a lowering of the doses of stimulants in clients who can’t tolerate higher doses. 
In these cases more careful monitoring of heart rate & blood pressure needs to be done. 

What other medications can cross-react with Strattera?
‍Strattera is broken down in the liver by 2D6 enzymes. Some medications that can interrupt this include: 
-Fluoxetine/Prozac
-Paroxetine/Paxil 
-Duloxetine/Cymblta 
-High dose Sertraline/Zoloft (>150mg)
It is also true that some clients are slow 2D6 metabolizers to begin with so you can get genetic testing to see but it is not 100% necessary as this is why we start low and go slow. 

Can Strattera lead to weight loss?
‍Yes in some clients it can. But the appetite suppression is usually not as intense as it is with stimulants. 
There is evidence it can help in binge-eating disorder.