Atomoxetine
STRATTERA
Pronunciation: AT-oe-mox-e-teen (stra-TAIR-a)
“Atomic Stratosphere”
highly sensitive CYP2D6 substrate → beach ball avatar used as the main mascot
What it isNorepinephrine-predominant reuptake inhibitor with weaker serotonin activity; nonstimulant treatment of ADHD.
Why this oneNeither controlled nor readily misused, making it useful when diversion or stimulant use is a concern.
What limits itLess effective than stimulants and slow to work; CYP2D6 inhibitors or poor metabolism markedly raise exposure.
Pearls
- Usable alone or added to a stimulant.
- Rapid escalation causes nausea, vomiting and somnolence; titrate slowly.
- Small heart rate and blood pressure rises; rare hepatitis.
- Priapism more frequent than with methylphenidate.
Atomoxetine prescription history
Animated chart of estimated U.S. prescriptions per year, ADHD meds (1938–2026). Atomoxetine enters in 2003 (estimated).
FDA-approved for
- ADHD (2002)
Off-label
- treatment-resistant depression
Classes and tags
Clinical profile
Legacy pregnancy categoryC
Defining liabilityBlood-pressure/heart-rate increases, rare hepatic injury and suicidal-thinking warning in younger patients.
FDA label
Read the full label on DailyMed ↗
| FDA dosing | Population | Start | Target | Max |
|---|---|---|---|---|
| ADHD | Pediatric <70 kg | 0.5 mg/kg/day QD (AM) or ÷BID | 1.2 mg/kg/day | 1.4 mg/kg/day or 100 mg/day, whichever is less |
| ADHD | Pediatric ≥70 kg and adults | 40 mg/day QD (AM) or ÷BID | 80 mg/day | 100 mg/day |
Titration Minimum of 3 days between increases; 4 weeks if on a strong CYP2D6 inhibitor or a CYP2D6 poor metabolizer
Renal Undefined
Hepatic Moderate (Child-Pugh B): 50% of normal dose; severe (Child-Pugh C): 25% of normal dose; mild: no change
Instructions
- Take with or without food; swallow capsule whole, do not open
- No taper needed on discontinuation
- Screen for bipolar disorder/mania before starting
- At least 14 days between an MAOI and atomoxetine (both directions)
Available strengths
- cap 10, 18, 25, 40, 60, 80, 100 mg
- sol 4 mg/mL
Contraindications
- MAOIs (concurrently or within 14 days)
- Narrow-angle glaucoma
- Pheochromocytoma or history of pheochromocytoma
- Severe cardiac or vascular disorders that would deteriorate with clinically important increases in BP or heart rate
Cautions
- Severe liver injury — discontinue and do not restart with jaundice/liver injury
- Serious cardiovascular reactions / sudden death; assess cardiac status first
- Increases in blood pressure and heart rate
- New psychotic or manic symptoms; screen for bipolar disorder
- Aggressive behavior or hostility
- Urinary retention/hesitancy
- Priapism
- Effect on growth in pediatric patients
- Suicidal thoughts and behaviors (boxed)
Adverse reactions
- Pediatric: nausea, vomiting, fatigue, decreased appetite, abdominal pain, somnolence
- Adults: dry mouth, nausea, decreased appetite, insomnia, constipation, dizziness, erectile dysfunction, urinary hesitation
Pregnancy Insufficient human data; some animal reproduction studies show adverse developmental outcomes; registry available
Lactation No human data; present in animal milk; weigh benefits and risks
Cost
Generic entry2010
Serotonicity
This drug is routinely called serotonergic. By Gillman’s human-effect criteria it does not raise serotonin in the synapse.
No clinically meaningful serotonin-elevating mechanism identified in this first-pass Gillman-based review.
Label contraindicationMAOIs (concurrently or within 14 days). The label governs prescribing; Gillman’s point concerns serotonin toxicity only.
It binds the serotonin transporter, and its SERT peg is drawn to that textbook affinity. The pale halo around the peg marks binding that, by Gillman’s human-effect criteria, does not produce clinical serotonin reuptake inhibition.
Gillman’s four human testsA measurable SERT affinity that fails all four is not clinical serotonicity.
- Retarded orgasm
- Efficacy in OCD and cataplexy
- Clonus and hyperreflexia in single-drug overdose
- Serotonin toxicity when combined with an MAOI
Non-elevating actionNone recorded
Evidence confidenceModerate
Background: what serotonicity is · what is and is not an SRI · what counts as a relevant MAOI.
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Memory aids: interaction avatars
Open Atomoxetine in the interactive console ↗
Self-check
- Which metabolic change can markedly raise atomoxetine exposure?
CYP2D6 inhibition or poor metabolism. - Which pediatric risk is boxed for atomoxetine?
Suicidality.