Atomoxetine (Strattera)

Brand name

  • Strattera

Drug Class

  • Norepinephrine (Noradrenaline) reuptake inhibitor
  • Increases extracellular concentrations of dopamine in prefrontal cortex and
  • Used for treatment of ADHD

Preparations

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

Indications

  • Treatment of ADHD
  • Major depression (Under investigation)

How does Atomoxetine work?

Atomoxetine increases the levels of the neurotransmitter noradrenaline in brain.  Noradrenaline plays an important role in regulating attention, impulsiveness and activity levels, however we don’t fully understood how raising the levels of noradrenaline in the brain helps ADHD.

Metabolism

  • Atomoxetine is primarily metabolized by the CYP2D6 pathway to 4-hydroxyatomoxetine.
  • Atomoxetine does not cause clinically important inhibition or induction of cytochrome P450 enzymes, including CYP1A2, CYP3A, CYP2D6, and CYP2C9.

Drug Interactions

  • Bupropion
  • Fluoxetine
  • Albuterol:
    • Atomoxetine should be administered with caution to patients being treated with systemically-administered (oral or intravenous) albuterol (or other beta2 agonists) because the action of albuterol on the cardiovascular system can be potentiated resulting in increases in heart rate and blood pressure.

 

If taken in combination of the following medications, abnormal heart rhythms (prolonged QT) is reported:

  • Antiarrhythmics: amiodarone, procainamide, disopyramide, sotalol
  • Some antidepressants: citalopram, escitalopram, clomipramine
  • Certain antibiotics: clarithromycin, erythromycin, moxifloxacin
  • Some antifungals: ketoconazole, voriconazole
  • Certain antimalarials: halofantrine, chloroquine, quinine, mefloquine, artemether
  • Certain antipsychotics: thioridazine, chlorpromazine, pimozide, sertindole, haloperidol
  • Cisapride
  • Lithium
  • Methadone
  • Terfenadine
  • Thiazide and Furosemide

Risk of seizure can be increased if atomoxetine is used in combination with the following medicines:

  • Antidepressants
  • Antipsychotics
  • Bupropion
  • Chloroquine
  • Mefloquine
  • Tramadol

Adverse Effects

Very common (> 10%):

  • Nausea
  • Dry mouth
  • Loss of appetite
  • Fatigue
  • Headache
  • Cough

Common (1-10%)

  • Constipation
  • Dizziness
  • Erectile dysfunction
  • Sleepiness
  • Abdominal pain
  • Urinary hesitation
  • Increased heart rate
  • High blood pressure
  • Irritability
  • Abnormal dreams
  • Ejaculation disorder
  • Hot flashes
  • Paraesthesia
  • Weight loss
  • Depresson
  • Sinus headache

Rare:

  • Suicide-related events
  • Hostility
  • Emotional imbalance
  • Aggression
  • Psychosis
  • Syncope
  • Tremor
  • Migraine
  • Sizure
  • Palpitation
  • QT prolongation
  • Jaundice
  • Raynaud’s phenomenon
  • Priapism

Contraindications

  • Atomoxetine should not be taken with an MAOI, or within 2 weeks after discontinuing an MAOI. Treatment with an MAOI should not be initiated within 2 weeks after discontinuing Atomoxetine.
  • Hypersensitivity
  • Severe HTN
  • Atrial flutter
  • Ventricular fibrillation
  • Ventricular flutter
  • Pheochromocytoma
  • Narrow angle glaucoma

Precautions

Atomoxetine should be used with caution in patients with hypertension, tachycardia, or cardiovascular or cerebrovascular disease because it can increase blood pressure and heart rate.

Warning

  • Atomoxetine increases the risk of suicidal ideation.
  • Post marketing data indicates that Atomoxetine could cause severe liver damage. Laboratory work up needs to be requested for liver enzymes and serum bilirubin.
  • Atomoxetine should be discontinue if patient develops jaundice or laboratory evidence of liver injury, and should not be restarted.
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