atomoxetine hydrochloride
(at oh mox' ah teen)
Strattera

Pregnancy Category C

Drug class
Selective norepinephrine reuptake inhibitor

Therapeutic actions
Selectively blocks the reuptake of norepinephrine at the neuronal synapse. The mechanism by which this action has a therapeutic effect in attention deficit hyperactivity disorder (ADHD) is not understood.

Indication
· Treatment of ADHD as part of a total treatment program

Contraindications and cautions
· Contraindicated with hypersensitivity to atomoxetine or constituents of Strattera; use of MAO inhibitors within the past 14 days; narrow-angle glaucoma
· Use cautiously with hypertension, tachycardia, cardiovascular or cerebrovascular disease, pregnancy, lactation

Pharmacokinetics
Route
Onset
Peak
Oral
Rapid
1–2 hr


Metabolism: Hepatic; T1/2: 5 hr
Distribution: May cross placenta; may pass into breast milk
Excretion: Urine and feces

Available forms
Capsules--5, 10, 18, 25, 40, 60 mg

Dosages
ADULTS AND CHILDREN > 70 KG
40 mg/day PO, increase after a minimum of 3 days to a target total daily dose of 80 mg PO given as a single dose in the morning or two evenly divided doses, in the morning and late afternoon or early evening; after 2–4 wk, total dosage may be increase to a maximum of 100 mg/day if needed.
PEDIATRIC PATIENTS < 70 KG
Initial dose 0.5 mg/kg/day PO, increase after a minimum of 3 days to a target total daily dose of approximately 1.2 mg/kg/day PO as a single daily dose in the morning; may be given in two evenly divided doses in the morning and late afternoon or early evening. Do not exceed 1.4 mg/kg or 100 mg/day, whichever is less.
PATIENTS WITH HEPATIC IMPAIRMENT
For moderate hepatic impairment, reduce dosage to 50% of the normal dose; for severe hepatic impairment, reduce dosage to 25% of the normal dose.

Adverse effects
· CNS: aggression, irritability, crying, somnolence, dizziness, headache, mood swings, insomnia
· CV: palpitations
· GI: dry mouth, nausea, dyspepsia, flatulence, decreased appetite, constipation, upper abdominal pain, vomiting
· Dermatologic: dermatitis, increased sweating
· GU: urinary hesitation, urinary retention, dysmenorrhea, erectile problems
· Respiratory: cough, rhinorrhea, sinusitis
· Other: fever, rigors, sinusitis, weight loss, myalgia

Interactions
Drug-drug
· Possible increased serum levels if combined with potent CYP2D6 inhibitors--paroxetine, fluoxetine, quinidine; monitor and adjust dosage of atomoxetine to 0.5 mg/kg/day with a target dose of 1.2 mg/kg/day for children < 70 kg or 40 mg/day with a target dose of 80 mg/day for children > 70 kg or adults
· Risk of neuroleptic malignant syndrome if combined with MAO inhibitors; do not combine with an MAO inhibitor and do not give atomoxetine within 14 days of using an MAO inhibitor

Nursing considerations
Assessment
· History: hypersensitivity to atomoxetine or constituents of Strattera; use of MAO inhibitors within the past 14 days; narrow-angle glaucoma, hypertension, tachycardia, cardiovascular or cerebrovascular disease, pregnancy, lactation
· Physical:T; skin--color, lesions; orientation, affect; P, BP, auscultation; R, adventitious sounds; bowel sounds, normal output

Interventions
· Ensure proper diagnosis before administering to children for behavioral syndromes: drug should not be used until other causes and concomitants of abnormal behavior (learning disability, EEG abnormalities, neurological deficits) are ruled out.
· Ensure that drug is being used as part of an overall treatment program including education and psychosocial interventions.
· Arrange to interrupt drug dosage periodically in children being treated for behavioral disorders to determine if symptoms recur at an intensity that warrants continued drug therapy.
· Monitor growth of children on long-term atomoxetine therapy.
· Administer drug before 6 PM to prevent insomnia if that is a problem.
· Monitor blood pressure early in treatment, particularly with adult patients.
· Arrange for consult with school nurse of school-age patients receiving this drug.
· Suggest the use of contraceptives for women of childbearing age who are using this drug.

Teaching points
· Take this drug exactly as prescribed. It can be taken once a day in the morning, if adverse effects are a problem, the drug can be taken in two evenly divided doses in the morning and in the late afternoon or early evening.
· Take drug before 6 PM to avoid night-time sleep disturbance.
· Avoid the use of alcohol and over-the-counter (OTC) drugs, including nose drops, cold remedies, and herbal therapies while taking this drug; some of these products cause dangerous effects. If you feel that you need one of these preparations, consult your health care provider.
· These side effects may occur: dizziness, insomnia, moodiness (these effects may become less pronounced after a few days, avoid driving a car or engaging in activities that require alertness if these occur, notify your health care provider if these are pronounced or bothersome); headache (analgesics may be available to help) loss of appetite, dry mouth (small frequent meals, sucking on sugarless lozenges have been known to help).
· The effects of this drug on the unborn baby are not known, women of childbearing age are advised to use contraceptives.
· Report palpitations, dizziness, weight loss, severe dry mouth and difficulty swallowing, pregnancy.

Adverse effects in Italic are most common; those in Bold are life-threatening.