Strattera

US Brand Name: Strattera
A link here will take you to the official website for the drug.

Other Brand Names:

Generic Name: atomoxetine HCl

What is Strattera: Strattera is the only NRI in the US pharmacopoeia.
Read up on these sections if you haven’t done so already, because they cover a lot of information about multiple medications that I’m not going to repeat on many pages.  I’m just autistic that way about not repeating myself.

What is Strattera’s FDA Approved Use: ADD/ADHD for adults and children

What are Strattera’s Off-Label Uses: Depression, panic/anxiety & bipolar depression – all from anecdotal evidence and case by case experimentation.  This medication is too new for any off-label studies to have been published yet.

Strattera’s pros & cons:

Pros: I love Strattera! When it works, it really works! Far less likely to trigger mania in the bipolar or seizures in the epileptic than most antidepressants. Either is still possible, it’s just that the odds are higher (i.e. the events are less likely).  In adults at least.  Just remember, kids are not small adults (see below). Recent research has shown that people in the bipolar spectrum have less dense prefrontal cortices than the non-bipolar, and norepinephrine reuptake does a lot of work in the prefrontal cortex, so that’s probably the reason why. With a low side effect profile for most people, this drug proves to be either ineffectual or just the greatest thing ever for someone.

Cons: Tends to poop-out rapidly for some. Approved only for ADD/ADHD so doctors won’t prescribe it or insurance plans won’t cover it for depression or bipolar. Doctors frequently screw up the titration.  If you’re bipolar and you haven’t stabilized it can aggravate your cycling. (This doesn’t contradict the above.  While Strattera (atomoxetine HCl) won’t trigger a mania, it will aggravate existing cycling, it’s a fine distinction.)

Strattera’s Typical Side Effects: The usual for NRIs – headache, dry mouth, urinary hesitance, constipation, early awakening. The headache tends to go away and only reappears with a dosage increase for most people. The urinary hesitance (think the Beavis and Butt-Head episode where they forgot how to “go”), constipation, dry mouth and early awakening strike at random throughout the time you take it. Except for the dry mouth and headache, they all hit me at random. I’ll wake up at 5:00 a.m. two or three days a week. Fortunately I like waking up at 5:00 a.m. now and then and all the other side effects are pretty mild.

For tips on how to cope with these side effects, please see our side effects page.
These aren’t all the side effects possible, just the most popular ones.

Strattera’s Not So Common Side Effects: Nausea, farting (pull my finger Beavis), higher or lower blood pressure, weight loss regardless of appetite change, fatigue and tiredness instead of increased energy and motivation (see comments). Strattera has raised my blood pressure, which is good because I’ve suffered from chronic low blood pressure most of my life. It’s also a good thing I live alone some days. While we’re on the subject of blood, some women will bleed like a stuck pig when it’s that time of the month while taking Strattera.  Oh, yeah, and there’s that wonderful feeling of euphoria. That can last for months. But Strattera (atomoxetine HCl) isn’t a party drug, kids. You can’t just take it before a rave, it takes days of being on the correct dosage to get that effect, which may or may not happen.  One buzzkill for guys could be a variety of sexual dysfunctions ranging from pain during or immediately after ejaculation (although for a small segment of the population that could be a bonus) to not being able to get it up with a forklift.  Sometimes these these side effects are temporary, sometimes they aren’t.  You’ll won’t know if it’s temporary until it stops.
These may or may not happen to you don’t, so don’t be surprised one way or the other.

Strattera’s Freaky Rare Side Effects: Strattera (atomoxetine HCl) hasn’t been on the market long enough for the really freaky side effects to surface. Plus NRIs generally have a low side effect profile. What did we get from the clinical trials that were freaky? Influenza? That was Strattera’s fault? The cold hands and feet I’ll buy, but influenza?  Then there’s the liver problems that everyone is freaking the hell out over.  Four people with serious liver problems in the entire population of those who take Strattera.  Shall we begin the hysteria yet?

Interesting Stuff Your Doctor Probably Won’t Tell You: You can’t mix Strattera (atomoxetine HCl) and Wellbutrin (bupropion)  because they don’t play well together in your brain. They both want to grab the same precursors to activate the reuptake inhibition of norepinephrine, and as both work on norepinephrine mixing the two probably isn’t such a hot idea in the first place.  The details on this haven’t been published anywhere that I’ve yet found, but there is a warning on Medline about mixing the two.

tell your doctor and pharmacist what other prescription and nonprescription medications, vitamins, nutritional supplements, and herbal products you are taking. Be sure to mention any of the following: albuterol syrup or tablets (Proventil, Ventolin), amiodarone (Cordarone, Pacerone), bupropion (Wellbutrin), celecoxib (Celebrex), chlorpromazine (Thorazine), cimetidine (Tagamet), clomipramine (Anafranil), doxorubicin (Adriamycin), fluoxetine (Prozac, Sarafem), metaproterenol syrup or tablets (Metaprel), metoclopramide (Reglan), methadone (Dolophine), paroxetine (Paxil), quinidine (Cardioquin, Quinaglute, Quinidex), ranitidine (Zantac), ritonavir (Norvir), sertraline (Zoloft), and terbinafine (Lamisil). Your doctor may need to change the doses of your medications or monitor you carefully for side effects.

Most of the meds listed have to do with enzyme inhibition in your liver.  That’s just basic pharmacology.  So any doctor prescribing the two together had better be doing so in very low dosages.  Otherwise the doctor is really gambling with with your liver and your brain.  What’s left out of the above list is tonic water!

So if you want to control norepinephrine and dopamine reuptake individually, you have to go totally off label and use Mirapex (pramipexole dihydrochloride)  or another anti-Parkinson’s medication for dopamine control.

On the subject of enzyme inhibition, your doctor may or may not have brought up the rare cases of liver damage caused by Strattera (atomoxetine HCl).  If you show any signs of liver trouble – easy bruising, bits of you turning yellow, your blood not clotting, frequent puking, that sort of stuff – then it’s time to see your doctor right away for a liver function test.  If you have a family history of lame-ass livers or are just paranoid about this sort of thing, then you can get regular liver function tests like they do for Depakote.

 

Like a lot of antidepressants (which Strattera started out as after all), there’s a risk of suicidal ideation in kids.  It’s not like the children with ADHD aren’t being misdiagnosed as being only ADHD and the doctor isn’t missing the bit about the kid as being bipolar or anything.  Or perhaps the parents are in complete denial about the behavior involved, and want it to only be ADHD, and not the evil bipolar.  It’s not always the drug’s fault in of itself.

It’s also best taken with food to avoid tummy troubles. I can take it on an empty stomach, but I’m a known freak. Strattera (atomoxetine HCl) is slightly less well absorbed with food, so you’ll have to try it with and without food to see if there is any difference, both for your stomach and your brain.

Strattera’s Dosage and How to Take Strattera: As usual I’ll cover dosages only for adults. However, this advice can probably be applied to kids and adolescents just as well. This is where people get completely hosed with Strattera (atomoxetine HCl). This med can work wonders for more people if they and their doctors would just have some goddamn patience!!! The initial dosage is 18-25 mg. Got that? 18-25mg. Not 40mg. Not 60mg. 18-25mg. Unfortunately some bean counter in the bowels of Eli Lilly’s accounting department determined that it was more profitable to restrict the size and number of 18mg and 25mg sample packs (only four capsules in each now), and let some people just fail with this med. So most of the sample packs sent out now are only 40mg capsules. It’s more profitable for Lilly if Strattera (atomoxetine HCl) doesn’t work for everyone it could work for!! Isn’t that crazy? Even the Amen Clinic where Mouse and I are treated gets very few of the 18mg and 25mg sample packs, and only because they treat kids! And they’re in real tight with their Eli Lilly sales rep! Anyway, the highest an adult should start at is 25mg a day and just stay there for at least two weeks. Wait at least that long before going up to 40mg, and then only if it’s going to make a big difference, not a small difference.

Now, I got the MAO thing straightened out.  My apologies for any psychopharmacological confusion.  Forgive me, as I can be an idjit on psychiatric drugs and I was still wiped out from the effects of too much Strattera (atomoxetine HCl), even after taking it for a couple months.

Here’s why – if you don’t have enough norepinephrine to reuptake, Strattera (atomoxetine HCl) will do either or both of two things.  The more likely is that it will start depleting you of norepinephrine, which will be completely counterproductive to what it’s supposed to be doing for you in the first place.  There’s also a chance it might make you more vulnerable to the adverse effects of MAO.  As my doctor explained it to me it’s like WWI trench warfare – the NRI (be it Strattera (atomoxetine HCl),  Edronax (reboxetine) or even a multiple reuptake inhibitor like Effexor (venlafaxine)) sends its chemical signals after your neurons, but they are repelled.  The sergeant won’t have any of that, so it sends them after another set of neurons that are more receptive.  In doing so it allows excess MAO enzymes to do a flanking maneuver and hit those neurons instead.   Either or both of those reasons are why people will feel wiped out when they take these outrageously high starting dosages. Then if they go back down to the previous dosage, they still feel crappy and give up. Well, it takes about two weeks to get over taking too much Strattera (atomoxetine HCl). Once again, have some freaking patience.

Anyway, once you get past the 25mg a day barrier, dosages are as follows: 36-40 mg a day, 50 mg a day, 60 mg a day, 80 mg a day, 100 mg a day. Doses are usually divided between morning and afternoon, but some people get drowsy with Strattera, while others get hyper, so the dosing can be really flexible. I take my 40mg all in the morning, being a “poor metabolizer.”  A.k.a. a cheap date.  See the Basic Information on Psychiatric Drugs page for more details on how you can find out where you fit in the poor or extensive metabolizer categories.  One person wrote me about how they take a dose of Strattera (atomoxetine HCl) every other day.  That’s one lazy liver!

Days to Reach a Steady State: As the active portion of Strattera has a half-life in people with normal metabolisms of 6 to 8 hours, and most people take it once a day, you may or may not reach a steady state (see the section on how to read our drug guides) in 36 to 48 hours.  Eli Lilly didn’t provide any steady state data.

How Long Strattera Takes to Work: If my experience with Strattera (atomoxetine HCl) is any gauge, you could start feeling something within three days. Many others have reported Strattera kicking in within 3-4 days as well. However, you should give it at least two weeks before raising the dosage or giving up.

Strattera’s Half-Life:  Strattera (atomoxetine HCl) does one of those weird double metabolisms. Atomoxetine itself has a mean average half-life of five hours, with poor metabolizers (7% of the Caucasian population, 2% of the African American population in Lilly’s trials) taking up to 24 hours to process it. Then the metabolite is further metabolized into yet another substance, and that has a mean average half-life of 6-8 hours, with the poor metabolizers taking 34-40 hours to deal with it. While Lilly has the resources to tell a poor metabolizer from a regular person, you and your doctor may not.  There is a lab test for CYP2D6 efficiency, according to the Strattera (atomoxetine HCl) PI sheet, but your doctor may have to contact Eli Lilly to find out just what it is and how to order it.  And how much it costs.

Average Time For Strattera to Clear Out of Your System: Presume a total half-life of 13 hours and that it’s out of your system in 3-4 days.

How to Stop Taking Strattera: Your doctor should be recommending that you reduce your dosage by 20mg a day every 3-4 days if you need to stop taking it, if not more slowly than that.   Based on the 13 hour half-life.  For more information, please see the page on how to safely stop taking these crazy meds.

If you feel a little wonky after five or six days, you can consider yourself a poor metabolizer and you may need to take two weeks to step down each 20mg, but you have to balance how much it sucks to be on Strattera versus what it’s like getting off of it.

If you’ve worked your way up to a particular dosage, it’s usually best to spend this many days at the next lowest dosage before going down the next lowest dosage before that and so forth. This is the least sucky way to avoid problems when stopping any psychiatric medication. Presuming you have the option of slowly tapering off them.

How Strattera Works In Your Brain:  Like all NRIs Strattera (atomoxetine HCl) doesn’t make you produce more norepinephrine, rather it makes your neurons soak for a longer period of time in the norepinephrine you already produce.   Norepinephrine is a new player in the ADD/ADHD game.  For depression it is one of the big three neurotransmitters, along with serotonin and dopamine.  My wild-ass guess / rule of thumb puts 80% of depression issues somewhere in the realm of serotonin, norepinephrine and/or dopamine.

Chance That Strattera Will Work and How Strattera Compares to Other Meds:  If you read the PI sheet you’ll see that weasel wording “ADHD symptoms statistically significantly improved more on atomoxetine HCl than on placebo” in the four studies they did on kids and the two on adults.

I did find one study with kids using Ritalin (methylphenidate) as well as a placebo, unfortunately the numbers for the improvement are pretty obscure in the abstract.  So I can’t tell you just how well it worked, and there’s nothing in the abstract with Strattera (atomoxetine HCl) going head-to-head against the Ritalin (methylphenidate), dammit!  Other studies I’ve found with kids are all the same – “statistically significant improvement” but no hard numbers.

I had better luck with adults.  Although the number of studies are fewer, I did find one that published hard numbers in the abstract.  Over the course of 10 weeks in two trials participants saw an 18-30% reduction in symptoms as measured in the Conners’ Adult ADHD Rating Scale, depending on dosage.  That compared with about 20% for those taking placebo.  “Mean reductions in the scores on the Clinician Global Impression of Severity Scale, patient-rated CAARS and Wender-Reimherr Adult Attention Deficit Disorder Scale were also significantly greater with atomoxetine than with placebo. Continued efficacy was demonstrated in a noncomparative, 34-week extension phase.”

So making it an average of 25% better – that’s about all I can pin down.  Mileage will always vary, of course.

Comments: Be sure to read the sections on ADD medications and/or antidepressants and especially NRIs if you haven’t done so already.

Approved by the FDA to treat ADD/ADHD in November 2002, Strattera (atomoxetine HCl) is the This US variant of Edronax (reboxetine).  It’s the first non-stimulant medication approved to treat ADD/ADHD, and as such that’s a big plus to parents concerned about giving potent stimulants to their kids.  Because it is so new, there’s not much literature on it!  There is some stuff out there though, but most of what I’m writing comes from the world of anecdotal evidence.

One study indicates that Strattera doesn’t have much in the way of a discontinuation syndrome.  Reports from the user community supports this.  If you have to suddenly stop taking it, you’re usually OK.

As my personal pharmacological guru Dr. Stahl states, “atomoxetine increase both dopamine and norepinephrine in frontal cortex and may thereby enhance cognitive functioning in attention-deficit/hyperactivity disorder.”1 That’s the region of the brain where people with bipolar disorder have lots of problems.  It is through the reuptake of norepinephrine (and possibly dopamine – the jury is still out on that point) in your frontal and prefrontal cortices that Strattera does its magic.  Thus it is effective for adults with ADD/ADHD.

As far as kids are concerned, Strattera tests as being as effective as good old Ritalin (methylphenidate) with fewer side effects.  It also works well for girls.

I’ve received a copy of a not-yet-published study that shows Strattera (atomoxetine HCl) to be less effective than amphetamines for some forms of ADHD in children.  This is not surprising.  When it comes to the types of ADHD that need to be treated with amphetamines Strattera (atomoxetine HCl) by itself is unlikely to be effective.  My doctor, who works with a lot of kids, confirms this.  However he and the doctors at the Amen Clinic do use it as monotherapy and an adjunctive med with the amphetamines.  Mouse takes it along with an amphetamine and has found it to be most useful.  More on that in a bit.

Now that we’ve covered some good science, let’s get into the world of anecdotal evidence:

I was prescribed Strattera (atomoxetine HCl) for ADD, but I’ve found it to be remarkably effective as an antidepressant. It kept me strangely happy for several weeks. Not manic, just happy. I’m pretty much in a good mood most of the time now. No, really, I am.

Norepinephrine is one of the neurotransmitters that central nervous stimulants work on, hence the ADD action. I have a hell of a lot more concentration and motivation. Just read my blog. I’ve gone from not being able to read books or watch TV shows longer than an hour to creating this website. I can also attest to Strattera’s anti-anxiety effects. As soon as I was up to 50mg a day of Topamax (topiramate) I could no longer drink regular coffee because I would get an instant panic attack. After being on Strattera (atomoxetine HCl) for a couple weeks I just craved a real latté, not the decaffeinated ones I had been making. With a bottle full of lorazepam, I figured it was worth the risk. I got the latté, drank it and was incredibly productive that day with no panic. I’ve been back on full-strength lattés ever since. I’ve getting the best possible effects from this drug. I take it first thing in the morning (although I don’t recommend that for everyone, as many people can’t tolerate it on an empty stomach) and it makes me more awake and alert during the day. Then around nine or ten p.m. I get sleepy and usually have a good night’s sleep. Who can ask for more? Of course that’s not the case for everyone. Some people are sleepy all day, a side effect that may or may not go away. Other people suffer from insomnia.  But I’m quite pleased that it has gotten me in touch with my inner Benjamin Franklin.

Then I did the stupid thing that far too many people taking Strattera (atomoxetine HCl) do, I increased the dosage because it wasn’t working well enough. Don’t get me wrong, as an antidepressant it couldn’t be beat, as long as I combined it with Risperdal (risperidone) that is. I’m one of those people who need an antipsychotic too. I was a happy, shiny person. But the ADD function wasn’t all there. I was getting greedy, I wanted the focus and concentration to hold down the type of job I had before. So I went from 40mg a day to 50mg a day. It was an unmitigated disaster. For a week I could barely get out of bed, each day the lethargy becoming worse than before. I thought it might be norepinephrine overload so I stopped taking the l-tyrosine I had been taking. I turns out that was totally the wrong thing to do, so I kept getting worse and worse! I gave up and went back to 40mg a day. Guess what? It didn’t work as well as it used to! That really sucked. Per my doctor’s instructions I tried Provigil (modafinil) again, and the Strattera (atomoxetine HCl) & Provigil (modafinil) cocktail is proving to be most effective. Later my doctor found out about Strattera (atomoxetine HCl) doing the norepinephrine depletion and making you more vulnerable to MAO if you don’t have enough norepinephrine to reuptake (see the dosage section above), so one or both of those happened to me. Yeah, that’s what happens.  Instead of stopping the l-tyrosine, I should have increased the amount I was taking.

It took two weeks for the Strattera to work like it used to. I’m probably a poor metabolizer, as two weeks is about right for the increased dosage to clear out of my system if I’m metabolizing the drug slowly. Or maybe it had something to do with my MAO being out of whack. I don’t know. Whatever the reason, if you do increase your Strattera and it knocks you flat on your ass, don’t give up after decreasing your dosage! Have some freaking patience! And talk to your doctor about l-tyrosine to boost your levels of norepinephrine. Unlike mixing 5-HTP/l-tryptophan and SSRIs, mixing l-tyrosine and Strattera is not potentially fatal. It can get weird, it can potentially trigger mania if you’re bipolar, but it is far less of a risky combination. L-tyrosine converts to norepinephrine and dopamine, and those are what Strattera (atomoxetine HCl)works on. I take 2000mg of l-tyrosine a day, and that combined with my 40mg of Strattera (atomoxetine HCl) and 100mg of Provigil (modafinil) takes care of most of my ADD issues without risking mania or seizures, or screwing up the meds I take to keep my mania and seizures under control. Talk about walking a fine line.

The addition of norepinephrine reuptake has been a tremendous improvement to Mouse’s ADD issues.  She takes amphetamines for ADD and those were not enough.  Strattera (atomoxetine HCl) has given her noticeable more focus and, more importantly, more follow-through.  While not perfect (face it, none of the existing meds will deal with the bipolar-ADD combo that well), Strattera (atomoxetine HCl) was pretty much the missing piece of the puzzle.  Here’s a good example that parents can especially relate to.  I had to get Mouse to Fairfield for her appointment with our doctor.  She just woke up when I walked through the door.  She managed to get dressed, take her meds, find her cell phone, purse and wallet and know that she had to buy a pack of cigarettes from the corner store in under ten minutes.  Six months ago doing most, not all just most of those things, would have taken at least 45 minutes.  With lots of complaining.  Sure, it’s not all meds, there’s been lots of coping strategies, but she couldn’t get over the hurdle of dealing with the coping strategies without the Strattera (atomoxetine HCl) in the first place.

Another aspect that has been a positive benefit for girls is that Strattera (atomoxetine HCl) seems to have helped with sexual dysfunctions caused by other meds.  Because of the drug-drug interactions involved, this won’t work for everything, but it is an option.  For guys it’s another story.  Strattera (atomoxetine HCl) isn’t as bad as the SSRIs in that regard, but it can and has caused sexual problems with a small segment of the male population taking it.  I’m still as horny as ever.  Only Paxil (paroxetine) has ever reined me in.

Strattera (atomoxetine HCl) doesn’t work for everybody, and a couple people have gotten hypomanic at the higher end of the therapeutic range, but for a lot of bipolar types it looks like an NRI like Strattera (atomoxetine HCl) or Edronax (reboxetine) is the way to go when it comes to dealing with bipolar depression.  Unfortunately there doesn’t seem to be enough of a market to interest the drug companies for this.  Strattera (atomoxetine HCl) is the only NRI on the US market.  Every other med that messes with norepinephrine reuptake is mixed with serotonin reuptake, because, you know, serotonin is always a problem with depression and its reuptake is never a problem in of itself.  Just ask that computer monitor I destroyed while I was taking Serzone (nefazodone).  Oh, wait, you can’t anymore.  The point is, with its notorious tendency to poop-out on people, having just one pure NRI on the market just won’t do.  We have a bazillion SSRIs?  Why are we allowed only one NRI?  Oh, like the TCAs are good enough for us.  The few of them that are especially selective in norepinephrine reuptake have all sorts of side effect issues at the dosages high enough to make a difference for a lot of people.

While I could still use better results for my ADD and depression symptoms, the combination of Strattera (atomoxetine HCl), Provigil (modafinil) and whatever anti-Alzheimer’s medication I settle on is just going to be as good as it gets given my complex combination of bipolar, epilepsy & autism.  I can’t tolerate stimulants stronger than Provigil (modafinil).  And I was really stupid for letting my disorders go unmedicated for so long.  So I’m paying the price for that as well.  I’m grateful for what relief of symptoms that I am getting from these meds, and when balancing the cost of side effects and out-of-pocket expense against that relief, they are worth the price.

Norepinephrine? I’m soaking in it!

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