strattera
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Synonyms | |||
Atomoxetine, marketed under the brand name Strattera, represents a significant departure from traditional ADHD pharmacotherapy. As a selective norepinephrine reuptake inhibitor, it was the first non-stimulant medication approved for attention-deficit/hyperactivity disorder, offering an alternative mechanism that doesn’t carry the same controlled substance designation as methylphenidate or amphetamine-based treatments. The development journey was anything but straightforward - our team initially struggled with the molecule’s pharmacokinetic profile, particularly the extensive CYP2D6 metabolism that creates such variable exposure between extensive and poor metabolizers.
Strattera: Non-Stimulant ADHD Treatment with 24-Hour Coverage - Evidence-Based Review
1. Introduction: What is Strattera? Its Role in Modern Medicine
Strattera (atomoxetine hydrochloride) occupies a unique position in the ADHD treatment landscape as the first FDA-approved non-stimulant medication for both pediatric and adult populations. Unlike traditional stimulants that work primarily on dopamine systems, Strattera targets norepinephrine reuptake, offering continuous 24-hour symptom control without the abuse potential that characterizes Schedule II controlled substances. What is Strattera used for? Primarily ADHD management across age groups, though we’ve found some interesting off-label applications in treatment-resistant anxiety cases that I’ll discuss later.
The significance of Strattera in clinical practice extends beyond its non-controlled status. For patients with substance use histories, comorbid anxiety disorders, or those who simply cannot tolerate stimulant side effects, having this alternative has been transformative in my practice. The benefits of Strattera include smoother symptom control throughout the day without the dramatic peaks and troughs we see with short-acting stimulants.
2. Key Components and Bioavailability Strattera
The composition of Strattera centers on atomoxetine hydrochloride, which converts to atomoxetine - the active moiety. The standard release form includes capsules ranging from 10mg to 100mg strengths. What many clinicians don’t fully appreciate is the profound impact of CYP2D6 polymorphism on bioavailability. In extensive metabolizers (most of the population), the half-life is about 5 hours, while in poor metabolizers (approximately 7% of Caucasians), it extends to 21 hours. This genetic variation explains why some patients develop side effects at what appear to be conservative doses.
The formulation doesn’t include additional absorption enhancers like piperine because atomoxetine already demonstrates nearly complete bioavailability after oral administration. Food doesn’t significantly affect absorption, though I typically recommend taking it with food to minimize gastrointestinal discomfort, particularly during the initial titration phase.
3. Mechanism of Action Strattera: Scientific Substantiation
Understanding how Strattera works requires diving into prefrontal cortex neurochemistry. Atomoxetine potently and selectively inhibits the presynaptic norepinephrine transporter, increasing norepinephrine availability in the prefrontal cortex without significant effects on subcortical dopamine systems. This is crucial - unlike stimulants that boost dopamine in reward pathways, Strattera’s mechanism of action primarily enhances executive function through noradrenergic modulation in cortical regions responsible for attention, organization, and impulse control.
The scientific research reveals that this selective action translates to improved “top-down” cognitive control without the euphoric effects that contribute to abuse potential. Think of it as fine-tuning the brain’s executive control center rather than providing a general neurological boost. The effects on the body are more subtle than stimulants - patients typically report feeling more organized and less impulsive rather than experiencing dramatic focus enhancement.
4. Indications for Use: What is Strattera Effective For?
Strattera for Pediatric ADHD
In children over 6 years, Strattera demonstrates robust efficacy with effect sizes around 0.7 based on teacher and parent ratings. The continuous coverage proves particularly valuable for managing evening homework and family time symptoms that short-acting stimulants often miss.
Strattera for Adult ADHD
Many adults prefer Strattera because it eliminates the midday dosing challenges in workplace settings. The treatment effects emerge gradually over several weeks, but once established, provide consistent symptom control without the stigma of controlled substance prescriptions.
Strattera for Comorbid Anxiety and ADHD
This is where I’ve seen some of the most impressive results off-label. The norepinephrine modulation appears to benefit both ADHD and anxiety symptoms, making it an excellent choice for this common comorbidity pattern. I recently had a college student whose social anxiety improved dramatically alongside her attention symptoms.
Strattera for Treatment-Resistant Cases
When stimulants fail due to side effects or inadequate response, Strattera offers a mechanistically distinct alternative. About 30-40% of stimulant non-responders in my practice have achieved satisfactory control with atomoxetine.
5. Instructions for Use: Dosage and Course of Administration
The instructions for use for Strattera require careful attention to titration schedules and metabolic considerations. For most patients, I initiate treatment low and advance slowly:
| Population | Starting Dosage | Target Dosage | Administration |
|---|---|---|---|
| Children <70 kg | 0.5 mg/kg | 1.2 mg/kg | Once daily or divided |
| Children >70 kg & Adults | 40 mg | 80-100 mg | Once daily or divided |
The course of administration typically begins with once-daily morning dosing, though some patients benefit from divided dosing to minimize side effects. The full therapeutic effect may take 4-8 weeks to emerge, requiring careful patient education about realistic expectations. Common side effects during initiation include decreased appetite, nausea, and fatigue, which usually diminish over several weeks.
6. Contraindications and Drug Interactions Strattera
The contraindications for Strattera are relatively limited but crucial. Absolute contraindications include narrow-angle glaucoma and use within 14 days of MAO inhibitors. We need to be particularly cautious about drug interactions - Strattera metabolism depends heavily on CYP2D6, meaning concomitant use with potent inhibitors like paroxetine or fluoxetine can effectively convert extensive metabolizers into poor metabolizers with significantly increased atomoxetine exposure.
Important safety considerations include:
- Black box warning for increased suicidal ideation in children and adolescents
- Potential for severe liver injury (rare but documented)
- Cardiovascular effects including increased heart rate and blood pressure
- Urinary retention issues, particularly in patients with benign prostatic hyperplasia
Regarding pregnancy, Strattera carries Category C designation with limited human data, so we weigh risks carefully in reproductive-age women.
7. Clinical Studies and Evidence Base Strattera
The clinical studies supporting Strattera are extensive, with over 20 randomized controlled trials involving more than 6,000 patients. The scientific evidence consistently demonstrates separation from placebo on both ADHD rating scales and functional outcomes. One particularly compelling study in the Journal of the American Academy of Child and Adolescent Psychiatry followed patients for 2 years, showing maintained efficacy without tolerance development.
The effectiveness appears somewhat lower than stimulants in head-to-head trials (effect sizes around 0.7 vs 0.9 for methylphenidate), but the continuous coverage and different side effect profile make it preferable for many patients. Physician reviews increasingly emphasize Strattera’s value in specific subpopulations, particularly those with comorbid conditions or substance use concerns.
8. Comparing Strattera with Similar Products and Choosing a Quality Product
When comparing Strattera with similar products, the fundamental distinction is the mechanism - norepinephrine reuptake inhibition versus dopamine/norepinephrine releasers like stimulants. Patients often ask which Strattera is better for their situation, and the answer depends on their specific needs:
- For patients needing 24-hour coverage without midday dosing: Strattera
- For those with substance use histories: Strattera
- For rapid symptom control: Stimulants typically work faster
- For maximum efficacy: Stimulants generally show larger effect sizes
Since Strattera is a branded product with no current generic competition in many markets, quality concerns are minimal. However, patients should obtain medication through legitimate pharmacies to avoid counterfeit products.
9. Frequently Asked Questions (FAQ) about Strattera
What is the recommended course of Strattera to achieve results?
Most patients begin noticing subtle benefits within 1-2 weeks, but full therapeutic effects typically require 4-8 weeks of consistent dosing. I recommend giving it at least 2 months before determining effectiveness.
Can Strattera be combined with stimulant medications?
While not FDA-approved, some specialists use combination therapy in treatment-resistant cases. The interactions are manageable with careful monitoring, though I typically exhaust monotherapy options first.
How does Strattera differ from antidepressants that also affect norepinephrine?
Unlike SNRIs that affect both norepinephrine and serotonin, Strattera is highly selective for norepinephrine reuptake inhibition, which explains its different therapeutic profile.
Is weight loss common with Strattera?
Decreased appetite occurs initially in about 15-20% of patients, but significant weight loss is uncommon after the first month as tolerance develops to this effect.
10. Conclusion: Validity of Strattera Use in Clinical Practice
The risk-benefit profile of Strattera supports its validity as a first-line ADHD treatment, particularly for patients who cannot or prefer not to use stimulant medications. While the onset is slower and effect sizes somewhat smaller than stimulants, the continuous coverage, lack of abuse potential, and different side effect profile make it an invaluable option. The use of Strattera in clinical practice continues to expand as we better understand which patient subgroups derive the most benefit.
I remember when we first started using Strattera back in 2003 - the child psychiatry department was divided between the traditionalists who swore by methylphenidate and those of us willing to try this new approach. Dr. Chen, our department head, was skeptical it would find a significant niche. But then came Michael, a 9-year-old with ADHD and profound anxiety who’d failed three stimulants due to emotional side effects. His mother was at her wit’s end - the school was threatening expulsion, and his self-esteem was crumbling.
We started Michael on 25mg daily, and honestly, the first two weeks were rough - nausea, fatigue, and his teacher reported no improvement. But around week 3, something shifted. His mother called, almost in tears, because he’d sat down and completed his homework without constant reminders for the first time ever. By month 2, his teacher comments transformed from “disruptive” to “engaged participant.” What surprised me was how his anxiety symptoms diminished alongside the ADHD improvements - something we hadn’t fully anticipated based on the trial data.
Then there was Sarah, a 34-year-old lawyer who needed ADHD treatment but was in recovery from stimulant abuse during college. She was terrified of triggering relapse. Strattera gave her the organizational benefits without the euphoria that concerned her. Three years later, she still sends me Christmas cards updating me on her career progression.
The longitudinal follow-up has revealed some interesting patterns - the patients who stick with Strattera beyond the initial side effect phase tend to maintain benefits for years without dose escalation. We’ve had fewer “poop-out” cases than with some stimulant regimens. The suicide risk warning scared many families initially, but in our cohort of several hundred patients, we haven’t seen any completed suicides and only two cases of transient suicidal ideation that resolved with dose adjustment.
Looking back, the early struggles with dosing and expectations were worth navigating. Strattera isn’t for every ADHD patient, but for the right candidate, it can be transformative in ways that extend beyond symptom ratings to overall quality of life. The research continues to evolve, but fifteen years of clinical experience has solidified its place in my toolkit.