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April 28, 2011 at 7:45 pm #89516
Strattera®
What is the active ingredient?
The active ingredient is atomoxetine. It is a direct relative of fluoxetine or Prozac® which, incidentally, is made by the same company. Even more interesting is that fluoxetine is a direct relative of diphenhydramine or Benedryl®, an over the counter antihistamine.
How does it work?
It is a presynaptic reuptake inhibitor of noradrenaline. It allows more of the chemical to be available in the synapse (the bridge between the neurons).
How is it metabolized and excreted?
It is metabolized in the liver by cytochrome enzymes and excreted in the kidney. The specific cytrochrome enzyme is 2D6 which is important because it does have a drug interaction with fluoxetine and paroxetine HCl (Paxil ®).
How fast does it work and how long does it last?
Unlike the psychostimulants, this takes a while to build a blood level. The doses should be increased about every 10 days- two weeks to a maximum effective dose of at least 1.2-1.4 mg/kg/day or 100 mg which is lower. Because it is a blood level-based medication, you wake up with it and go to sleep with it though it has a higher peak effect during the day. Sometimes, the dose can be split to minimize side effects (though this increases its cost).
What are the common side effects?
>60% of the patients may suffer from initial insomnia, appetite suppression, headaches, mild nausea, emotional lability as the medications are wearing off, a seriousness in attitude often seen as a perception of dysphoria, dry mouth, dry eyes, diarrhea, and gastric irritation. There are other side effects but they are not common.
Are there any specific major risk factors?
There are cardiovascular risk factors and possibility of sudden death IF there is a preexisting cardiac structural defect, a family history of a conduction problem and/or if the patient themselves had a sudden loss of consciousness that could only be explained by an erratic hear rate. The medication has been known to rarely induce suicidal thinking when first taking the medication or when the dose is increased which is similar to that of most anti-depressants. There has also been some increase in liver enzymes in some patients, again rarely, but should there be any clinical signs of liver toxicity (e.g. excessive itchiness, yellow eyes or skin, excessive malaise) then it is a matter of getting a blood test to determine liver functioning. The liver enzymes normalize after stopping the medication.
Can it be safely combined with other medications?
Yes, though it may potentiate the effects of similar agents including those that have a central effect on the brain (e.g. alcohol, cannabis, cocaine etc.)
If it doesn’t work, what should I do next?
Ask your doctor for guidance always but switching to a psychostimulant is usually successful. Some people just respond to psychostimulants, like dextro-amphetamine or methylphenidate. One might also consider buproprion (Wellbutrin®) though it does not have a specific indication for ADHD.
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