When Does Strattera Work for ADHD??

There has been considerable interest in the ADHD community in the use of a non-stimulant medicine for the treatment of ADHD.  The most commonly prescribed non stimulant medication in the United States in Atomoxetine (Strattera).  Anecdotal reports and scientific journals report that Atomoxetine works very well in some patients and not at all in others.  Most of the scientific studies done on Atomoxetine have found that it works about as well as short acting stimulants but not nearly as well as the long acting or sustained release stimulants.  As more research studies are completed a clearer picture has emerged of when Atomoxetine is most helpful.  The findings from these studies report that Atomoxetine is probably most useful in:

* Patients without Oppositional Defiance Disorder (ODD) symptoms

* Patients with Inattentive ADHD

* Patients with ADHD and reading difficulties

* Patients with ADHD and anxiety

* Patients at risk for substance abuse

* Patients with tic disorders

Atomoxetine was helpful for treating hyperactivity, inattention, and impulsive symptoms but was not helpful for the treatment of co-morbid Oppositional Defiance Disorder (ODD).  In families, the treatment of co-morbidities such as ODD is as important as the treatment of the core symptoms of ADHD.  The percentage of individuals with co-morbid Oppositional symptoms in combined type ADHD and Hyperactive/Impulsive ADHD is amazingly high.  One study found that more than 50% of patients with the combined type of ADHD had oppositional symptoms.  That same study reported that greater than 40 percent of patients with hyperactive/impulsive ADHD exhibited symptoms of ODD.  If you have ever lived with an individual with ODD you will understand how disruptive these symptoms are to a healthy family dynamic.  Most adults and families would consider Atomoxetine to be an ADHD treatment failure if the symptoms of ODD were  not improved while taking a medication.

Patients with inattentive ADHD may benefit most from Atomoxetine treatment as clinical trials have proved this drug to be very efficient in treating the symptoms of inattention and  lack of focus in ADHD.  Individuals with inattentive ADHD are more likely to have internalizing symptoms such as anxiety and less likely to have externalizing symptoms such as aggression and conduct disorders.  Patients with ADHD and anxiety are very good candidates for Atomoxetine treatment as stimulants can often worsen anxiety symptoms.  Atomoxetine has proved to be much less useful in the treatment of externalizing symptoms.

Atomoxetine improved  visuospacial deficits in children with ADHD and reading difficulties.  Children with ADHD and reading difficulties are thought to have a very specific executive function deficit.  The connection between ADHD and visuospacial deficits are poorly understood and require more study but it is this same connection which is thought to be the reason why visual therapy improves attention in some children with ADHD.   

Some other interesting facts about Atomoxetine include:

1.  Atomoxetine may work better for ADHD if you have never been on a stimulant.  Children who have never been tried on stimulants responded more positively to Atomoxetine than children who had been previously treated with amphetamine salts or methylphenidate.

2.  There is a subset of patient who do not respond at all to stimulants but do respond to Atomoxetine.

3.  Atomoxetine may be better for morning control of symptoms than stimulants because of their steady duration of action.  The stimulants work only when they are at therapeutic levels which occurs typically 30-60 minutes after taking the medication.  Atomoxetine reaches it's full therapeutic potential in about 6 weeks though some individuals report improvement immediately.

4.  Atomoxetine works better for all types of ADHD at a daily dose of  1.4 mg/kg (0.65 mg per pound) when compared to the dose of .8 mg/kg (0.36 mg per pound) and once daily dosing of Atomoxetine is as effective and as well tolerated with regards to side effects as twice a day dosing. 

5.  Side effects which required discontinuation of the medicine occurred in less than 10% of individuals started on Atomoxetine. The most common side effects in children and teenagers were upset stomach, decreased appetite, nausea or vomiting, dizziness, and tiredness.

6.  Atomoxetine can be taken in combination with the stimulants which is useful in patients who are in the process of stopping the use of the stimulants but will not receive the full effect of the Atomoxetine for several weeks.

For a certain subset of patient with ADHD, Atomoxetine may prove to be the ideal medication.  Further study into the effectiveness of this medication will allow us to understand better why this medicine is effective in certain populations and totally ineffective in others.