Atomoxetine (Page 3 of 12)

Assessing Cardiovascular Status in Patients being Treated with Atomoxetine

Children, adolescents, or adults who are being considered for treatment with atomoxetine should have a careful history (including assessment for a family history of sudden death or ventricular arrhythmia) and physical exam to assess for the presence of cardiac disease, and should receive further cardiac evaluation if findings suggest such disease (e.g., electrocardiogram and echocardiogram). Patients who develop symptoms such as exertional chest pain, unexplained syncope, or other symptoms suggestive of cardiac disease during atomoxetine treatment should undergo a prompt cardiac evaluation.

5.4 Effects on Blood Pressure and Heart Rate

Atomoxetine hydrochloride should be used with caution in patients whose underlying medical conditions could be worsened by increases in blood pressure or heart rate such as certain patients with hypertension, tachycardia, or cardiovascular or cerebrovascular disease. It should not be used in patients with severe cardiac or vascular disorders whose condition would be expected to deteriorate if they experienced clinically important increases in blood pressure or heart rate [see Contraindications ( 4.5)] . Pulse and blood pressure should be measured at baseline, following atomoxetine hydrochloride dose increases, and periodically while on therapy to detect possible clinically important increases.

The following table provides short-term, placebo-controlled clinical trial data for the proportions of patients having an increase in: diastolic blood pressure ≥15 mm Hg; systolic blood pressure ≥20 mm Hg; heart rate greater than or equal to 20 bpm, in both the pediatric and adult populations (see Table 1).

Table 1a

Pediatric Acute Placebo-Controlled Pediatric Acute Placebo-Controlled
Maximumb Endpoint Maximumb Endpoint
Atomoxetine Placebo Atomoxetine Placebo Atomoxetine Placebo Atomoxetine Placebo
% % % % % % % %
DBP (≥15 mm Hg) 21.5 14.1 9.3 4.8 12.6 8.7 4.8 3.5
SBP (≥20 mm Hg) 12.5 8.7 4.9 3.3 12.4 7.8 4.2 3.2
HR (≥20 bpm) 23.4 11.5 12.2 3.8 22.4 8.3 10.2 2

a Abbreviations: bpm=beats per minute; DBP=diastolic blood pressure; HR=heart rate; mm Hg=millimeters mercury; SBP=systolic blood pressure.

b Proportion of patients meeting threshold at any one time during clinical trial.

In placebo-controlled registration studies involving pediatric patients, tachycardia was identified as an adverse event for 0.3% (5/1,597) of these atomoxetine hydrochloride patients compared with 0% (0/934) of placebo patients. The mean heart rate increase in extensive metabolizer (EM) patients was 5 beats/minute, and in poor metabolizer (PM) patients 9.4 beats/minute.

In adult clinical trials where EM/PM status was available, the mean heart rate increase in PM patients was significantly higher than in EM patients (11 beats/minute versus 7.5 beats/minute). The heart rate effects could be clinically important in some PM patients.

In placebo-controlled registration studies involving adult patients, tachycardia was identified as an adverse event for 1.5% (8/540) of atomoxetine hydrochloride patients compared with 0.5% (2/402) of placebo patients.

In adult clinical trials where EM/PM status was available, the mean change from baseline in diastolic blood pressure in PM patients was higher than in EM patients (4.21 versus 2.13 mm Hg) as was the mean change from baseline in systolic blood pressure (PM: 2.75 versus EM: 2.40 mm Hg). The blood pressure effects could be clinically important in some PM patients.

Orthostatic hypotension and syncope have been reported in patients taking atomoxetine hydrochloride. In child and adolescent registration studies, 0.2% (12/5,596) of atomoxetine hydrochloride-treated patients experienced orthostatic hypotension and 0.8% (46/5,596) experienced syncope. In short-term child and adolescent registration studies, 1.8% (6/340) of atomoxetine hydrochloride-treated patients experienced orthostatic hypotension compared with 0.5% (1/207) of placebo-treated patients. Syncope was not reported during short-term child and adolescent placebo-controlled ADHD registration studies. Atomoxetine hydrochloride should be used with caution in any condition that may predispose patients to hypotension, or conditions associated with abrupt heart rate or blood pressure changes.

5.5 Emergence of New Psychotic or Manic Symptoms

Treatment emergent psychotic or manic symptoms, e.g., hallucinations, delusional thinking, or mania in children and adolescents without a prior history of psychotic illness or mania can be caused by atomoxetine at usual doses. If such symptoms occur, consideration should be given to a possible causal role of atomoxetine, and discontinuation of treatment should be considered. In a pooled analysis of multiple short-term, placebo-controlled studies, such symptoms occurred in about 0.2% (4 patients with reactions out of 1,939 exposed to atomoxetine for several weeks at usual doses) of atomoxetine-treated patients compared to 0 out of 1,056 placebo-treated patients.

5.6 Screening Patients for Bipolar Disorder

In general, particular care should be taken in treating ADHD in patients with comorbid bipolar disorder because of concern for possible induction of a mixed/manic episode in patients at risk for bipolar disorder. Whether any of the symptoms described above represent such a conversion is unknown. However, prior to initiating treatment with atomoxetine hydrochloride, patients with comorbid depressive symptoms should be adequately screened to determine if they are at risk for bipolar disorder; such screening should include a detailed psychiatric history, including a family history of suicide, bipolar disorder, and depression.

5.7 Aggressive Behavior or Hostility

Patients beginning treatment for ADHD should be monitored for the appearance or worsening of aggressive behavior or hostility. Aggressive behavior or hostility is often observed in children and adolescents with ADHD. In pediatric short-term controlled clinical trials, 21/1,308 (1.6%) of atomoxetine patients versus 9/806 (1.1%) of placebo-treated patients spontaneously reported treatment emergent hostility-related adverse events (overall risk ratio of 1.33 [95% C.I. 0.67 to 2.64 – not statistically significant]). In adult placebo-controlled clinical trials, 6/1,697 (0.35%) of atomoxetine patients versus 4/1,560 (0.26%) of placebo-treated patients spontaneously reported treatment emergent hostility-related adverse events (overall risk ratio of 1.38 [95% C.I. 0.39 to 4.88 – not statistically significant]). Although this is not conclusive evidence that atomoxetine hydrochloride causes aggressive behavior or hostility, these behaviors were more frequently observed in clinical trials among children, adolescents, and adults treated with atomoxetine hydrochloride compared to placebo.

5.8 Allergic Events

Although uncommon, allergic reactions, including analycial reactions, angioneurotic edema, urticaria, and rash, have been reported in patients taking atomoxetine hydrochloride.

5.9 Effects on Urine Outflow from the Bladder

In adult ADHD controlled trials, the rates of urinary retention 1.7% (9/540) and urinary hesitation 5.6% (30/540) were increased among atomoxetine subjects compared with placebo subjects (0%, 0/402 ; 0.5%, 2/402, respectively). Two adult atomoxetine subjects and no placebo subjects discontinued from controlled clinical trials because of urinary retention. A complaint of urinary retention or urinary hesitancy should be considered potentially related to atomoxetine.

5.10 Priapism

Rare postmarketing cases of priapism, defined as painful and nonpainful penile erection lasting more than 4 hours, have been reported for pediatric and adult patients treated with atomoxetine hydrochloride. The erections resolved in cases in which follow-up information was available, some following discontinuation of atomoxetine hydrochloride. Prompt medical attention is required in the event of suspected priapism.

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