Atomoxetine (Page 5 of 12)

Adult Clinical Trials

Reasons for discontinuation of treatment due to adverse reactions in acute adult placebo-controlled trials — In the acute adult placebo-controlled trials, 11.3% (61/541) atomoxetine subjects and 3.0% (12/405) placebo subjects discontinued for adverse reactions. Among atomoxetine hydrochloride-treated patients, insomnia (0.9%, N=5); nausea (0.9%, N=5); chest pain (0.6%, N=3); fatigue (0.6%, N=3); anxiety (0.4%, N=2); erectile dysfunction (0.4%, N=2); mood swings (0.4%, N=2); nervousness (0.4%, N=2); palpitations (0.4%, N=2); and urinary retention (0.4%, N=2) were the reasons for discontinuation reported by more than 1 patient.

Seizures — Atomoxetine hydrochloride has not been systematically evaluated in adult patients with a seizure disorder as these patients were excluded from clinical studies during the product’s premarket testing. In the clinical development program, seizures were reported on 0.1% (1/748) of adult patients. In these clinical trials, no poor metabolizers (0/43) reported seizures compared to 0.1% (1/705) for extensive metabolizers.

Commonly observed adverse reactions in acute adult placebo-controlled trials — Commonly observed adverse reactions associated with the use of atomoxetine hydrochloride (incidence of 2% or greater) and not observed at an equivalent incidence among placebo-treated patients (atomoxetine hydrochloride incidence greater than placebo) are listed in Table 4. The most commonly observed adverse reactions in patients treated with atomoxetine hydrochloride (incidence of 5% or greater and at least twice the incidence in placebo patients) were: constipation, dry mouth, nausea, decreased appetite, dizziness, erectile dysfunction, and urinary hesitation (see Table 4).

Additional data from ADHD clinical trials (controlled and uncontrolled) has shown that approximately 5 to 10% of adult patients experienced potentially clinically important changes in heart rate (≥20 beats per min) or blood pressure (≥15 to 20 mm Hg) [see Contraindications (4) and Warnings and Precautions (5) ].

Table 4: Common Treatment-Emergent Adverse Reactions Associated with the Use of Atomoxetine Hydrochloride in Acute (up to 25 weeks) Adult Trials

Adverse Reactiona Percentage of Patients Reporting Reaction
Atomoxetine Hydrochloride (N=1697) Placebo (N=1560)
Cardiac Disorders
Palpitations 3 1
Gastrointestinal Disorders
Dry mouth 20 5
Nausea 26 6
Constipation 8 3
Abdominal painb 7 4
Dyspepsia 4 2
Vomiting 4 2
General Disorders and Administration Site Conditions
Fatigue 10 6
Chills 3 0
Feeling jittery 2 1
Irritability 5 3
Thirst 2 1
Investigations
Weight decreased 2 1
Metabolism and Nutritional Disorders
Decreased appetite 16 3
Nervous System Disorders
Dizziness 8 3
Somnolencec 8 5
Paraesthesia 3 0
Psychiatric Disorders
Abnormal dreams 4 3
Insomniad 15 8
Libido decreased 3 1
Sleep disorder 3 1
Renal and Urinary Disorders
Urinary hesitatione 6 1
Dysuria 2 0
Reproductive System and Breast Disorders
Erectile dysfunctionf 8 1
Dysmenorrheag 3 2
Ejaculation delayedf and/or ejaculation disorderf 4 1
Skin and Subcutaneous Tissue Disorders
Hyperhidrosis 4 1
Vascular Disorders
Hot flush 3 0

a Reactions reported by at least 2% of patients treated with atomoxetine, and greater than placebo. The following reactions did not meet this criterion but were reported by more atomoxetine-treated patients than placebo-treated patients and are possibly related to atomoxetine treatment: peripheral coldness, tachycardia, prostatitis, testicular pain, orgasm abnormal, flatulence, asthenia, feeling cold, muscle spasm, dysgeusia, agitation, restlessness, micturition urgency, pollakiuria, pruritus, urticaria, flushing, tremor, menstruation irregular, rash, and urinary retention. The following reactions were reported by at least 2% of patients treated with atomoxetine, and equal to or less than placebo: anxiety, diarrhea, back pain, headache, and oropharyngeal pain.

b Abdominal pain includes the terms: abdominal pain upper, abdominal pain, stomach discomfort, abdominal discomfort, epigastric discomfort.

c Somnolence includes the terms: sedation, somnolence.

d Insomnia includes the terms: insomnia, initial insomnia, middle insomnia, and terminal insomnia.

e Urinary hesitation includes the terms: urinary hesitation, urine flow decreased.

f Based on total number of males (atomoxetine hydrochloride, N=943; placebo, N=869).

g Based on total number of females (atomoxetine hydrochloride, N=754; placebo, N=691).

The following adverse events occurred in at least 2% of adult CYP2D6 poor metaboliser (PM) patients and were statistically significantly more frequent in PM patients compared to CYP2D6 extensive metaboliser (EM) patients: vision blurred (4% of PMs, 1% of EMs); dry mouth (35% of PMs, 17% of EMs); constipation (11% of PMs, 7% of EMs); feeling jittery (5% of PMs, 2% of EMs); decreased appetite (23% of PMs, 15% of EMs); tremor (5% of PMs, 1% of EMs); insomnia (19% of PMs, 11% of EMs); sleep disorder (7% of PMs, 3% of EMs); middle insomnia (5% of PMs, 3% of EMs); terminal insomnia (3% of PMs, 1% of EMs); urinary retention (6% of PMs, 1% of EMs); erectile dysfunction (21% of PMs, 9% of EMs); ejaculation disorder (6% of PMs, 2% of EMs); hyperhidrosis (15% of PMs, 7% of EMs); peripheral coldness (3% of PMs, 1% of EMs).

Male and Female Sexual Dysfunction — Atomoxetine appears to impair sexual function in some patients. Changes in sexual desire, sexual performance, and sexual satisfaction are not well assessed in most clinical trials because they need special attention and because patients and physicians may be reluctant to discuss them. Accordingly, estimates of the incidence of untoward sexual experience and performance cited in product labeling are likely to underestimate the actual incidence. Table 4 above displays the incidence of sexual side effects reported by at least 2% of adult patients taking atomoxetine hydrochloride in placebo-controlled trials.

There are no adequate and well-controlled studies examining sexual dysfunction with atomoxetine hydrochloride treatment. While it is difficult to know the precise risk of sexual dysfunction associated with the use of atomoxetine hydrochloride, physicians should routinely inquire about such possible side effects.

6.2 Postmarketing Spontaneous Reports

The following adverse reactions have been identified during post approval use of atomoxetine hydrochloride. Unless otherwise specified, these adverse reactions have occurred in adults and children and adolescents. Because these reactions are reported voluntarily from a population of uncertain size, it is not always possible to reliably estimate their frequency or establish a causal relationship to drug exposure.

Cardiovascular system – QT prolongation, syncope.

Peripheral vascular effects — Raynaud’s phenomenon

General disorders and administration site conditions — Lethargy.

Musculoskeletal system — Rhabdomyolysis

Nervous system disorders — Hypoaesthesia, paraesthesia in children and adolescents; sensory disturbances; tics

Psychiatric disorders — Depression and depressed mood; anxiety, libido changes.

Seizures — Seizures have been reported in the postmarketing period. The postmarketing seizure cases include patients with pre-existing seizure disorders and those with identified risk factors for seizures, as well as patients with neither a history of nor identified risk factors for seizures. The exact relationship between atomoxetine hydrochloride and seizures is difficult to evaluate due to uncertainty about the background risk of seizures in ADHD patients.

Skin and subcutaneous tissue disorders — Alopecia, hyperhidrosis.

Urogenital System— Male pelvic pain; urinary hesitation in children and adolescents; urinary retention in children and adolescents.

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