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Prazosin for PTSD Symptoms and Nightmares in Active-Duty Combat Soldiers

Summary and Comment |
July 22, 2013

Prazosin for PTSD Symptoms and Nightmares in Active-Duty Combat Soldiers

  1. Joel Yager, MD

Prazosin reduced hyperarousal symptoms and increased overall functioning.

  1. Joel Yager, MD

Prazosin, an alpha-1-adrenoceptor antagonist, effectively treats nightmares related to post-traumatic stress disorder (PTSD) in active-duty soldiers and veterans. In a randomized, placebo-controlled, 15-week trial, investigators assessed prazosin's value for treating other PTSD symptoms.

Exclusions included unstable medical illness, hypotension, pregnancy or not using reliable birth control, recent substance abuse, psychosis, cognitive impairment, suicidality, severe depression meriting hospitalization, recent PTSD-focused psychotherapy, and trazodone (which may raise prazosin's slight risk for priapism). Medication was given twice daily to 65 active-duty soldiers and 2 recently discharged veterans, all with PTSD and combat exposure. Twenty patients took stable doses of selective serotonin reuptake inhibitors.

Mean maintenance prazosin doses at midmorning were 4.0 mg for men and 1.7 mg for women; bedtime doses were 15.8 mg and 7.0 mg, respectively. Prazosin outperformed placebo for reducing nightmares and hyperarousal symptoms and improving sleep quality and self-reported daily functioning. Prazosin nonsignificantly trended toward greater reductions in avoidance, reexperiencing, and depressive symptoms. PTSD remitted in three prazosin patients and no controls. No prazosin-associated serious adverse events occurred; blood pressures did not differ between treatment groups.

Comment

These researchers previously reported that bedtime dosing of prazosin improved nightmares but not other PTSD symptoms (NEJM JW Psychiatry Jun 11 2007). In the current study, the twice-daily dosing may account for prazosin's reported additional benefits.

Prazosin's abilities to reduce adrenergic activity in the central nervous system (thought to contribute to hyperarousal symptoms and sleep disturbances) may explain these positive findings. However, most soldiers continued to experience PTSD symptoms, even though the maintenance doses were higher than many patients tolerate in other settings. Larger studies to examine prazosin given adjunctively with other medications and psychotherapies for PTSD would be welcome. When other treatments are insufficient, physically healthy and closely monitored patients might benefit from prazosin as used here.

  • Disclosures for Joel Yager, MD at time of publication Editorial boards Bulletin of the Menninger Clinic; Eating Disorders: Journal of Treatment and Research; Eating Disorders Review (Editor-in-Chief); Harvard Review of Psychiatry; International Journal of Eating Disorders; UpToDate Leadership positions in professional societies American Psychiatric Association (Chair, Steering Committee and Executive Committee on Practice Guidelines; Co-Chair, DSM5 Clinical and Public Health Committee; Chair, Council on Research and Quality Care)

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Reader Comments (2)

ANN HARVEY

How are these people still serving as active duty combat soldiers when they have been diagnosed with PTSD?? This seems in fathomable to me. They are at extremely high risk of worsening their own mental health and also of putting others in danger.

SANDEEP SALUJA Physician, Internal Medicine, Saran Ashram

Prazosin seems to be finding a place in psychiatry.There is also emerging evidence of its use in treating alcohol dependence.Similar mechanisms seem to be at play.

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