Prazosin for PTSD nightmares

Prazosin for PTSD nightmares

by Yunji -

Before reading the articles on the efficacy of Prazosin in Veterans, I considered Prazosin as a go-to medication for PTSD related nightmares. The 2010 Veterans Administration Department of Defense recommends Prazosin to treat sleep disorders and nightmares with a Level B evidence-strength (Kung, Espinel, Lapid, 2012).

From my limited nurse practitioner experiences as a student, I have heard some patients on Prazosin report a reduction in the frequency of vivid nightmare. Frequent distressing nightmares can cause significant negative effects on an individual’s quality of life, mental and physical health because of its effect on quality sleep.

 

According to Kung, Espinel, and Lapid (2012), systemic review of 21 studies published in 2012 concluded that only one study found no Prazosin efficacy; on the other hand, 20 studies found positive Prazosin efficacy for reducing nightmares. These studies involved a diverse (e.g., veterans, adults, children, adolescents, refugees, combat soldiers on active duty) group of people who had a diagnosis of PTSD.

 

After reviewing the articles referenced below, I started to ask myself what other treatment options are available for nightmares. Aurora et al (2010) outlines the following recommended practice guidelines for sleep disorder in adults:

 

1.     Prazosin is recommended for treating PTSD related nightmares (level A)

2.     Image rehearsal therapy is recommended for treating nightmares (level A)

3.     Systemic desensitization and progressive deep muscle relaxation training are suggested for treatment of idiopathic nightmares (level B)

4.     Venlafaxine is not suggested for treatment of PTSD associated nightmares (level B)

5.     Clonidine may be considered for treatment of PTSD associated nightmares (level C)

6.     Treatment of PTSD associated nightmares, but the data are low grade and sparse: Trazodone, atypical antipsychotic, topiramate, low dose cortisol, fluvoxamine, triazolam, nitrazepam, phenelzine, gabapentin, cyproheptadine, tricyclic antidepressants

7.     Behavioral therapies for treating PTSD associated nightmares, but the data are low grade: Exposure, relaxation and rescripting therapy (ERRT), sleep dynamic therapy, hypnosis, eye-movement desensitization and reprocessing (EMDR)

 

We need high quality research data to help identify best practice guidelines for PTSD related nightmares. The article we were assigned to read for our journal club found Prazosin was not effective. However, there are other studies that found a reduction in the frequency of nightmares and improvement in the quality of sleep with Prazosin. Every patient is unique. Medications that work well for some may not work for others. In my opinion, it is viable to consider prescribing Prazosin for PTSD related nightmares after proper patient education on the risks and benefits of Prazosin,

 

References

 

Aurora, N., Zak S., Auerbach H., Casey R., Chowduri S., Krippot A., Maganti K., Ramar K., Kristo A., Bista R., Lamm I., Morgenthaler I. (2010). Best practice guide for the treatment of nightmare disorder in adults. Journal of Clinical Sleep Medicine, 6(4), 389-401.

 

Kung, S., Espinel, Z., & Lapid, M. I. (2012). Treatment of nightmares with prazosin: A systematic review. Mayo Clinic Proceedings, 87(9), 890–900. http://doi.org.ucsf.idm.oclc.org/10.1016/j.mayocp.2012.05.015

 

Raskind, M.A., Peskind, E.R., Chow, B., Harris, C., Davis-Karim, A., Homes, H.A….& Romesser, J. (2018). Trial of prazosin for post-traumatic stress disorder in military veterans. New England Journal of Medicine, 378(6), 507-517.

 


Re: Prazosin for PTSD nightmares

by Rene -

Hello Everyone,

Great post Yunji.

If you didn’t know I’m a military Veteran, USAF specifically and I’ve worked with many of my brothers and sisters in uniform suffering with PTSD.  I have a strong interest in working with them when I finish my education.  This week’s Journal club was very informative, and shocking as someone put in their post.  Currently my clinical rotations are at Travis Air Force Base (AFB) and working in the Mental Health Clinic I see how often Prazosin is prescribed to patients with PTSD for nightmares, it’s prescribed almost every single time.  So I too was shocked to find that this study conducted by the VA found that Prazosin is not effective at treating nightmares in patients with PTSD.  I searched the internet and found some research opposing this articles research findings

Raskind (2018) states, “Prazosin is an inexpensive, clinically available and brain active drug that reduces brain noradrenergic activity by antagonizing the effects of norepinephrine at the postsynaptic alpha-1 adrenoreceptor”.  By working on these receptors Prazosin has been proven to inhibit nightmares in individuals with PTSD.  Prazosin should be initiated as an adjunctive treatment to promote sleep in those suffering from PTSD nightmares, and it should be started at 1mg and then titrated up until the absence or the desired reduction of nightmares is achieved, with a max dose recommendation of 20mg at bedtime (Breen, Blankley, & Fine (2017).  According to Singh et al. (2016), the study found that prazosin improves nightmare symptoms and PTSD symptoms overall, including hyperarousal, other sleep disturbances, total sleep time, and the quality of sleep.  From talking to my patients about how the medications are working for them in interviews I found that more patients feel that prazosin does help them sleep better and reduce the incidence of nightmares.  In the end of the article we are responding to the authors stated that the study had some limitations, including the possibility of recruitment bias.  I’m interested to read more research on the subject.

 

References

Breen, A., Blankley, K., & Fine, J. (2017). The efficacy of prazosin for the treatment of posttraumatic stress disorder nightmares in U.S. military veterans. Journal of the American Association of Nurse Practitioners, 29(2), 65-69. 10.1002/2327-6924.12432 Retrieved from https://ucsf.idm.oclc.org/login?url=http://dx.doi.org/10.1002/2327-6924.12432

Raskind, M. A. (2018). Pharmacology of sleep and PTSD: Prazosin - an alpha-1 adrenoreceptor antagonist approach to post-traumatic stress disorder pharmacotherapy. In E. Vermetten, A. Germain & T. C. Neylan (Eds.), Sleep and combat-related post traumatic stress disorder (pp. 349-359). New York, NY: Springer New York.10.1007/978-1-4939-7148-0_30 Retrieved from https://ucsf.idm.oclc.org/login?url=https://doi.org/10.1007/978-1-4939-7148-0_30

Singh, B., Hughes, A. J., Mehta, G., Erwin, P. J., & Parsaik, A. K. (2016). Efficacy of prazosin in posttraumatic stress disorder: A systematic review and meta-analysis. LID - 10.4088/PCC.16r01943 doi]


Re: Prazosin for PTSD nightmares

by Joanna -

Yunji,

Thanks for listing the different treatment options and modalities for PTSD related nightmares. As clinicians, we want to target the symptoms in a pharmacological way, there are many therapy modalities that the patient can engage in to also help reduce those nightmares. However, as you've listed, the data is limited. I'm hoping for future research and sufficient evidence to help target those with PTSD related nightmares. 

In regards to image rehearsal therapy, a study shows that the residual nightmares and PTSD symptoms may help, but after undergoing a trauma-focused PTSD treatment (Lu, Wagner, Van, Whitehead, Boehnlein, (2009). 


Reference 

Lu, M., Wagner, A., Van, M.L., Whitehead, A., Boehnlein, J. (2009). Imagery rehearsal therapy for post traumatic nightmares in U.S. veterans. Journal of Trauma and Stress, 22(3), 236-9. doi: 10.1002/jts.20407