Prazosin and nightmares

Prazosin and nightmares

by Yacharter -

The results of the study  showing Prazosin was not effective for alleviating nightmares for veterans was very surprising to me.  I have had success in using prazosin in my primary care practice for abuse related nightmares.  I can imagine the severity of nightmares experienced by veterans could be more difficult to process compared to that of civilians.  I would like to see a study to further determine if prazosin could be more effective to target specific types of nightmare or trauma experiences.  

Comparatively, Clonidine has also been shown equally effective for reducing nightmares in some studies when compared to Prazosin (Mousavi, Barati, Afshar, and Bashardoust, 2005). After reading this study, I may consider a trail of clonidine versus prazosin the next time I encounter a veteran with nightmares.  


Mousavi, S., Marati, M., Afshar, H., & Bashardoust, N. (2005). The Comparison Between Prazosin versus Clonidine effects on Combat related PTSD nightmares. Retrieved from https://www.researchgate.net/publication/26424404_The_comparison_between_prazosin_versus_clonidine_effects_on_combat_related_PTSD_nightmares on 3/8/18.  

Re: Prazosin and nightmares

by Don -

Thank You Yarcharter for your post,

As stated by so many of our peers, I too was very surprised by the article concerning prazosin for PTSD nightmares in the veteran’s population. Your comments concerning clonidine really peaked my interest. I asked some colleagues at my clinical site concerning the use of clonidine for night mares and to my surprise, two of them said that they also prescribe propranolol as well. They found that these two drugs worked equally as well as prazosin.  At another clinical site, the psychiatrist as well as the nurse practitioner both said that they used would prescribe clonidine before prescribing prazosin in the fight against night mares in the PTSD population if the patient has no blood pressure issues. I have personally prescribed prazosin to three veterans myself. On their follow-up visit two weeks later, all three stated their night- mares intensity as well as frequency had decreased. Thank you for your post and giving additional options for those who prescribe medications for people suffering from night mares.

 

 


Re: Prazosin and nightmares

by Mousumi Mukerji -

Dear colleagues,

Thanks for sharing your experiences with other agents you have seen used to treat PTSD-related nightmares, namely propanol (a beta blocker) and clonidine (another alpha 2 adrenergic receptor agonist). 

I found a retrospective study (Detweiler et al, 2016) which compared and contrasted use and effectiveness of a variety of medications prescribed in the Salem, VA Veteran's Administration Medical Center (VMAC) setting for this purpose. This group reported that alpha 2 adrenergic receptor agonists were the second most prescribed class of medications used to treat nightmares. Clonidine and terazosin were both superior to prazosin in efficacy, though they were used less. Clonidine was not completely effective in eliminating hyperarousal symptoms in response to nightmares, but it achieved a partial response rate in about 63% of trials of the medication, at a dosage range of 0.1 to 2.0 mg. The authors describe the mechanism of action of clonidine thus: "Clonidine is a centrally active alpha-adrenergic agonist that stimulates alpha 2-adrenoreceptors in the brain stem, especially the locus ceruleus, and activates inhibitory neurons, resulting in a decrease in vasomotor tone and heart rate." (Deweiler et al, 2016). 

I see clonidine used in children and adolescents pretty often, both for treating ADHD symptoms and for treating anxiety symptoms. It seems like a reasonable choice for PTSD-related nightmares in the same class of medication as prazosin. 

Reference:

Detweiler, M., Pagadala, B., Candelario, J., Boyle, J., Detweiler, J., & Lutgens, B. (2016). Treatment of Post-Traumatic Stress Disorder Nightmares at a Veterans Affairs Medical Center. Journal of Clinical Medicine, 5(12), 117. doi:10.3390/jcm5120117



Re: Prazosin and nightmares

by Christopher Jones -

I appreciate all the stimulating dialogue in original post and responses. There remains an evidence basis for prazosin’s use in congruence with Yacharter’s experience—as in a review from The Journal of Neuropsychiatry and Clinical Neurosciences by Writer, Meyer, & Schillerstrom (2014)—though the article we read for the journal club (Raskind, Peskind, & Chow, 2018) certainly renders the evidence basis and our clinical decision making more nuanced and complex.

In context of such nuance and complexity, I am even more grateful for the interprofessional approach encouraged by reaching out to our pharmacist colleagues, as I can imagine the benefit of consulting them on such an issue. In addition to interprofessional consultation, the strong replies in this forum also show the benefit of intraprofessional consultation as well, as the future of care really does point more towards the benefit of working as professionals together.

Works Cited:

Raskind, M. A., Peskind, E.R., Chow. B. (2018). Trial of prazosin for post-traumatic stress disorder in military veterans. New England Journal of Medicine, 378, 507-517.

Writer, B. W., Meyer, E. G., & Schillerstrom, J. E. (2014). Prazosin for Military Combat-Related PTSD Nightmares: A Critical Review. The Journal of Neuropsychiatry and Clinical Neurosciences, 26(1), 24-33. doi:10.1176/appi.neuropsych.13010006