Alternatives to Prazosin: Propranolol

Alternatives to Prazosin: Propranolol

by Rene -

I recently discovered that a small hand full of Psychiatric providers at the VA like to prescribe propranolol for nightmares associated with PTSD, instead of prazosin or as an effective alternative.  They explained that by reducing the heart rate and reducing surges in adrenaline the medication helps the Military member reduce nightmares associated with PTSD.  Reducing fear and anxiety is one of the primary goals for them when prescribing propranolol for sleep.  The VA has conducted many studies but few randomized control trials exist, per my search. 

The article Revisiting propranolol and PTSD, suggest that propranolol as a fear reducing agent when it is coupled with behavioral therapy soon after exposure to psychological trauma.  The study also suggest that when PTSD has already developed chronic treatment with propranolol can be an effective treatment, because people with PTSD tend to have long-term elevated noradrenergic hyperarousal.  However they suggest that in individuals that have suffered with PTSD for an extended period of time propranolol may be less effective. 

My preceptor often switches between propranolol and prazosin for nightmares if one or the other isn’t as effective as should would have liked.  According to the patient I saw prescribed propranolol it was effective at reducing their nightmare frequency. 

 

 

References

Giustino, T. F., Fitzgerald, P. J., & Maren, S. (2016). Revisiting propranolol and PTSD: Memory erasure or extinction enhancement? Neurobiology of Learning and Memory, 130, 26-33. https://ucsf.idm.oclc.org/login?url=https://doi.org/10.1016/j.nlm.2016.01.009 Retrieved from http://www.sciencedirect.com/science/article/pii/S1074742716000216


Re: Alternatives to Prazosin: Propranolol

by Lauren -

Hi Rene, 
Thank you for posting about propanolol as a treatment option for nightmares. In the literature (and in my own limited experience) I have seen it prescribed either as a PRN for anxiety, or prior to trauma re-activation for exposure therapy purposes (Brunet, Saumier, Liu, Streiner, Tremblay, & Pitman, 2017). Interestingly, there is some evidence that propanolol can induce vivid dreams as a relatively unwanted side effect (Lexicomp, 2018), however whether or not those vivid dreams are nightmares is unclear; the only literature linking propanolol to actual nightmares is from the 80's (which isn't to say it isn't credible, but which is to say it is 30+ years old). 

Looking at the article you referenced in your post, it seems as though propanolol has limited efficacy for people who have experienced long-standing PTSD symptoms (as opposed to recent trauma). Propanolol, used in conjunction with extinction training, seems to be effective in dampening the heightened response associated with PTSD in people recently exposed to trauma (Giustino, Fitzgerald, & Maren, 2016). 
References
Brunet, A., Saumier, D., Liu, A., Streiner, D., Tremblay, J., & Pitman, R. (2017). Reduction of PTSD symptoms with pre-reactivation propanolol therapy: A randomized controlled trial. American Journal of Psychiatry, doi.org/10.1176/appi.ajp.2017.17050481

Giustino, T.F., Fitzgerald, P.J., & Maren, S. (2016). Revisiting propanolol and PTSD: Memory erasure or extinction enhancement? Neurobiology of Learning and Memory, 130, 26-33. 

Re: Alternatives to Prazosin: Propranolol

by Joanna -

Rene,

Thank you for bringing this up. I did not know about any alternative treatments with PTSD related nightmares besides prazosin. I researched the use of propranolol and its use for PTSD and now, better understand its effects. 

According to Hampton (2015), norepinephrine signaling, which plays an important role in mood and arousal as well as, encoding, retrieval, and reconsolidation of emotional memories- is elevated in individuals with PTSD. The drugs needed are ones that can block norepinephrine receptors to prevent and treat PTSD. Furthermore, Hampton (2015) states that the researcher team discovered that propranolol, a b-noradrenergic receptor antagonist can reserve functional deficits in the medial prefrontal cortex by restoring the balance between the neurons in the prelimibic and infralimbic activity. This will facilitate fear extinction that is "otherwise disrupt by stress". Propranolol treatment with PTSD involves "normalizing prefrontal cortical function" (Hampton, 2015) and may be most beneficial when stress is high, soon right after a traumatic event. 

I will now take propranolol as a choice, based on your experience and the research in helping alleviate PTSD symptoms. 


Reference 

Hampton, T. (2015). New insights on how propranolol may alleviate PTSD. JAMA, 314(5), 442. doi:10.1001/jama.2015.8966

Re: Alternatives to Prazosin: Propranolol

by Dale Wong -

Hi Rene!

I wasn't aware that propranolol was used to treat nightmares. In my clinical experiences, aside from prazosin, we tend to treat some of the presenting symptoms associated with nightmares, including anxiety. I can see how it may be helpful to give an anxiolytic such as Hydroxyzine or Lorazepam. I wasn't too familiar with propranolol for sleep but it appears it can be effective for those experiencing anxiety. According to one study, lipophilic drugs, such as propranolol and metoprolol, can actually increase the waking cycle due to a decrease in REM (TA & C, 1985). 

Looking into the effects of propranolol and PTSD-associated symptoms, it appears that it may serve as a prophylaxis for PTSD and may actually reduce the catecholamine levels, thereby inhibiting the consolidation of memory (McGhee et al., 2009). However, the study revealed that the prevalence of PTSD was the same for patients who received propranolol versus those who were not prescribed. The article did concede that more research would need to be done on a larger scale considering the small sample  size and the fact that the study was conducted only on burned veterans. But this is an interesting topic and post! Thank you for sharing!

References

McGhee, L. L., Maani, C. V., Garza, T. H., DeSocio, P. A., Gaylord, K. M., & Black, I. H. (2009). The effect of propranolol on posttraumatic stress disorder in burned service members. Journal of Burn Care & Research, 30(1), 92-97. doi:10.1097/bcr.0b013e3181921f51

TA, B., & C, A. (1985). Beta-blockers and sleep: A controlled trial. Retrieved from https://www.ncbi.nlm.nih.gov/pubmed/2865152