This material is the result of work supported with resources and the use of facilities of the Mental Health and Research and Development Service Lines, Atlanta Veterans Affairs Medical Center, Decatur, GA.
Arshya Vahabzadeh, MD
PGY-2, Resident Psychiatrist
Emory University School of Medicine
Erica Duncan, MD
Attending Psychiatrist
and Associate Professor
Mental Health Service Line
Atlanta Veterans Affairs Medical Center
Decatur, GA
Department of Psychiatry and Behavioral
Sciences
Emory University School of Medicine
Atlanta, GA
The authors respond
We agree with the comments by Drs. Vahabzadeh and Duncan regarding the cardiovascular adverse effects of prazosin. It is important to assess the hemodynamic status of the patient before initiating prazosin therapy, and usually, initiation is attempted only if a patient is normotensive or hypertensive because of potential orthostatic hypotension and syncope, which can occur in up to 4% of patients.1 As noted by Drs. Vahabzadeh and Duncan, prazosin often is viewed as a dual treatment for both nightmares and blood pressure in individuals who are hypertensive prior to initiation. Prazosin therapy usually is initiated at 1 mg at bedtime and titrated by 1 to 2 mg every 3 to 5 days.2 The average dose was approximately 3 mg in studies evaluating prazosin for treating PTSD-associated nightmares (dose range: 1 to 10 mg).2 Until the patient is stabilized on a prazosin dose, blood pressure should be monitored daily for inpatients. Outpatients should be educated regarding the signs and symptoms of hypotension, especially dizziness and light-headedness upon standing, along with monitoring blood pressure at his or her next clinic appointment.
Prazosin does not carry an FDA indication for PTSD. Although this is important to consider, the level of evidence in terms of treatment of nightmares also is key. Aurora et al found prazosin was the only medication with a level A rating for treating PTSD-associated nightmares, indicating it as a recommended therapy option.2 Because we do not have any medications indicated for PTSD-associated nightmares, it is crucial to practice evidence-based medicine and base therapy choices on available literature supporting the most effective and safe options.
Safety is an issue in many clinicians’ minds, especially when treating geriatric patients with PTSD because of the risk of hypotensive effects with prazosin leading to negative outcomes, such as falls. In Peskind et al’s open-label study of 9 older patients (mean age: 76) with intractable PTSD-associated nightmares treated with prazosin (mean dose: 2.3 mg; increased by 1 mg per week to a maximum dose of 4 mg), 8 patients experienced >50% reduction in nightmares after 8 weeks of treatment, and 1 patient experienced transient orthostasis when starting prazosin that resolved spontaneously with only mild decreases in blood pressure noted otherwise (<20 mm Hg decrease in systolic blood pressure upon standing).3 Although this study was small, it provides evidence that prazosin can be an effective and safe treatment option in geriatric patients and is devoid of the highly sedating side effects of some other treatment options.
Rebecca L. Graham, PharmD
Second-Year Psychiatric Pharmacy Resident
Veterans Affairs San Diego Healthcare System
(VASDHS)
Susan G. Leckband, RPh, BCPP
Clinical Psychiatric Pharmacist Specialist
VASDHS
Assistant Clinical Professor
Skaggs School of Pharmacy and
Pharmaceutical Sciences
Department of Psychiatry
University of California, San Diego
Rene A. Endow-Eyer, PharmD, BCPP
Psychiatric Clinical Pharmacy Specialist
VASDHS
Assistant Clinical Professor
Skaggs School of Pharmacy and
Pharmaceutical Sciences
Department of Psychiatry
University of California, San Diego
San Diego, CA