Prazosin: Effective or Not? 2/22/2018

Prazosin (brand name = Minipress) is an alpha agonist medication that has long been used for hypertension and benign prostatic hyperplasia (BPH). It has anecdotally been found to be helpful for nightmares and sleep disturbance in patients with Post Traumatic Stress Disorder (PTSD) and has become increasingly used in veterans with PTSD. The starting dose is 1mg qhs and it can be increased by 1-2 mg/day every 3-4 days up to 15mg qhs. Side effects of prazosin include low blood pressure, dizziness, lightheadedness and urinary incontinence.

There are some small sized studies to support the findings. A recent larger study called PACT did not show improvement in nightmares and sleep disturbance related to PTSD, which was a surprising result to many. The study included 304 veterans across 13 different Veterans Affairs Medical Center sites. Patients with social instability and patients already responding to other medications for their nightmares were excluded from the study, which may have affected the results. Because it was a double-blind placebo controlled study, care had to be taken to not include patients who could severely decompensate if they were randomized into the placebo group.

That is not to say that the medication is not useful for any patients with PTSD and sleep disturbance. It has been found to be particularly helpful for patients who have trauma nightmares, where they become sweaty with heart racing during a nightmare. Interestingly, these patients were excluded from the study because of safety concerns.

 Prazosin has not been found to be helpful for other symptoms of PTSD directly, but, of course, if someone has healthier sleep habits, this can positively impact their mood and anxiety levels. Treatment for PTSD should always include therapy aimed to help with dealing with anxiety and possibly processing the trauma. Typically the SSRIs and other antidepressant medications are the first line medications used to the treat the core symptoms of PTSD.

The take home message is that Prazosin should not be considered a “one stop shop” for medication treatment for nightmares related to PTSD, but that doctors and providers should try to identify patients who will likely benefit from it. The second part is that it will be important to have alternative options for treating nightmares related to PTSD and sleep disturbance. Other options may include Trazodone, Benadryl, Clonidine and, further down the list, low dose antipsychotic medications like Risperdal and Seroquel.


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