Study Identifies Early Discontinuation and Sub-Optimal Dosing for Drug to Treat Sleep Disorders Associated with PTSD
Clinical practice guidelines issued by both VA and the DoD recommend prazosin for Veterans experiencing sleep problems, including nightmares, related to PTSD. Likewise, the proportion of Veterans with a diagnosis of PTSD that received a least one prescription for prazosin between FY1999 and FY2009 increased from 1% to 9%. However, a prior VA study reported that prazosin prescribing across the VA healthcare system varied by 12-fold in FY2006 and decreased with distance from the Puget Sound VA Medical Center, where the early prazosin PTSD clinical trials were conducted. This study sought to identify a cohort of Veterans with PTSD initiating prazosin, and then characterize the typical duration of use and dosing patterns over the first year following initiation. Using VA administrative data from FY2009 and FY2010, investigators identified 12,844 Veterans with PTSD who initiated prazosin during 2010. In addition to examining the longitudinal course of prazosin use following initiation, investigators also analyzed potential correlates of persistent prazosin use for at least one year, including patient demographics and outpatient medication exposure.
- Approximately 20% of Veterans never refilled the initial prescription, while only 38% of Veterans continued the medication for at least one year.
- Veterans taking serotonin- reuptake inhibitor (SSRIs) or serotonin-norepinephrine reuptake inhibitor (SNRIs) antidepressants were more likely to maintain prazosin treatment for one year (41%) compared to non-users (33%). One-year prazosin persistence also increased with the patient's age and number of concurrent medications.
- Prazosin persistence was not associated with gender, rural residence, or distance from the Puget Sound VAMC.
- The mean maximum dose of prazosin reached in the first year of treatment was 3.6 mg/day, with only 15% of Veterans reaching the minimum guideline recommended dose of 6 mg/day.
- Research is needed to identify what factors inhibit patients from reaching the minimum recommended target dose and what characteristics are associated with prazosin response.
- Results rely on administrative data from 2010; reasons for discontinuing prazosin were unavailable.
- Prescriptions received outside VA and the impact of receiving adjunctive psychosocial treatments were not accounted for, and investigators could not clearly differentiate between patients prescribed prazosin for PTSD or for hypertension, benign prostatic hypertrophy, or other off-label uses.
This study was partly funded through VA HSR&D's Mental Health Quality Enhancement Research Initiative (RRP 11-001), and Dr. Lund was supported by an HSR&D Career Development Award. Drs. Alexander and Lund are part of HSR&D's Center for Comprehensive Access & Delivery Research and Evaluation, Iowa City, IA. Drs. Bernardy and Friedman are part of the National Center for PTSD, White River Junction VAMC, White River, Junction, VT.
Alexander B, Lund B, Bernardy N, Christopher M, and Friedman M. Early Discontinuation and Suboptimal Dosing of Prazosin: A Potential Missed Opportunity for Veterans with Post-traumatic Stress Disorder. Journal of Clinical Psychiatry. May 2015;76(5):e639-644.