Clinical update on the use of prazosin for night-time symptoms of PTSD

ObjectiveTo provide a clinical update on the treatment of night-time symptoms of posttraumatic stress disorder (PTSD) with prazosin, which is a centrally acting alpha-1 adrenergic receptor antagonist.MethodsWe performed a narrative review of the relevant literature and Clinical Practice Guidelines pertaining to treatment of trauma-related nightmares and insomnia with prazosin.ResultsThere is a high degree of heterogeneity among the limited clinical trials to date. However, the most recent systematic review and meta-analysis supports the use of prazosin for suitable patients with PTSD-related nightmares and insomnia. Prazosin is generally well tolerated but patients may experience first-dose hypotension, orthostatic hypotension, or syncope among other side effects.ConclusionAlthough the evidence is very mixed, prazosin may be considered for a targeted time-limited trial in patients whose PTSD is dominated by nightmares and insomnia, who are unresponsive to first-line treatment with trauma-focused psychotherapy and/or evidence-based pharmacotherapies such as antidepressants, and after excluding treatable conditions like obstructive sleep apnoea. The trial should ensure that an adequate dose is used for an adequate duration (if tolerated) with monitoring of blood pressure and any emergent side effects as well as sleep-targeted benefits.