Prazosin may help reduce nightmares in people with PTSD, but more evidence is needed

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People who suffer from post-traumatic stress disorder (PTSD) often have nightmares that relive the experience and these can sometimes be as terrifying as the original trauma. These nightmares can be very difficult to treat effectively as there are few options available.

A team of researchers from the Mayo Clinic have published a systematic review that looks at the effectiveness of an alpha blocker drug called prazosin in treating people with nightmares.

Articles were included if prazosin was used to treat nightmares and outcome measures included nightmares or related symptoms of sleep disorders.

The reviewers conducted a comprehensive search and found a number of studies that they considered worthy of inclusion in their analysis:

  • 4 randomised controlled trials
  • 4 open-label studies
  • 4 retrospective chart reviews
  • 9 single case reports

They did not pool these studies in a meta-analysis and their decision to include levels of evidence below RCTs rings some alarm bells in relation to their intentions. Are they trying to present an unbiased summary of the evidence or are they trying to promote this treatment?

Here’s what they found:

  • The dose of prazosin used in the studies ranged from 1 to 16 mg/d
  • 3 of the RCTs reported significant improvement in the number of nightmares
  • 1 RCT reported no reduction in nightmares
  • The other non-RCT studies consistently reported reduced levels of nightmare severity from prazosin use

I would recommend watching the 5 minute video of lead author Simon Kung on the Mayo Clinic Proceedings website. He presents the results of his review in a positive way and looks forward to the publication of two large RCTs of prazosin in US veterans in the near future. He highlights the relatively small number of patients included across the 12 studies in the review (259 patients in total), but does not really explain why non-RCT evidence was included in his review.

Prazosin is a promising treatment for nightmares, but further studies are badly needed to provide more certainty about it’s efficacy and safety. One possible line of enquiry that I’ve read suggests that a research study could use a tool to assess the frequency of bad dreams before and after the use of alpha blockers for current indications with a control group who are on no such medication. It will be interesting to see if either of the RCTs in the pipeline follow this line.

Link

Kung S, Espinel Z, Lapid MI. Treatment of nightmares with prazosin: a systematic review. Mayo Clin Proc. 2012 Sep;87(9):890-900. doi: 10.1016/j.mayocp.2012.05.015. Epub 2012 Aug 9.

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