HelixTalk Episode #72 - Drop It Like It’s Hot: Prazosin and the 2017 VA/DoD PTSD Guidelines

Date posted: January 9, 2018, 6:00 am

In this episode, we will review the surprising results of the VA/DoD’s 2017 Clinical Practice Guidelines on Management of PTSD, particularly as it relates to the use of one particular agent, prazosin.

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Key Concepts

1. The 2017 VA/DoD PTSD guidelines made a number of updates from the older, 2010 guidelines.  Most notably, the new guidelines have downgraded the recommendation for the use of prazosin, which had been a fairly widely accepted agent for nightmares associated with PTSD.
2. The demotion of prazosin within the guidelines is based on unpublished data.  The use of unpublished data within clinical practice guidelines is highly unusual and is not commonly done.  There is a lack of data regarding nightmare management for PTSD and further studies are desperately needed.
3. For first-line therapy of PTSD, the guidelines recommend psychotherapy and NOT drug therapy for most patients.
4. For patients requiring pharmacologic therapy, there are four recommended agents: sertraline, paroxetine, fluoxetine, and venlafaxine.  Older guidelines recommended any SSRI or SNRI, but the new guidelines have selected specific agents.
5. The guidelines recommend against a number of specific medications for PTSD including citalopram, quetiapine, topiramate, ketamine, and more.

References

1. VA/DoD PTSD Clinical Practice Guideline for the Management of Posttraumatic Stress Disorder and Acute Stress Disorder. 2017. Online. Available: https://www.healthquality.va.gov/guidelines/MH/ptsd/VADoDPTSDCPGClinicianSummaryFinal.pdf. 
2. Cooperative Studies Program #563 - Prazosin and Combat Trauma PTSD (PACT). https://clinicaltrials.gov/ct2/show/NCT00532493.