Adding clonidine to prazosine for ptsd nightmares

[Sikrouf]

Hey wondering if anyone has experience with the above (assuming the usual red flags such as substance use ans osa are checked)
Thanks

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[TexasPhysician]

I wouldn’t. I’d up the dose of Prazosin or switch agents.

 

[nexus73]

Orthostasis and falls. Not an ideal combo.

 

[clausewitz2]

I wouldn’t. I’d up the dose of Prazosin or switch agents.

Yeah, in what world would someone not be able to tolerate a higher dose of prazosin but be fine with clonidine on top?

 

[aim-agm]

Hey wondering if anyone has experience with the above (assuming the usual red flags such as substance use ans osa are checked)
Thanks

Do not combine clonidine and prazosin. Clonidine's hypotensive effects from alpha-2 agonism are mitigated by it's alpha-1 agonism. Prazosin will outcompete clonidine at the alpha-1 receptor and is an antagonist.

That said, I have had a lot of success with clonidine (and guanfacine) in PTSD. If they aren't responding to prazosin or aren't tolerating it, titrate off the prazosin and then try clonidine.

 

[Sikrouf]

Do not combine clonidine and prazosin. Clonidine's hypotensive effects from alpha-2 agonism are mitigated by it's alpha-1 agonism. Prazosin will outcompete clonidine at the alpha-1 receptor and is an antagonist.

Isnt the alpha1 agonist effect of clonidine only in IV form and transient ?

Thanks for your input guys

 

[Alemo]

Clonidine SLAPS* for PTSD and hyperarousal in BPD.



* occasionally helps some patients sometimes

 

[aim-agm]

Isnt the alpha1 agonist effect of clonidine only in IV form and transient ?

Thanks for your input guys

I might be wrong, but I believe the way it works is as such:
IV: Clonidine's action at alpha1 directly/quickly raises blood pressure, while it's action at alpha-2 indirectly/slowly drops blood pressure more, leading to transient hypertension.
PO: The levels of clonidine increase more slowly, and it's significantly greater affinity for alpha-2 means that it's hypotensive action predominates before alpha-1 stimulation is significant so there is no period of hypertension.

 

[Celexa]

Agree with the others this is an either or choice. Both together is not rational polypharmacy.

 

[docksan]

Why not just augment with low dose seroquel?

 

[Sikrouf]

Why not just augment with low dose seroquel?

Tried already we re way past the usual options

 

[calvnandhobbs68]

Tried already we re way past the usual options

Remember prazosin is often quite underdosed. If you look at Stahls and VA experience, they’ll use like 16mg+ of prazosin if the patient can tolerate it. I often see people going “oh well nothing at 3mg of prazosin guess we’re done here”.

 

[clausewitz2]

Remember prazosin is often quite underdosed. If you look at Stahls and VA experience, they’ll use like 16mg+ of prazosin if the patient can tolerate it. I often see people going “oh well nothing at 3mg of prazosin guess we’re done here”.

For men IIRC the median successful dose in the initial prazosin studies for PTSD nightmares was 20 mg

 

[Sikrouf]

Patient is at 25mg of XR prazosine and nothing to show for it im gonna push further but i doubt im gonna see a sudden full response

 

[Celexa]

Patient is at 25mg of XR prazosine and nothing to show for it im gonna push further but i doubt im gonna see a sudden full response

If there's been absolutely no change I wouldn't bother pushing higher. Trying clonidine instead is likely worth a shot.

 

[clausewitz2]

Patient is at 25mg of XR prazosine and nothing to show for it im gonna push further but i doubt im gonna see a sudden full response

Is there a reason he is on an extended release formulation? It occurs to me that if this is meant to be controlling blood pressure over at 24 hour period it might not be reaching an especially high peak during the 8-10 hours where you really want it to be effective.

Has this guy done any imagery rehearsal therapy? I am sure the psychologists will mob me when i say it but this is not a very complicated set of techniques but can be super effective for nightmares specifically. You probably could actually find enough resources to teach yourself et voila, you have a bigger armamentarium.

 

[Mad Jack]

I wouldn’t. I’d up the dose of Prazosin or switch agents.

100% this

 

[Mad Jack]

Is there a reason he is on an extended release formulation? It occurs to me that if this is meant to be controlling blood pressure over at 24 hour period it might not be reaching an especially high peak during the 8-10 hours where you really want it to be effective.

Has this guy done any imagery rehearsal therapy? I am sure the psychologists will mob me when i say it but this is not a very complicated set of techniques but can be super effective for nightmares specifically. You probably could actually find enough resources to teach yourself et voila, you have a bigger armamentarium.

Wrote a post asking the same question with regard to the extended release, it seems less than ideal for PTSD-related nightmares as you're missing that nighttime peak effect and rapid onset

 

[Sikrouf]

Is there a reason he is on an extended release formulation? It occurs to me that if this is meant to be controlling blood pressure over at 24 hour period it might not be reaching an especially high peak during the 8-10 hours where you really want it to be effective.

Has this guy done any imagery rehearsal therapy? I am sure the psychologists will mob me when i say it but this is not a very complicated set of techniques but can be super effective for nightmares specifically. You probably could actually find enough resources to teach yourself et voila, you have a bigger armamentarium.

We dont have immediate prazosine im from france but thats a good point i ll look into it even though i dont really see asking for the pills to be crushed with that kind of med (i sometimes do it with quetiapine XR as we dont have immediate release for that either)

 

[smalltownpsych]

Is there a reason he is on an extended release formulation? It occurs to me that if this is meant to be controlling blood pressure over at 24 hour period it might not be reaching an especially high peak during the 8-10 hours where you really want it to be effective.

Has this guy done any imagery rehearsal therapy? I am sure the psychologists will mob me when i say it but this is not a very complicated set of techniques but can be super effective for nightmares specifically. You probably could actually find enough resources to teach yourself et voila, you have a bigger armamentarium.

It Isn’t that complicated and it Is highly effective. Solid rapport and talking through the nighttime reliving if the events is a key part of the treatment and the nightmares decrease rapidly. That is a symptom that seems really easy to treat from my experience. The hyperarousal and subjective state of distress is much more challenging. The medication for nightmares helps and my patients and I are grateful for the relief, but it is one area where my intervention clearly trumps psychiatry. That being said, some of my patients have had therapy for years that didn’t help so I’m not exactly sure why it seems so easy for me other than it is integrated into my entire holistic approach that is grounded solidly in science. My trauma patients seem to appreciate the practical and strategic approach.

 

[smalltownpsych]

I think another key is to tell the patients right up front that the dreams aren’t going to go away, but there are strategies to reduce the intensity and frequency of them and that an active stance toward the material will be more effective than avoidance strategies. Kind of like the daytime stuff, exposure vs avoidance. “It ain’t that complicated, it’s just not that easy and there are no quick fixes but as long as we are going in the right direction that’s what counts. Pills, therapy, cats, dogs, horses, art, music, journaling, exercise, healthy food, there are a lot of ways to come at this and we will use everything that helps. By the way, alcohol and marijuana only seem to help or in the short term, but overtime it makes it worse. Not saying you have to quit today, but… or sometimes I’m glad you figured that out already.”
All depends on where they are at.

 

[Merovinge]

We dont have immediate prazosine im from france but thats a good point i ll look into it even though i dont really see asking for the pills to be crushed with that kind of med (i sometimes do it with quetiapine XR as we dont have immediate release for that either)

Wow, that's fascinating to me that France does not have the cheaper IR versions of medications that make more sense to take IR. For any bipolar spectrum patient I would much rather have quetiapine IR so that sedation is as loaded in the QHS range as possible (aka the same as Prazosin IR for nightmares). I really appreciate culture perspectives on medication options.

 

[deleted1100659]

Ive had a lot of success with low doses of prazosin for nightmares, even though I know higher doses have been cited.

I worry about medication interactions when I start to go high for prazosin, mainly cause my current population are on 34234334 medications.

But yeah i never do clonidine+prazosin together. I do prazosin and trazodone together sometimes but I strongly educate about becoming orthostatic on it, and if dizzyness happens and is severe, to stop taking.

I really don't like clonidine that much.

 

[Sikrouf]

As far as IRT goes theres no doubt it has to be tried, problems are 1) the patient isnt really good as far as french goes which makes things quite harder and 2) i m actually the attending supervising the resident on the case I dont really have time for such things at all and the attending has no clue about IRT

Next plan is probably to get in touch with the hospital pharmacist to see if we can get away with crushing prazosine pills

As far as BP goes the patient tolerates it without problem which is in line with the tolerance if the antihypertensive effect we can see with some patients which makes it a poor agent for that purpose

I dont really see any other options appart from clonidine and/or high dose serotonine/d2 antagonists to get the patient to sleep, hes been sleeping 2 hours a day for weeks now

 

[clausewitz2]

I dont really see any other options appart from clonidine and/or high dose serotonine/d2 antagonists to get the patient to sleep, hes been sleeping 2 hours a day for weeks now

I believe that he told you this, and I believe that he might even believe this, but unless he is well and truly manic, in which case nightmares are perhaps not the best focus of treatment, this cannot possibly be the case. I think the first step to be quite honest is a sleep diary or at least a more thorough sleep history. There may be an element of paradoxical insomnia here as well.

 

[Sikrouf]

I believe that he told you this, and I believe that he might even believe this, but unless he is well and truly manic, in which case nightmares are perhaps not the best focus of treatment, this cannot possibly be the case. I think the first step to be quite honest is a sleep diary or at least a more thorough sleep history. There may be an element of paradoxical insomnia here as well.

He was an inpatient for 3 weeks and its been confirmed by the night nurses for 3 weeks

Hes been sent home for unclear reasons by the resident and the wife confirms

Hes not manic, and theres no daytime napping, cafein intake has been cut and nicotine intake reduced by half

Gonna end up being a neuro consult for fatal insomnia evaluation 😅

 

[clausewitz2]

Gonna end up being a neuro consult for fatal insomnia evaluation 😅

Is he or his family from Northern Italy?

 

[Sikrouf]

Nop he and his parents are from africa but i didnt know about the italian kindred thank you for that

 

[ObsequiousAplomb]

Fatal insomnia eval. Wow.

So is prazosin spelled prazosine in France? I wonder if that means it's pronounced a lot differently? Here in my region of America we say it "prayZ-oh-sin." How's it pronounced in French?

We say "clonidine" "claw-nih-deen." Do they end up rhyming in French?

 

[watto]

If you can even do a rudimentary form of IRT and have him recall a positive memory each night before bed, using all 5 senses, it's a start. I would add some paradoxical intention in a guy like this and see if it helps reduce hyperarousal. In general, that's the goal here.

 

[Sikrouf]

Fatal insomnia eval. Wow.

So is prazosin spelled prazosine in France? I wonder if that means it's pronounced a lot differently? Here in my region of America we say it "prayZ-oh-sin." How's it pronounced in French?

We say "clonidine" "claw-nih-deen." Do they end up rhyming in French?

Spelled prazosine yeah
Sounds quite similar to the american just prAzosine

 

[docksan]

I say PRAH-zohsin (as in cat).

 

[cara susanna]

Is there a reason he is on an extended release formulation? It occurs to me that if this is meant to be controlling blood pressure over at 24 hour period it might not be reaching an especially high peak during the 8-10 hours where you really want it to be effective.

Has this guy done any imagery rehearsal therapy? I am sure the psychologists will mob me when i say it but this is not a very complicated set of techniques but can be super effective for nightmares specifically. You probably could actually find enough resources to teach yourself et voila, you have a bigger armamentarium.

FYI, we wouldn't recommend IRT for PTSD-related nightmares until the patient has tried an evidence-based therapy for PTSD first. PTSD EBPs often improve intrusive symptoms, including nightmares.

 

[clausewitz2]

FYI, we wouldn't recommend IRT for PTSD-related nightmares until the patient has tried an evidence-based therapy for PTSD first. PTSD EBPs often improve intrusive symptoms, including nightmares.

That makes a lot of sense. I think it came to mind because it is an approach that is relatively straightforward and limited and so something that a busy resident might actually be able to implement without f*ing things up too badly.

 

[calvnandhobbs68]

That makes a lot of sense. I think it came to mind because it is an approach that is relatively straightforward and limited and so something that a busy resident might actually be able to implement without f*ing things up too badly.

agree, it's a relatively simple approach that can be implemented even in primary care offices and certainly in the context of a couple psychiatric visits when you don't have access to/patient isn't able/patient isn't willing to participate in trauma focused therapies to address PTSD overall. I don't think I'd do it in place of PTSD specific psychotherapy but it can be helpful in the context of shorter visits.

 

[ObsequiousAplomb]

I say PRAH-zohsin (as in cat).

You know, I go back and forth with various people correcting me both ways. Prah was how I initially thought it was said.

 

[allantois]

Remember prazosin is often quite underdosed. If you look at Stahls and VA experience, they’ll use like 16mg+ of prazosin if the patient can tolerate it. I often see people going “oh well nothing at 3mg of prazosin guess we’re done here”.

I have a hard time seeing the logistics of someone taking 16 pills of prazosin every night as well as getting 480 pills from pharmacy every month

 

[calvnandhobbs68]

I have a hard time seeing the logistics of someone taking 16 pills of prazosin every night as well as getting 480 pills from pharmacy every month

Prazosin comes in 2mg and 5mg capsules....lol just sayin but the fact that you don't know that tells me you haven't cranked the prazosin up past 5mg

 

[Stagg737]

He was an inpatient for 3 weeks and its been confirmed by the night nurses for 3 weeks

Hes been sent home for unclear reasons by the resident and the wife confirms

Hes not manic, and theres no daytime napping, cafein intake has been cut and nicotine intake reduced by half

Gonna end up being a neuro consult for fatal insomnia evaluation 😅

How long has he been experiencing the nightmares and why the (I'm assuming) decline in sleep hours? Sounds like other issues may need to be prioritized in terms of pharmacologic targets.

What other options for nightmares have been tried? I've had success with topiramate, cyproheptadine, mirtazapine, and zolpidem (not initiated by me, but patients couldn't remember their dreams). Theoretically you could try Guanfacine and there's also some evidence for gabapentin as well:

https://www.mdedge.com/psychiatry/article/104676/ptsd/think-beyond-prazosin-when-treating-nightmares-ptsd

 

[Sikrouf]

Mirtazapine zolpidem been tried
Im not convinced about the usefullness of cypropheptadine given the pharmacodynamic profile of drugs already tried as i think its a bit redundant even though there is obvious limitations to this kind of reasoning but i ll keep it in mind thanks

We re still upping the dose of prazosine with little if anything to show for it

The sleep has been this way for at least 3 months now and it seems its the tolerance to the lack of sleep that brought the patient to care, not the decline in sleep hours

 

[watto]

Time for some lithium.

 

[docksan]

Mirtazapine zolpidem been tried
Im not convinced about the usefullness of cypropheptadine given the pharmacodynamic profile of drugs already tried as i think its a bit redundant even though there is obvious limitations to this kind of reasoning but i ll keep it in mind thanks

We re still upping the dose of prazosine with little if anything to show for it

The sleep has been this way for at least 3 months now and it seems its the tolerance to the lack of sleep that brought the patient to care, not the decline in sleep hours

Tenex?

 

[Sikrouf]

we dont have guanfacine in france