Treating nightmares in PTSD with doxazosin: a report of three cases

This paper reports three cases of patients successfully treated with doxazosin, as an alternative to prazosin, for nightmares associated with posttraumatic stress disorder (PTSD). All patients were male, middle-aged, severely ill, and had comorbid major depressive disorder (MDD). They developed PTSD after the Kiss nightclub fire in 2013, and were receiving care at a specialized outpatient clinic at the University Hospital of Santa Maria, Rio Grande do Sul, Brazil. A thorough clinical evaluation was conducted, including of specific sleep aspects (latency, length, frequency of nightmares, etc.)

The first patient was a relative of a victim and a survivor. He was taking venlafaxine 225 mg, quetiapine 125 mg, and chlorpromazine 200 mg, and reported nightmares at least three times a week. Doxazosin 1 mg at night was prescribed. After 2 weeks, he reported no more nightmares, but insomnia persisted as at presentation. Doxazosin was progressively increased to 4 mg in an attempt to improve insomnia, and chlorpromazine was reduced to 100 mg to avoid side effects. After 4 months of follow-up, he remained free of nightmares, but insomnia continued.

The second patient had helped rescue the victims. He also had type 2 diabetes mellitus and hypercholesterolemia. He was taking sertraline 200 mg, chlorpromazine 300 mg, and clonazepam 2 mg. He reported nightmares twice a week and consequent intermediate insomnia. He was very reluctant to reduce chlorpromazine or clonazepam doses, fearing that his symptoms would worsen. Doxazosin 2 mg at night was prescribed. He returned 7 weeks later without nightmares or insomnia.

The third patient was a survivor of the fire. He was taking sertraline 200 mg, lithium carbonate 1,500 mg, and clonazepam 1 mg. He was depressed and reported nightmares and insomnia. Doxazosin was started at a dose of 1 mg; after 2 weeks, nightmares had decreased. After 45 days, doxazosin was increased to 2 mg. At follow-up, he reported nightmares less than once a week.

Nightmares are core symptoms of PTSD, and even contribute to increasing rates of suicide among these patients.¹ Although antidepressants are considered the first-line treatment for PTSD, no evidence has found that these drugs are superior to placebo in treating PTSD-related insomnia and nightmares.²

Doxazosin, an alpha1-adrenergic antagonist prescribed to treat benign prostatic hyperplasia, is widely available for users of the Brazilian public health system. Furthermore, it has a long half-life (16 to 30 hours), allowing not only easy dosage, but maintenance of effect throughout the night. Finally, its good absorption profile reduces the risk of hypotension. All of these characteristics positively differentiate doxazosin from its analogue, prazosin, which has been described as an efficacious adjuvant treatment for PTSD-associated nightmares.³

To the best of our knowledge, this is the first case series of Brazilian patients with PTSD successfully treated with adjuvant doxazosin for associated nightmares. After initiation of adjunctive doxazosin, two patients were free from nightmares and one experienced improvement for up to 7 weeks. Our findings are in accordance with those of a review of medical records⁴ and a pilot clinical trial,⁵ but placebo-controlled studies are needed to confirm it.

References

• ¹
  Sjostrom N, Waern M, Hetta J. Nightmares and sleep disturbances in relation to suicidality in suicide attempters. Sleep. 2007;30:91-5.
• ²
  Hoskins M, Pearce J, Bethell A, Dankova L, Barbui C, Tol WA, et al. Pharmacotherapy for post-traumatic stress disorder: systematic review and meta-analysis. Br J Psychiatry. 2015;206:93-100.
• ³
  Brownlow JA, Harb GC, Ross RJ. Treatment of sleep disturbances in post-traumatic stress disorder: a review of the literature. Curr Psychiatry Rep. 2015;17:41.
• ⁴
  Roepke S, Danker-Hopfe H, Repantis D, Behnia B, Bernard F, Hansen ML, et al. Doxazosin, an alpha-1-adrenergic-receptor antagonist, for nightmares in patients with posttraumatic stress disorder and/or borderline personality disorder: a chart review. Pharmacopsychiatry. 2017;50:26-31.
• ⁵
  Rodgman C, Verrico CD, Holst M, Thompson-Lake D, Haile CN, De La Garza R 2nd, et al. Doxazosin XL reduces symptoms of posttraumatic stress disorder in veterans with PTSD: a pilot clinical trial. J Clin Psychiatry. 2016;77:e561-5.

Publication Dates

• Publication in this collection
  Apr 2019

History

• Received
  30 Sept 2018
• Accepted
  4 Feb 2019