How Plasma Donation Can Affect Your Patient's Pharmacotherapy

Mr. S, a 45-year-old veteran, was diagnosed with posttraumatic stress disorder (PTSD) 18 years ago after a tour of duty in the Persian Gulf. He had combat-related flashbacks triggered by the smell of gasoline or smoke from a fire, was easily startled, and began to isolate himself socially. However, his symptoms improved when he started volunteering at his local Veterans Affairs Medical Center. After he lost his job 3 years ago, Mr. S started experiencing flashbacks. He was irritable, easily startled, and avoided things that reminded him of his time in the Persian Gulf. His psychiatrist prescribed sertraline, titrated to 200 mg/d. The drug reduced the severity of his avoidance and hyperarousal symptoms and improved his mood. [ILLUSTRATION OMITTED] During a clinic visit, Mr. S says he is doing well and can fall asleep at night but is having recurring nightmares about traumatic events that occurred during combat. These nightmares wake him up and have become more frequent, occurring once per night for the past month. Mr. S says he has been watching more news programs about conflicts in Afghanistan and Iraq since the nightmares began. His psychiatrist starts quetiapine, 50 mg at bedtime for 7 nights then 100 mg at bedtime, but after 6 weeks Mr. S says his nightmares continue. PTSD occurs in approximately 19% of Vietnam war combat veterans (1) and 14% of service members returning from Iraq and Afghanistan. (2) PTSD symptoms are classified into clusters: intrusive/re-experiencing; avoidant/numbing; and hyperarousal. (3) Nightmares are part of the intrusive/re-experiencing cluster, which is Criterion B in DSM-IV-TR. See this article at CurrentPsychiatry.com for a description of DSM-IV-TR PTSD criteria. Among PTSD patients, 50% to 70% report PTSD-associated nightmares. (4) Despite adequate treatment targeted to improve PTSD's core symptoms, symptoms such as sleep disturbances or nightmares often persist. Nightmares and other sleep disturbances are associated with significant distress and daytime impairment and can interfere with PTSD recovery (4-8) by disrupting sleep-dependent processing of emotional experiences and causing repeated resensitization to trauma cues (Table 1, page 60). (8) Few randomized controlled medication trials specifically address PTSD-related nightmares. Most PTSD studies do not examine sleep outcomes as a primary measure, and comprehensive literature reviews could not offer evidence-based recommendations. (9), (10) The American Academy of Sleep Medicine (AASM) also noted a paucity of PTSD studies that identified nightmares as a primary outcome measure." See this article at CurrentPsychia try.com for a list of recommended medication options for PTSD-associated nightmares. Table1 Psychosocial consequences of sleep disruption in PTSD Increased reactivity to emotional cues Compromised ability to function in social and occupational roles Negative psychiatric outcomes, including suicidal ideation or worsening of depression or psychosis Interference of natural recovery from trauma exposure Repeated resensitization to trauma cues Neurocognitive deficits Neuroendocrine abnormalities PTSD: posttraumatic stress disorder Source: Adapted from reference 8 CASE CONTINUED Medication change, improvement After reviewing AASM's treatment recommendations, we prescribe prazosin, 1 mg at bedtime for 7 nights, then increase by 1 mg at bedtime each week until Mr. S's nightmares improve. He reports a substantial improvement in nightmare severity and frequency after a few weeks of treatment with prazosin, 5 mg at bedtime. Prazosin Prazosin is an [alpha]l-adrenergic receptor antagonist with good CNS penetrability. The rationale for reducing adrenergic activity to address intrusive PTSD symptoms has been well documented. (12), (13) In open-label trials, (14-18) a chart review, (19) and placebo-controlled trials, (20-22) prazosin reduced trauma nightmares and improved sleep quality and global clinical status more than placebo (Table 2). …