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 After 10 weeks of therapy with the generic drug, which costs about a
nickel per pill, recipients had no significant reduction in
recurrent nightmares or easier sleep compared to veterans receiving
placebo.
Sixteen weeks later, even after doctors were allowed to add some
other treatments, there was still no difference between the two
groups.
The study, known as PACT, did find a lower rate of new or worsening
suicidal thoughts among prazosin recipients. The rate with placebo
was 15 percent versus 8 percent with the drug. However, that trend
surfaced as part of an evaluation of side effects; suicidal ideation
was not a primary outcome and the number of cases was small.
Experts in PTSD familiar with the research have been shocked by the
findings, chief author Dr. Murray Raskind told Reuters Health in a
telephone interview.
But it's also likely that the drug is effective in some veterans
with more severe PTSD who have trauma nightmares, waking up sweaty
after thrashing around in bed. They were excluded from the study for
safety reasons. In normal nightmares, sleepers are usually unable to
move.
The results should discourage doctors from giving prazosin as a
one-size-fits-all therapy and encourage them to identify veterans
who will find it effective, he said.
"It should put the focus on personalized precision medicine.
Fortunately, our patients will tell us" when it's working and will
ask for it if they're taken off the drug and their symptoms return,
said Raskind, director of the VA's Northwest Network Mental Illness
Research Education and Clinical Center.
An estimated 5 percent to 10 percent of the U.S. population has PTSD,
with much higher rates among veterans and active-duty soldiers.
It manifests itself in many ways but nightmares and sleep problems
are often cited as the worst aspects.
When veterans reported that the medicine, when given for high blood
pressure, seemed to be alleviating their nightmares, the drug was
quickly embraced as a PTSD treatment. Some clinical trials have
affirmed its reputation.
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"Thus, the failure of this new, large, multisite trial to replicate
the previous studies is surprising and disappointing," Dr. Kerry
Ressler of McLean Hospital in Belmont, Massachusetts, said in an
editorial in The New England Journal of Medicine, where the study
appears.
Ressler said the drug may not have seemed effective because patients
with social instability or veterans who were already benefiting from
another drug were not included. Some volunteers may also have been
suffering from undiagnosed sleep apnea, which might have masked the
benefits of the drug.
The study allowed for the daily dose to be adjusted upward - up to
20 milligrams per day for men and 12 mg for women - to try for
maximal alleviation of nightmares without serious adverse effects.
Among the 187 men, 54% of the prazosin recipients and 70% getting
placebo reached the maximum dose.
"We found out from our referring doctors that the very distressed
vets who had these trauma nightmares - waking up sweaty, thrashing
around - were not put in the study," said Dr. Raskind. "So we got a
sample of quite stable veterans who reported enough symptoms for
PTSD and had nightmares. But we had to exclude people with
psychosocial instability because we didn't want to risk giving
placebo to someone who would harm themselves, harm others, get in
trouble with the law, or lose their jobs because they were
randomized to placebo for 6 months. So I think what we did was
recruit a very treatment-resistant, stable sample."
Not surprisingly, prazosin lowered blood pressure more than placebo,
and it still may be given for that purpose, said Raskind, who is
also a professor of psychiatry at the University of Washington
School of Medicine in Seattle.
Rates of serious side effects were comparable in the two groups.
Prazosin patients had higher rates of dizziness, lightheadedness and
urinary incontinence. Two veterans, both in the placebo group, were
hospitalized following suicidal ideation.
SOURCE: http://bit.ly/2EdOqgR The New England Journal of Medicine,
online February 7, 2018.
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