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Emerging pharmacological treatments for post-traumatic stress disorder.

Post-traumatic stress disorder (PTSD) affects nearly 15% of returning war veterans and about 8% of the general population who have survived traumatic experiences and interpersonal violence (Feder et al., 2014). PTSD is categorized as a stress-related disorder with a range of possible symptoms: nightmares, intrusive thoughts, hypervigilance, and avoidance of anything that could trigger a re-experiencing of the trauma (American Psychological Association, 2017).

Some of our veterans and civilians live with PTSD in silence, while others seek treatment. Often PTSD treatment includes a combination of medication, such as an anti-depressant, with talk therapy. Treatment results are varied depending on the specific study, study methods, and size of the study.

Emerging PTSD literature has identified three relatively commonly used medications that medical-surgical nurses administer, depending on the type of patients cared for on the unit: prazosin, acetylcysteine, and ketamine. Ketamine, for example, is administered to patients being treated for pain and is often reserved for ICU patients, but is being seen more on medical-surgical units. These medications are now the foci of several new studies that are assessing drug safety and efficacy in patients with active PTSD symptoms (Back et al., 2016; Feder et al., 2014; Koola, Varghese, & Fawcett, 2014).

Prazosin

Medical-surgical nurses will recognize prazosin (trade names include Minipress[R], Vasoflex[R], Lentopres[R], and Hypovase[R]) as an alpha-blocker that is used in the treatment of benign prostatic hyperplasia (BPH). In men with prostatic hyperplasia, prazosin causes blood vessels and muscles to relax around the urethra, thereby improving urinary flow. For BPH, a typical initial dose of prazosin is 1-2 mg orally two to three times per day, with a maintenance dose of between 615 mg orally in a divided dose (Drugs.com, 2017).

In PTSD, too much adrenaline hormone is released, causing stress, which can lead to nightmares. The nightmares can seem real and make the sufferers feel like they are back in direct combat. According to Koola and colleagues (2014), higher doses of prazosin, up to 40 mg orally per day, results in significant remission rates of flashbacks and nightmares and are safe to administer at the higher dosages. Dizziness and hypotension are known side effects. In patients who are also taking anti-hypertensives with high-dose prazosin, reductions to blood pressure medications may be needed (Koola et al., 2014). Any change to existing medications would require careful communication and coordination among the care team.

Acetylcysteine

Medical-surgical nurses will recognize acetylcysteine the reversal medication for acetaminophen overdose. Acetaminophen is metabolized by the liver, and can over whelm the supply of glutathione reserves, which are necessary to combat a toxic metabolite that accumulates in the liver after acetaminophen overdose. Glutathione reserves are not only important in the liver, but research is suggesting glutathione reserves in the brain facilitate dopamine transmission and have important antioxidant properties (Back et al., 2016).

Back and colleagues (2016) reported on the first randomized controlled trial of 35 veterans who, in the treatment arm of the study, received 2,400 mg/day orally of acetylcysteine. Preliminary results suggest significant improvement in PTSD symptoms and provide impetus for continued and larger studies. The study also reported that acetylcysteine was well tolerated with good compliance (Back et al., 2016).

Ketamine

Nurses will recognize low-dose ketamine as a drug used in procedural sedation, and more recently seen in pain clinics for chronic pain. Ketamine, when used as an anesthetic, is typically given at 2 mg/kg intravenously (IV) for analgesia (Feder et al., 2014). Ketamine exerts sympathomimetic properties the can increase blood pressure and heart rate, but without the deleterious effect on breathing reflexes (Feder et al., 2014).

A proof-of-concept study was conducted at Mount Sinai Hospital in New York on 41 patients with chronic PTSD (Feder et al., 2014). Lower doses of ketamine (0.5 mg/kg IV) versus midazolam (0.045 mg/kg IV) were compared (Feder et al., 2014). The group who received the low-dose ketamine described a reduction in PTSD severity at 24 hours, and this result persisted in some patients for up to two weeks (Feder et al., 2014). Ketamine was found to be superior to midazolam in reducing PTSD severity (Feder et al., 2014 Replication studies are needed.

Conclusion

As these studies and others establish drug safety and efficacy in subject volunteers, additional studies are needed. Both the research community and clinicians seek new, safe, and effective treatment modalities for PTSD patients to provide relief from intrusive and disabling symptoms.

References

American Psychological Association. (2017). Post-traumatic stress disorder. Retrieved March 10, 2017, from http://www.apa.org/topics/ptsd/ index.aspx20161023234232845238209

Back, S.E., McCauley, J.L., Korte, K.J., Gros, D.F., Leavitt, V., Gray, K.M., ... Kalivas, P.W. (2016). A double-blind, randomized, controlled pilot trial of N-acetylcysteine in veterans with posttraumatic stress disorder and substance use disorders. Journal of Clinical Psychiatry, 77(11), e-1439-e 1446. doi: 10.4088/JCP.15m1023920161023235 131346943974

Drugs.com. (2017). Prazosin dosage. Retrieved March 10, 2017, from http://www.drugs.com/dosage/prazosin.html

Feder, A., Parides, M.K., Murrough, J.W., Perez, A.M., Morgan, J.E., Saxena, S., ... Charney, D. S. (2014). Efficacy of intravenous ketamine for treatment of chronic posttraumatic stress disorder a randomized clinical trial.JAMA Psychiatry, 7/(6), 681-688.

Koola, M.M., Varghese, S.P., & Fawcett, J.A. (2014). High-dose prazosin for the treatment of post-traumatic stress disorder. Therapeutic Advances in Psychopharmacology, 4(1), 43-47.

Patricia J. Bartzak, DNP, RN, CMSRN, is a Clinical Nurse, Burn/Trauma Unit, Brigham & Women's Hospital, Boston, MA. She is the "Joining Forces" Column Editor.
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Title Annotation:Joining Forces
Author:Bartzak, Patriia J.
Publication:MedSurg Nursing
Article Type:Report
Date:Mar 1, 2017
Words:919
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