Clinical Case Series: The Use of Prazosin for Combat-Related Recurrent Nightmares among Operation Iraqi Freedom Combat Veterans

Military Medicine, Jun 2005 by Daly, Christine Maura, Doyle, Michael E, Radkind, Murray, Raskind, Elaine, Daniels, Colin

The patient was seen for follow-up evaluation 2 weeks later. At that time, he reported complete resolution of the nightmares. Therefore, no increase in the Prazosin dose was required. The follow-up evaluation 1 month later revealed continued remission of nightmares and improved sleep.

Case 2

A 20-year-old Army Reservist was wounded in action in May 2003 with a disabling leg injury when his vehicle was hit by a rocket-propelled grenade. The patient presented to the BHC in November 2003 with a complaint of recurrent nightmares of the explosion, which repeatedly awakened him in a "cold sweat" throughout the night. The patient also reported severe sleep disturbances and troublesome daytime irritability. He attributed these associated symptoms to his recurrent nightmares. His symptoms were consistent with PTSD. Prazosin (1 mg at bedtime) therapy was initiated to treat his recurrent nightmares. The patient was receiving no other medications.

The patient was seen for follow-up evaluation 5 days later, at which time he reported having a marked reduction in the frequency and intensity of his nightmares and noted substantial improvement in his sleep. No increase in the Prazosin dose was made. The patient was seen again after 2 weeks, at which time he noted complete resolution of his nightmares.

Case 3

A 20-year-old regular Army soldier was wounded in action in Iraq when the vehicle he was driving was hit with an improvised explosive device. He sustained upper extremity burns while rescuing fellow soldiers from the burning wreckage. When evaluated 8 weeks later, the soldier reported recurring, sleep-disrupting nightmares of the event. When screened for additional psychiatric symptoms, he particularly noted having a phobic avoidance of military vehicles, which made him very anxious and distraught. He also noted hypervigilance, particularly while driving. These major presenting symptoms were consistent with PTSD. Prazosin (1 mg at bedtime) therapy was initiated for the treatment of the nightmares. No other psychotropic medications were initiated.

The patient was seen weekly for follow-up evaluation. After 2 weeks of Prazosin therapy, the patient reported resolution of his nightmares and substantial improvement in sleep. When seen 1 month later, the patient reported discontinuation of the medication, for unclear reasons. With medication discontinuation, the patient's nightmares quickly recurred. The patient resumed Prazosin (1 mg at bedtime) therapy and, after 3 days, again reported resolution of the nightmares.

Discussion

Low-dose Prazosin therapy was associated with the elimination or substantial reduction of combat-related nightmares typical of PTSD for a high percentage of soldiers who presented with these distressing symptoms after their return from OIF. These open-label results are consistent with the demonstration of Prazosin efficacy for treatment-resistant, combat-related nightmares and associated sleep disruption in a placebo-controlled trial among Vietnam combat veterans with chronic PTSD.15 Although Prazosin is indicated clinically for hypertension, no incidents of dizziness, falls, or other manifestations of excessive blood pressure reduction were reported by these patients. The observed impressive reduction of combat nightmares and improved sleep, as well as the absence of adverse effects, among soldiers who recently returned from OIF provide a strong rationale for a placebo-controlled trial of Prazosin treatment for these distressing nighttime symptoms in this population.