Part 1 describes the reasoning and recommendations up to node 2 of the algorithm.

Transcription

1 Presented by: David Osser, MD Assciate Prfessr f Psychiatry Harvard Medical Schl Dr. Osser has n cnflicts f interest t disclse. This dcument is a summary f selected clinical pearls frm Dr. Osser s presentatin: PTSD Pharmactherapy Algrithm Part 1: Assessment and Management f Sleep Symptms. Click here t watch the presentatin Part 1 describes the reasning and recmmendatins up t nde 2 f the algrithm. Presentatin utline: 1. Intrductin 2. Differential diagnsis f PTSD: the imprtance f cmrbidities 3. Sleep Assessment in PTSD: Is sleep disturbed? (nde 2) 4. Prazsin fr nightmares and disturbed sleep (nde 2a) 5. Trazdne fr disturbed sleep initiatin (nde 2b) 6. Other ptins fr imprving sleep latency in PTSD 7. Undesirable initial chices fr sleep management in PTSD Dcument Cntents Flwchart fr the Algrithm... 2 Cmrbidity Assessment... 3 Sleep Assessment... 3 Cnsider Prazsin fr Nightmares r Disturbed Awakenings (Nde 2a)... 3 Ratinale... 3 Evidence f efficacy... 3 Dsing... 3 Cnsider Trazdne if Sleep Initiatin is Disturbed (Nde 2b)... 4 Abut trazdne... 4 Adverse effects... 4 Rle in PTSD... 4 Dsing... 5 Other ptins cmmnly used fr imprving sleep latency... 5 Undesirable initial chices fr sleep in PTSD

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3 The diagnsis f cmrbidities is imprtant because if present, these culd change the basic algrithm. It is imprtant t lk fr: Substance use disrders Avid benzdiazepines Depressin Biplar disrder Psychsis Impulse cntrl disrders Sleep impairment is a cre symptm f PTSD Cmmn sleep disturbances include: Hyperarusal linked t difficulties initiating r maintaining sleep Trauma-related nightmares Disturbed awakenings withut nightmare recllectin Prlnged sleep latency (ften due t fear f nightmares) Fr many patients, imprving sleep symptms can imprve cre daytime PTSD symptms (hypervigilance, avidance, re-experiencing). Lk fr ther causes f insmnia: sleep apnea, restless legs syndrme, peridic limb mvements f sleep, sleep hygiene issues, excess caffeine cnsumptin, medical prblems Pathphysilgy f sleep disturbances in PTSD Increased nradrenergic activity during sleep and while trying t fall asleep Prazsin MOA Nn-sedating antagnist Five placeb-cntrlled RCTs 4 published trials unpublished study ClinicalTrials.gv Effect sizes frm published studies General PTSD symptms: arund 1 Nightmares reductin: arund 2 Unpublished study N difference frm placeb Gal f treatment: eliminate disturbed awakenings 3

4 Prtcl fr men (Raskind, 2013) Mean average dse: 16 mg (15.6 mg) Maximum dse: 25 mg Dse at bedtime 1 mg HS fr 2 nights 2 mg fr 5 nights 4 mg fr 7 nights 6 mg fr 7 nights 10 mg fr 7 nights 15 mg fr 7 nights Mid-mrning dse (10-11 AM) Week 2: 1 mg Week 3 4: 2 mg Week 5-6: 6 mg Prtcl fr wmen (Raskind, 2013) Median dse: 7 mg Maximum dse: 10 mg Dse at bedtime 1 mg HS fr 2 nights 2 mg fr 5 nights 4 mg fr 7 nights 6 mg fr 7 nights 10 mg fr 7 nights 15 mg fr 7 nights Mid-mrning dse (10-11 AM) Week 2-3: 1 mg Week 4 5: 2 mg Sedating antidepressant Efficacy fr sleep disturbances shwn in pen-label studies Pharmacdynamic prperties: 5-HT 2A antagnist 1 antagnist H 1 antagnist Sedatin Dizziness Orthstatic hyptensin Syncpe Priapism (infrequent, but risk may be increased if cmbined with prazsin) Cnsider prescribing trazdne when: The patient has sleep initiatin difficulties withut nightmares r ncturnal hyperarusals 4

5 The patient still has initial insmnia, even after prazsin was effective fr nightmares and ncturnal hyperarusals There is minimal evidence fr treating nightmares and ncturnal hyperarusals with trazdne in case prazsin was nt effective. Usually started at 50 mg bedtime, with instructins t reduce t 25 mg if t sedating Gabapentin (case reprts nly) Mirtazapine (n evidence, but cmmnly used, causes weight gain) Hydrxyzine (n evidence but cmmnly used - watch fr new PDR max f 100 mg) Melatnin (n evidence, but cmmnly used at 3-10 mg) Diphenhydramine (n evidence - hypntic effect in thers dissipates after 3 dses) Dxepin, Amitriptyline Adverse effects: Antichlinergic Antihistaminic (weight gain) Cardiac (nt safe in case f verdse) High ptential fr abuse in PTSD In patients with r withut cmrbid substance use disrder Might be cnsidered if Past histry f clear respnse withut significant abuse r misuse Nt effective fr primary symptms f PTSD May reduce effectiveness f psychtherapies Widely prescribed fr sleep in PTSD Review paper: The benefits did nt justify the risks. It shuld nt be used as a first-line treatment fr insmnia Weight gain Nt dse related, can ccur at small dses Mre likely t be discntinued than prazsin 5