Prazosin Titration Clinics
VA health care systems use pharmacists to manage veterans prescribed prazosin through PTC consultations. PTCs provide a process for close follow-up and assessment of PTSD-related outcomes. Due to the frequency of follow-up, this service may be beneficial for older veterans with more complex comorbidities and medication regimens. Any veteran with PTSD-related nightmares may be referred to the PTC for a consultation by any health care provider. Once referred to the clinic, MH CPSs assume responsibility for the prazosin prescription, including dose adjustments. For example, if a veteran reported no issues with tolerability but continued to have frequent and distressing nightmares, the dose may be increased, typically by 1-mg to 2-mg increments. Once the veteran reaches a stable and tolerable dose of prazosin, they are discharged from the PTC, and the referring health care provider resumes responsibility for the prazosin prescription.
Clinically Measured Outcomes
Nightmare frequency and intensity were measured using the Recurrent Distressing Dreams item B2 of the Clinician Administered PTSD Scale (CAPS) (Table 1). The PTSD Checklist (PCL-5), Insomnia Severity Index (ISI), and total sleep hours were used to determine the effect of prazosin on symptom severity (Table 2). The PCL-5 is a 20-item self-report used to monitor and quantify symptom level and change over time. It evaluates the frequency over the past month that a patient was bothered by any of the Diagnostic and Statistical Manual of Mental Disorders (DSM-5) PTSD criterion.2 Scores range from 0 (not at all) to 4 (extreme), with a maximum score of 80. The ISI is a 7-item self-report of sleep symptoms, with a total score of 28, where increasing scores indicate increasing severity of insomnia (Table 3).
Clinically measured outcome scales were performed and assessed by MH CPSs. CAPS frequency and intensity were measured at each clinic visit. PCL-5 and ISI scores were assessed at baseline and at the endpoint of study or discharge from clinic (Table 4). Patients who continued in the PTC after the end of the study date or who were lost to follow-up did not complete these measures at time of discharge.
Data Analysis
The primary outcome was change in CAPS nightmare frequency and intensity from time of initial clinic visit to time of discharge or end of study. The secondary outcomes included change in PCL-5, ISI, and sleep hours. Other secondary outcomes included measures of tolerability: BP changes, adverse effects (AEs) reported, and outcome of prazosin therapy when AEs were reported. Change in PTSD symptoms, PCL-5, and ISI were assessed using the Wilcoxon signed rank tests. Findings were considered to be statistically significant at P ≤ .05. Other variables were reported descriptively.
Results
Thirty-two veterans, aged ≥ 65 years, with clinical diagnosis of PTSD at the time of referral to the PTC were reviewed (Table 5). All patients were male and 93.8% were white. Thirty were Vietnam era veterans, 1 served in the Persian Gulf era, and 2 served in the post-Korean War era. Twenty-eight veterans had a combat history. Severe PTSD symptoms were reported as indicated by baseline PCL-5 scores, and moderate severity insomnia symptoms as indicated by baseline ISI scores.