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Update on Pharmacotherapies for PTSD

Update on Pharmacotherapies for PTSD. Michelle Pent, MD, MPH April 29, 2011. Presentation. Anxiety-spectrum disorder DSM-IV criteria A: Exposure to traumatic event with perceive threat to life or physical integrity and response of intense fear B: Re-experience of the traumatic event

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Update on Pharmacotherapies for PTSD

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  1. Update on Pharmacotherapies for PTSD Michelle Pent, MD, MPH April 29, 2011

  2. Presentation • Anxiety-spectrum disorder • DSM-IV criteria • A: Exposure to traumatic event with perceive threat to life or physical integrity and response of intense fear • B: Re-experience of the traumatic event • C: Avoidance of stimuli associated with the trauma • D: Hyperarousal

  3. Target Symptoms • Intrusive ruminations • Nightmares • Flashbacks • Hyperarousal • Hypervigilance • Associated irritability, anger, poor focus and concentration, and physiologic distress

  4. Neurochemistry • Amygdala • Central Nervous System • Norepinephrine, Serotonin, Dopamine, GABA • Peripheral Nervous System • Sympathetic Nervous System • “Fight or flight”

  5. Treatment • Psychotherapy • Pharmacotherapy • Most evidence suggests psychotherapy is most effective • CBT • EMDR • DBT where indicated

  6. Complimentary Treatments • Yoga/Meditation • Acupuncture • Mindfulness Training • Relaxation Therapy

  7. Pharmacotherapy • Objective is to improve symptoms by minimizing anxiety • Selective Serotonin Reuptake Inhibitors • Other antidepressants • Anxiolytics • Other

  8. Selective Serotonin Reuptake Inhibitors (SSRIs) • Raise serotonin levels in the brain • Remain standard of care for anxiety disorders • Linked with • Improvement in baseline level of anxiety • Diminished intrusive ruminations

  9. SSRIs • Fluoxetine (Prozac) • Sertraline (Zoloft) • Fluvoxamine (Luvox) • Paroxetine (Paxil) • Citalopram (Celexa) • Escitalopram (Lexapro)

  10. SSRIs • Lag time before efficacy • Usually 4-6 weeks • Adequate trial a minimum of 8 weeks • Side effects • Nausea, diarrhea • Weight gain • Agitation • Sexual dysfunction

  11. Other Antidepressants • Selective Serotonin Norepinephrine Reuptake Inhibitors (SNRIs) • Venlafaxine (Effexor) • Duloxetine (Cymbalta) • Desvenlafaxine (Pristiq) • Tricyclic Antidepressants • Amitryptyline (Elavil) • Doxepin (Sinequan)

  12. Anxiolytics • Benzodiazepines • Alpha adrenergic antagonists • Buspirone • Antihistamines

  13. Benzodiazepines • Diminish anxiety by enhancing GABA in the central nervous system • No longitudinal effect on anxiety • Significant tolerance and dependence • Essentially contraindicated in patients with history of substance abuse • Intended for short term use • Increasingly considered inappropriate for long term treatment of anxiety disorders

  14. Benzodiazepines • Diazepam (Valium) • Lorazepam (Ativan) • Alprazolam (Xanax) • Clonazepam (Klonopin) • Oxazepam (Serax) • Chlordiazepoxide (Librium) • Temazepam (Restoril)

  15. Other Anxiolytics • Buspirone (Buspar) • Serotonin agent • May cause headache, nausea • Antihistamines • Diphenhydramine (Benadryl) • Hydroxyzine (Vistaril) • Side effects include sedation, confusion at high doses

  16. Other Anxiolytics • Alpha adrenergic antagonists • Blood pressure medications • Prazosin (Minipress) • Clonidine (Catapres) • Side effects include dizziness and other complications of low blood pressure

  17. Other Anxiolytics • Gabapentin • Anticonvulsant/Mood Stabilizer • Enhances GABA in central nervous system • Some usefulness for anxiety • Limited addictive potential

  18. Use of Antipsychotics • May be useful as anxiolytics • Use does not necessarily imply psychosis • Significant sedation, weight gain, metabolic disturbance • Most commonly used • Quetiapine (Seroquel) • Olanzapine (Zyprexa) • Ziprasidone (Geodon)

  19. Treating Sleep

  20. Sleep • Review of sleep hygiene is critical • Complimentary treatments can also be effective

  21. Sleep • Benzodiazepine analogues • Eszopiclone (Lunesta) • Zolpidem (Ambien) • Addictive potential • Benzodiazepines • Short term use

  22. Sleep • Trazodone (Desyrel) • Often exacerbates nightmares • Mirtazapine (Remeron) • Associated with weight gain • Melatonin • Ramelteon (Rozerem)

  23. Sleep • Antihistamines • Alpha antagonists • Sedating antipsychotics • Seroquel, Zyprexa

  24. Choosing a Medication? • Safety • Tolerability • Efficacy • Cost

  25. Educate patient that symptoms unlikely to improve with medication in the absence of psychotherapy

  26. Questions?

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