title: Early discontinuation and suboptimal dosing of prazosin: a potential missed opportunity for veterans with posttraumatic stress disorder.
abstract: OBJECTIVE
  Clinical Practice Guidelines issued by the US Department of Veterans Affairs (VA) and the Department of Defense recommend prazosin for sleep/nightmares for veterans with posttraumatic stress disorder (PTSD). As existing literature suggests this novel treatment option to be underutilized, we examined a cohort of veterans with PTSD initiating prazosin to characterize their typical duration of use and dosing patterns.
  
  
  METHODS
  Administrative data from fiscal year 2010 were used to identify veterans with PTSD according to ICD-9 codes extracted from inpatient and outpatient encounters. The longitudinal course of prazosin use following initiation was examined using refill data, and estimated prazosin doses were calculated based upon total milligrams and the day's supply dispensed.
  
  
  RESULTS
  A total of 12,844 veterans with PTSD initiated prazosin during 2010. Twenty percent of veterans never refilled the initial prescription, and 37.6% persisted on the drug for at least 1 year. Patients more likely to remain on prazosin for at least 1 year were older (ages 40-59 years [OR = 1.28; 95% CI, 1.15-1.45] and ages ≥ 60 years [OR = 1.25; 95% CI, 1.12-1.40]) relative to younger patients and taking more medications (4-6 [OR = 1.40; 95% CI, 1.27-1.55], 7-9 [OR = 1.73; 95% CI, 1.56-1.94], and ≥ 10 [OR = 2.04; 95% CI, 1.83-2.29]) relative to 0-3 medications. The mean maximum prazosin dose reached in the first year of treatment was 3.6 mg/d, and only 14.1% of patients reached the minimum guideline recommended dose of 6 mg/d.
  
  
  CONCLUSIONS
  Of patients with PTSD newly initiated on prazosin in 2010, < 40% were still taking the drug 1 year later, and < 20% received the minimum recommended dose according to current VA guidelines. Further investigation is required to determine the precise clinical factors underlying these prescribing patterns and overcome barriers to guideline-concordant treatment.
authors.affiliation: Iowa City VA Health Care System (Mailstop 152), 601 Hwy 6 West, Iowa City, IA 52246 bruce.alexander@va.gov.
authors.forename: Bruce
authors.initials: B
authors.lastname: Alexander
authors.forename: Brian C
authors.initials: BC
authors.lastname: Lund
authors.forename: Nancy C
authors.initials: NC
authors.lastname: Bernardy
authors.forename: Melissa L D
authors.initials: ML
authors.lastname: Christopher
authors.forename: Matthew J
authors.initials: MJ
authors.lastname: Friedman
mesh_terms: D058668:Adrenergic alpha-1 Receptor Antagonists / Q000008:administration & dosage*; D000328:Adult; D011307:Drug Prescriptions / Q000706:statistics & numerical data*; D005260:Female; D006801:Humans; D008137:Longitudinal Studies; D008297:Male; D008875:Middle Aged; D017410:Practice Guidelines as Topic; D011224:Prazosin / Q000008:administration & dosage*; D013313:Stress Disorders, Post-Traumatic / Q000188:drug therapy*; D014481:United States; D014728:Veterans / Q000706:statistics & numerical data*; D016903:Drug Monitoring
chemical_list: D058668:Adrenergic alpha-1 Receptor Antagonists; D011224:Prazosin