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Post-traumatic stress disorder (PTSD)

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First line  

  • Sertraline
    • Initiate on 50mg/day
    • Dosage can be increased by 50mg monthly to a maximum of 200mg/day
    • Generally fewer side effects
    • If suicidal ideation prior to commencing treatment monitor on a weekly basis initially
  • Paroxetine HCL
    • Initiate on 20mg/day
    • Dosage can be increased by 20mg monthly to a maximum of 60mg/day
    • Greater risk of discontinuation symptoms
  • Fluoxetine
    • Initiate on 20mg/day
    • Dosage can be increased by 20mg monthly to a maximum of 60mg/day 
    • More alerting – potentially less suited if person with PTSD is agitated at start

 

  • SSRIs have many drug interactions
    • Other serotonergic drugs = Increased risk of Serotonin Syndrome
    • Drugs that affect haemostasis (e.g. Aspirin and NSAID’s) = Increased risk of bleeding (especially Upper GI) - prescribe a PPI if at risk
    • Drugs inducing hyponatraemia (e.g. Diuretics) = Increased risk of developing hyponatraemia
    • Other drugs metabolised by CYP2D6
  • Trazadone 50mg-100mg night - if insomina present, can be added to first line 
  • Mirtazapine 15mg night - if insomnia present, can be added to first line  

Second line

If SSRI is not tolerated or still showing clinically significant symptoms

  • Venlafaxine
    • Initiate on 75mg/day
    • Dosage can be increased by 75mg monthly  to a maximum of 300mg/day 

Third line 

If still showing clinically significant symptoms use Quetiapine on its own or in conjuction with SSRI or venlafaxine if either tolerated

  • Quetiapine
    • Initiate 25mg/day at night
    • After 1 week 25mg bd.
    • Dosage can be increased by 50mg monthly to a maximum of 400mg/day
    • ECG before starting medication for all people with PTSD
  • Prazosin
    • Risk of severe first-dose hypotension; the first and second doses should be taken whilst sitting on a bed just before lying down. It is important to keep well hydrated while taking prazosin and to get up slowly – initially sitting up on the bed and then slowly standing up. For the first two nights it is important to sit on the toilet to pass water rather than stand up.
    • prazosin dosing schedule for PTSD:
Time Morning  Before bed
 Days 1-2 Nil 1mg
Days 3-7 Nil 2mg
Week 2 1 mg 4mg
Week 3 2mg 6mg
Week 4 2mg 10mg

Fourth line 

Less evidence-based treatments

  • Amitriptyline
  • Mirtazapine
  • Phenelzine
  • Risperidone

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