Magazine article Clinical Psychiatry News

VA Deems Venlafaxine Top Treatment for PTSD

Magazine article Clinical Psychiatry News

VA Deems Venlafaxine Top Treatment for PTSD

Article excerpt

TUCSON, ARIZ. -- The most recent set of treatment guidelines for posttraumatic stress disorder also are the first ever to boost venlafaxine to first-line status as "strongly recommended" alongside the well-established selective serotonin reuptake inhibitors.

Another milestone in the Veterans Affairs/Department of Defense PTSD treatment guidelines released in late 2010 is that mirtazapine has risen in status to second-line therapy in response to recent mounting evidence of efficacy.

Earlier PTSD treatment guidelines still in place--including the 2007 Australian guidelines, the 2005 British Association for Psychopharmacology guidelines, and the Canadian treatment guidelines--list mirtazapine as third-line therapy to be reserved for seriously treatment-resistant cases. Venlafaxine is generally classified as second- or third-tier therapy in these earlier guidelines, Dr. Gerardo Villarreal noted at the meeting.

The new Veterans Affairs/Department of Defense (VA/DoD) evidence-based guidelines strongly recommend that all adults with PTSD be offered pharmacotherapy with a first-line agent. That means either an SSRI, for which the strongest evidence of benefit exists for sertraline, paroxetine, and fluoxetine, or a serotonin norepinephrine reuptake inhibitor (SNRI), among which venlafaxine has the strongest supporting evidence, said Dr. Villarreal, a psychiatrist at the University of New Mexico, Albuquerque, and the New Mexico VA Health Care System.

The guidelines also strongly recommend offering all patients trauma-focused psychotherapy that includes elements of exposure and/or cognitive structuring, or stress inoculation training.

The VA/DoD report advises pursuing monotherapy with one of the recommended medications for at least 8 weeks, provided the drug is tolerated. If at that point there's no improvement, the recommendation is to either increase to the maximum tolerated dose, switch to another recommended drug, or augment with a second agent.

Atypical antipsychotic agents are recommended as add-on therapy; the guidelines note that the strongest evidence is for risperidone. Dr. Villarreal said his personal practice is to reserve the second-generation antipsychotic agents for the most severe cases, including those involving psychosis or severe dissociation, because of the significant metabolic and other side effects accompanying use of these drugs.

Other recommended second-tier medications for PTSD, in addition to mirtazapine and adjunctive atypical antipsychotics, include the tricyclic antidepressants, nefazodone, prazosin when prescribed for sleep problems or nightmares, and monoamine oxidase inhibitors.

The VA/DoD guidelines specifically do not recommend benzodiazepines, tiagabine, guanfacine, valproate, or topiramate. None of these drugs has demonstrated evidence of benefit.

The guidelines panel provided a lengthy list of drugs for which to date there is deemed insufficient evidence to support a treatment recommendation in PTSD: trazodone, atypical antipsychotics as monotherapy, conventional antipsychotics, buspirone, bupropion, nonbenzodiazepine hypnotics, lamotrigine, gabapentin, clonidine, propranolol, and prazosin as monotherapy.

The VA/DoD list of "insufficient evidence" medications is seen as a nod toward the Institute of Medicine (IOM), which in October 2007 released an influential review of the research evidence on PTSD treatments. …

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