Comparing the Risks and Benefits of Adjunctive Medications for PTSD - - PowerPoint PPT Presentation

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Comparing the Risks and Benefits of Adjunctive Medications for PTSD - - PowerPoint PPT Presentation

Feb 15, 2023 533 likes •768 views

Comparing the Risks and Benefits of Adjunctive Medications for PTSD Presenter Name Beth Cohen, MD MAS San Francisco VA Health Care System & University of California, San Francisco September 19, 2019 Beth Cohen Has nothing to disclose.

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Comparing the Risks and Benefits of Adjunctive Medications for PTSD

Presenter Name

Beth Cohen, MD MAS San Francisco VA Health Care System & University of California, San Francisco September 19, 2019

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Beth Cohen

  • Has nothing to disclose.
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Challenges in Pharmacologic Treatment of PTSD

  • In RCTs of first-line serotonin reuptake inhibitor (SRI) therapy:
  • 40% of patients do not have clinically significant improvements in

PTSD symptoms

  • 70% do not achieve remission
  • Little evidence on what to do next
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Our Initial Research Goal

  • Many patients are prescribed antipsychotic medications
  • mixed evidence in trials
  • only 1 trial specifically in patients already on SRIs
  • many concerning metabolic side effects

To determine the risks and benefits of adding antipsychotics to an SRI in patients with PTSD?

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Feedback from Partners

  • Patient partners:
  • many different types of medications used
  • “you feel like a guinea pig”
  • wanted information to participate in shared decision making
  • Stakeholder partners:
  • providers want to “do something”
  • no studies compare strategies, so there is no guidance
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Our Updated Research Goal

  • To compare the risks and benefits of several medications that are

commonly added to SRIs:

  • antipsychotics
  • mirtazapine
  • tricyclic antidepressants
  • prazosin
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Methods

  • National VA electronic records 2007-2015
  • PTSD but no bipolar/psychotic disorder
  • SRI ≥ 30 days
  • Augmenting medication added for ≥60 days:
  • Antipsychotics (N=70,900)
  • Mirtazapine (N=54,672)
  • Tricyclics (N=21,984)
  • Prazosin (N=100,269)
  • Compare outcomes in 1 year before vs. after addition of augmenting

medication

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Methods: Outcomes

  • Benefits:
  • PTSD symptoms (PTSD Checklist)
  • Mental health ER visits and hospitalizations
  • Suicidality
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Methods: Outcomes

  • Risks:
  • Weight
  • Blood pressure
  • Labs: cholesterol, glucose, hemoglobin A1c
  • Cardiovascular disease events
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Results: PTSD Symptoms

  • On average, each group had very small improvements after addition
  • f augmenting med
  • Similar by medication class
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Results: PTSD Symptoms

  • PTSD symptoms gradually increase and peak around time Rx is added
  • In 3-4 months, symptoms return to baseline levels
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Mental Health Emergency Room Visits

  • Augmenting med groups have different baseline mental health ER visit rates

but % improvement is similar

  • In contrast to PTSD symptoms, there were more substantial average

reductions ER visits

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Suicidal Thoughts

  • Small but clinically meaningful reductions in suicidal thoughts
  • Biggest improvements with prazosin and antipsychotics
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Weight

  • Most weight gain with antipsychotics/mirtazapine and no return to

baseline

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Hemoglobin A1c

  • Greatest increase with mirtazapine and tricyclics
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Other Metabolic Outcomes

  • Triglycerides: increased 3-8% except for prazosin
  • No significant increases in blood pressure or cholesterol, but:
  • 20-30% increased/started medications to treat
  • Increase in diagnoses of cardiovascular disease events
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Summary

  • 2nd line medications may be useful when PTSD symptoms worsen
  • Benefits similar across classes
  • Use associated with weight gain and other metabolic risks:

mirtazapine>antipsychotics>tricyclics>prazosin

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Next Steps

  • Presenting locally and nationally
  • Working with stakeholder partners- NCPTSD, VA Office of Mental

Health Operations

  • Compare to a “control” group with inadequate SRI response
  • Identify which patients are most likely to benefit
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Thank You

  • Project Team: Nancy Bernardy, Shira Maguen, Thomas Neylan,

Annie Ryder, Karen Seal, Janet Tang, Ana-Marie Urbieta, Ilse Weichers, Anne Woods, Dmitri Young

  • VA Measurement Science QUERI: Mary Whooley, Craig Meyer,

Niru Krishnamurthi, David Schopfer, Hui Shen, Katherine Williams, Ning Zhang

  • Funding: PCORI
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Learn More

  • www.pcori.org
  • info@pcori.org
  • #PCORI2019
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Questions?

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Thank You!

Beth Cohen

Comparing the Risks and Benefits of Adjunctive Medications for PTSD September 19, 2019