What are the recommended medications for a patient with Post-Traumatic Stress Disorder (PTSD) and Alcohol Use Disorder (AUD)?

Medication Recommendations for PTSD and Alcohol Use Disorder

For patients with comorbid PTSD and alcohol use disorder (AUD), the recommended first-line pharmacological approach is an SSRI (sertraline or paroxetine) for PTSD symptoms combined with naltrexone for alcohol use disorder, alongside trauma-focused psychotherapy. 1, 2

First-Line Pharmacotherapy

For PTSD:

• SSRIs (first-line):
  • Sertraline: 50-200 mg/day 1
  • Paroxetine: 20-60 mg/day 1
  • These medications have shown 53-85% response rates in PTSD treatment 1

For Alcohol Use Disorder:

• Naltrexone (first-line): 50 mg daily 3
  • Reduces alcohol craving and consumption
  • Has shown superior outcomes when combined with trauma-focused therapy 3

Second-Line Pharmacotherapy Options

For PTSD:

• Prazosin: 1-15 mg at bedtime (start at 1 mg and titrate up) 2
  • Level A recommendation specifically for PTSD-related nightmares
  • Particularly effective for trauma-related nightmares with demonstrated efficacy in multiple controlled trials

For Alcohol Use Disorder:

• Topiramate: Titrate to effective dose 2
  • Has demonstrated efficacy in reducing heavy drinking
  • Associated with decreased liver enzyme levels
• Baclofen: Up to 80 mg/day (per French ANSM recommendation) 2
  • May increase abstinence rates and prevent relapse
  • The only alcohol pharmacotherapy tested in patients with significant liver disease

Important Medication Considerations

• Avoid benzodiazepines: Despite their anxiolytic properties, benzodiazepines:

  • May worsen outcomes in PTSD 1
  • Carry high abuse potential, especially concerning in patients with AUD 2
  • Should not be used beyond 10-14 days if needed for acute alcohol withdrawal 2

• For alcohol withdrawal management:

  • Short-acting benzodiazepines (lorazepam, oxazepam) are safer in patients with hepatic dysfunction if withdrawal management is needed 2
  • Use symptom-triggered regimen rather than fixed-dose schedule 2
  • Monitor with CIWA-Ar scale (score >8 indicates moderate withdrawal, ≥15 indicates severe withdrawal) 2

Psychotherapy Integration

• Combine pharmacotherapy with evidence-based psychotherapy: 2, 1
  • Trauma-focused cognitive behavioral therapy (CBT) approaches show superior outcomes compared to medication alone
  • Combined CBT and pharmacotherapy is more effective than usual care plus pharmacotherapy 2
  • Specific recommended approaches:
    • Prolonged Exposure (PE)
    • Cognitive Processing Therapy (CPT)
    • Eye Movement Desensitization and Reprocessing (EMDR)

Treatment Algorithm

1. Initial treatment:

   • Start SSRI (sertraline 50 mg/day or paroxetine 20 mg/day) for PTSD symptoms
   • Start naltrexone 50 mg daily for AUD
   • Refer for trauma-focused psychotherapy (PE, CPT, or EMDR)

2. After 4-6 weeks:

   • If PTSD symptoms persist: Increase SSRI dose (up to 200 mg/day for sertraline or 60 mg/day for paroxetine)
   • If nightmares persist: Add prazosin starting at 1 mg at bedtime, titrating up as needed

3. After 8-12 weeks:

   • If alcohol cravings/use persist: Consider adding/switching to topiramate or baclofen
   • If PTSD symptoms persist: Consider switching to alternative SSRI or adding prazosin if not already prescribed

4. Monitor:

   • PTSD symptoms using standardized measures (e.g., PCL-5)
   • Alcohol use patterns and cravings
   • Liver function tests when using medications metabolized hepatically

Special Considerations

• Treatment response may vary by patient subtype: 4

  • Patients with less severe alcohol dependence and early-onset PTSD may respond better to sertraline
  • Those with more severe alcohol dependence and later-onset PTSD may not respond as well to SSRIs

• Hepatic function:

  • Monitor liver function in patients taking medications with hepatic metabolism
  • Baclofen has been studied specifically in patients with liver disease 2

• Treatment duration:

  • Continue effective treatment for at least 6-12 months to decrease relapse rates 1
  • Long-term treatment planning is essential for both conditions

By following this evidence-based approach that addresses both conditions simultaneously, patients with comorbid PTSD and AUD have the best chance for improved outcomes in terms of reduced mortality, morbidity, and enhanced quality of life.