Management of trauma-related nightmares in PTSD: Can doxazosin serve as a pragmatic alternative to prazosin?

OBJECTIVES

Trauma-related nightmares (TRNs), core features of post-traumatic stress disorder (PTSD), partially or fully replicate the traumatic event and are often associated with nocturnal awakenings and significant emotional distress. In light of the imminent withdrawal of prazosin in France, this review explores the potential of doxazosin as a pharmacological alternative while emphasizing the central role of psychotherapeutic interventions in TRNs management.

METHODS

Following a brief overview of TRNs and existing therapeutic strategies, both pharmacological and non-pharmacological, this review examines the available evidence on doxazosin, a selective α1-adrenergic receptor antagonist, and proposes a practical initiation protocol for clinicians.

RESULTS

Although limited and heterogeneous, the literature suggests that doxazosin may reduce the frequency and intensity of TRNs and improve sleep continuity, particularly in patients with marked adrenergic hyperactivation or those who previously responded to prazosin. Tolerance is generally good and extended-release formulations enable convenient nocturnal dosing. However, randomized controlled trials have produced mixed results due to small sample sizes, population heterogeneity, and comorbidities such as alcohol-related disorders. Across studies, psychotherapeutic interventions remain the most evidence-based and durable treatment for TRNs, and pharmacological options are best considered as adjuncts within an integrated care pathway.

CONCLUSIONS

Doxazosin may represent a pragmatic pharmacological option for managing TRNs in PTSD, especially in the context of prazosin withdrawal. Its use should complement, rather than replace, first-line psychotherapeutic approaches and be integrated into a comprehensive, coordinated, and individualized treatment plan with careful monitoring of adverse effects. Larger, well-designed randomized controlled trials are needed to determine optimal dosing, treatment duration, and predictors of response.