Treatment of PTSD-Associated Nightmares

Medication Dosage and Administration

• The American Academy of Sleep Medicine recommends doses of 0.2-0.6 mg (in divided doses) for efficacy in treating PTSD-associated nightmares, with sedative effects most pronounced within the first few hours after administration, making bedtime dosing advantageous for managing sleep disturbances 1
• Clonidine dosing characteristics are summarized in the following table:

2

• The target dose range for clonidine in autism is 0.15-0.20 mg/day divided into 3 doses, as recommended by the American Academy of Child and Adolescent Psychiatry, with a strength of evidence level of moderate 3
• The Indian guidelines recommend dosing of 0.1 mg tablets with a maximum of 0.2-0.4 mg/day based on weight for immediate-release clonidine, with a strength of evidence level of low 4
• The American College of Obstetricians and Gynecologists suggests that clonidine is typically administered with a starting dose of 0.05-0.1 mg at bedtime for ADHD patients, with titration by increasing the dose by 0.1 mg BID-TID to a maximum of 0.4 mg per day 5

Safety and Precautions

• The American College of Obstetricians and Gynecologists states that limited data suggests clonidine is likely not associated with adverse pregnancy outcomes 5
• Clonidine is found in human milk with a milk to plasma ratio of 2 and a relative infant dose up to 7.1%, according to the American College of Obstetricians and Gynecologists, and breastfed infants should be monitored for drowsiness, hypotonia, and other adverse effects when the mother is taking clonidine 5
• Limited information is available on the use of guanfacine during pregnancy and breastfeeding; use with caution after risk-benefit discussion, as advised by the American College of Obstetricians and Gynecologists, with a strength of evidence level of low 5
• Clonidine is not recommended for children under 6 years, and should be avoided in children with depression, as recommended by the American Academy of Pediatrics, with a strength of evidence level of high 6
• Concomitant CNS depressants may potentiate sedative effects of clonidine, and it should be used with extreme caution in patients with cardiac issues, as recommended by the American Heart Association and American College of Cardiology, with a strength of evidence level of high 7, 8

Monitoring and Assessment

• Baseline assessment, including personal and family cardiac history, is necessary before starting clonidine treatment, and an ECG should be considered if cardiac risk factors are present, as recommended by the American Heart Association and American College of Cardiology, with a strength of evidence level of high 2, 7, 8
• The American Academy of Pediatrics suggests assessing for substance abuse before beginning medication treatment for adolescents with newly diagnosed ADHD, considering diversion risk, and ensuring medication coverage for driving 9

Side Effects and Interactions

• Clonidine can cause sedation/somnolence, especially during the first 2 weeks of treatment, and common side effects include dry mouth, dizziness, irritability, headache, and cardiovascular effects such as bradycardia and hypotension, as noted by the American Academy of Child and Adolescent Psychiatry 2
• Guanfacine has a more favorable side effect profile compared to clonidine, with less sedation, more stable blood pressure effects, and reduced risk of rebound hypertension upon discontinuation, according to the European Society of Cardiology, with a strength of evidence level of moderate 10
• Guanfacine characteristics are summarized in the following table:

10, 6

• Ginkgo biloba can interact with various medications, including duloxetine, due to its effects on platelet-activating factor and CYP450 enzymes, as noted by the American College of Cardiology and the American Journal of Kidney Diseases, and the American College of Cardiology recommends considering the potential interactions between ginkgo biloba and other medications, with a strength of evidence level of moderate 11, 12, 13, 14