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Prazosin Hydrochloride

Pronunciation

Class: alpha-Adrenergic Blocking Agents
VA Class: CV150
CAS Number: 19237-84-4
Brands: Minipress

Introduction

Postsynaptic α1-adrenergic blocking agent; quinazoline derivative.101 b

Uses for Prazosin Hydrochloride

Hypertension

Management of hypertension (alone or in combination with other classes of antihypertensive agents).101 153 161

Current antihypertensive and urology guidelines (e.g., JNC 7) no longer recommend α1-blockers as preferred first-line therapy for patients with hypertension.b

Acute management of severe hypertension in patients with increased concentrations of circulating catecholamines.b

Benign Prostatic Hyperplasia (BPH)

Has been used to reduce urinary obstruction and relieve associated manifestations in patients with symptomatic BPH; efficacy relative to other α1-adrenergic blockers remains to be established.112 113 114 115 116 117 118 119 120 121 122 123 124 125 126 127 128 129 130 131 132 133

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Posttraumatic Stress Disorder (PTSD)

Has been used in the management of PTSD, particularly in combat veterans and in patients experiencing nighttime PTSD symptoms (e.g., nightmares, sleep disturbances).200 201 202 203 204 205 206 207 208 209 210 211 212 215 216 217 221 222 225

Some clinicians currently recommend prazosin as first-line or alternative therapy when treating PTSD patients with prominent nighttime symptoms, particularly in combat veterans.201 204 212 215 217 222 225 Further studies necessary in civilians with noncombat trauma-related PTSD and in treatment of daytime PTSD symptoms.200 201 203 204 208 216

Prazosin Hydrochloride Dosage and Administration

Administration

Oral Administration

Administer orally in divided doses 2 or 3 times daily.101

Manufacturers make no specific recommendations regarding administration with meals.101 221

Dosage

Available as prazosin hydrochloride; dosage expressed in terms of prazosin.101 b

Individualize dosage according to patient response and tolerance.101 b Initiate at low dosage to minimize frequency of postural hypotension and syncope.101 b

Postural effects are most likely to occur 2–6 hours after a dose; monitor BP during this period after first dose and with any dosage increases.161 179

If therapy is interrupted for a few days, restart using initial dosage regimen.

Pediatric Patients

Hypertension
Oral

Initially, 0.05–0.1 mg/kg daily given in 3 divided doses.195 Increase dosage as necessary up to a maximum of 0.5 mg/kg daily given in 3 divided doses.195

Adults

Hypertension
Monotherapy
Oral

Initially, 1 mg 2 or 3 times daily.101 b Do not initiate with higher dosages.101 b May increase dosage gradually to 20 mg daily given in divided doses.101 b

Usual maintenance dosage: 6–15 mg daily given in divided doses.101 b

Careful monitoring of BP is recommended during initial titration or subsequent upward dosage adjustment;161 avoid large or abrupt reductions in BP.161 179

For the acute management of severe hypertension, initially, 1–2 mg; dosage may be repeated after 1 hour, if necessary.b

Combination Therapy
Oral

When other hypotensive agents or diuretics are added to existing prazosin therapy, reduce dosage to 1 or 2 mg 3 times daily; gradually increase according to patient's response and tolerance.101 b

Posttraumatic Stress Disorder

Optimum dosage not established.200 201 212 In clinical studies, usual initial dosage was 1 mg at bedtime; dosage was then gradually increased based on patient's response and tolerance.200 201 202 203 204 205 206 207 208 209 210 211 212 217 220 Maintenance dosages ranging from 1 to 25 mg daily (given once daily at bedtime or in 2 divided doses) have been use.200 203 206 210 212 217 220 225 Some experts recommend a target maintenance dosage of 1–10 mg daily; others recommend a higher target dosage of 2–20 mg daily.224 225

Prescribing Limits

Pediatric Patients

Hypertension
Oral

Maximum 0.5 mg/kg daily.195

Adults

Hypertension
Oral

Maximum 20 mg daily.101 b Although higher dosages usually do not increase efficacy, a few patients may benefit from ≤40 mg daily.101 b

Special Populations

Hepatic Impairment

No specific dosage recommendations at this time.b

Renal Impairment

Initially, 1 mg twice daily.b Patients with chronic renal failure may require only small dosages.b

Geriatric Patients

No specific dosage recommendations at this time;b generally increase dosage more slowly in geriatric hypertensive patients than in younger adults.

Cautions for Prazosin Hydrochloride

Contraindications

Known hypersensitivity to prazosin, quinazolines (e.g., alfuzosin, doxazosin, terazosin), or any ingredient in the formulation.101

Warnings/Precautions

Warnings

Postural Hypotension

Like other α-adrenergic blocking agents, marked hypotension, especially in the upright position, can occur; may be accompanied by syncope, palpitations, and other postural effects (e.g., dizziness, lightheadedness, vertigo).101

Postural effects are most common after an initial dose, shortly after dosing (e.g., within 90 minutes), when dosage is rapidly increased, or when other antihypertensive agents are added to therapy.101 b

To decrease risk of excessive hypotension and syncope, initiate therapy at a low dosage (i.e., 1 mg) and titrate slowly; initiate concomitant antihypertensive agents with caution.101 b

If syncope or hypotension occurs, place patient in a recumbent position and institute supportive therapy as necessary.101 b

General Precautions

Intraoperative Floppy Iris Syndrome (IFIS)

IFIS observed during cataract surgery in some patients currently receiving or previously treated with α1-adrenergic blocking agents.101 218

If patient has received α1-blockers, ophthalmologist should be prepared to modify the surgical technique (e.g., through use of iris hooks, iris dilator rings, viscoelastic substances) to minimize complications of IFIS.101 218

Benefit of discontinuing α1-blockers, including prazosin, prior to cataract surgery not established.101 218

Prostate Cancer

Exclude possibility of prostate cancer before initiation of therapy for BPH.155 156

Specific Populations

Pregnancy

Category C.101

Lactation

Distributed into milk in small amounts.101 Caution if used in nursing women.101 b

Pediatric Use

Safety and efficacy not established in children <18 years of age.101 b

Geriatric Use

Geriatric patients may be particularly susceptible to postural effects and other adverse effects.153 161

Common Adverse Effects

Dizziness, lightheadedness, headache, drowsiness, lack of energy, weakness, palpitation, nausea.101 b

Interactions for Prazosin Hydrochloride

Protein-bound Drugs

Potential pharmacokinetic interaction (displacement of prazosin or other protein-bound drug).b

Specific Drugs and Laboratory Tests

Drug

Interaction

Comments

Analgesic agents (aspirin, indomethacin, phenylbutazone [no longer commercially available in the US], propoxyphene)

No interaction observed101

Antiarrhythmic agents (procainamide, quinidine)

No interaction observed101

Antigout agents (allopurinol, colchicine, probenecid)

No interaction observed101

Antihypertensive agents (e.g., propranolol)

Possible additive hypotensive effects and symptomatic hypotension101

Initiate additional antihypertensive agents with caution; may reduce prazosin dosage and gradually increase dosage based on clinical response101

Benzodiazepines (chlordiazepoxide, diazepam)

No interaction observed101

Digoxin

No interaction observed101

Diuretics

Possible additive hypotensive effects and symptomatic hypotension101 b

Effect usually used to therapeutic advantageb

Initiate diuretics with caution; may reduce prazosin dosage and gradually increase dosage based on clinical response101

Hypoglycemic agents (insulin, chlorpropramide, phenformin [no longer commercially available in the US], tolazamide, tolbutamide)

No interaction observed101

Phenobarbital

No interaction observed101

Phosphodiesterase (PDE) type 5 inhibitors (e.g., sildenafil, tadalafil, vardenafil)

Possible additive hypotensive effects and symptomatic hypotension101

Initiate PDE type 5 inhibitor at lowest possible dosage101

Test for pheochromocytoma

Possible increase in urinary metabolite of norepinephrine and VMA; false positive results may occur in pheochromocytoma screening tests101

If elevated VMA is observed, discontinue prazosin and repeat test after 1 month101

Prazosin Hydrochloride Pharmacokinetics

Absorption

Bioavailability

Peak plasma concentrations attained within about 2–3 hours.b

Bioavailability is approximately 60%.b

Onset

In patients with hypertension, maximum reduction in BP usually occurs 2–4 hours after administration.b

Food

Food does not affect the extent of absorption; however, absorption may be delayed.b

Distribution

Extent

Not known whether prazosin crosses the placenta;b distributed into milk in small amounts.b Crosses the blood-brain barrier.200 204 205 206 208 210

Plasma Protein Binding

Approximately 97%.b

Elimination

Metabolism

Extensively metabolized, principally in the liver by demethylation and conjugation.101 b

Elimination Route

Excreted principally in feces via biliary excretion and to a lesser extent in urine (6–10%).101 b

Half-life

2–4 hours.b

Stability

Storage

Oral

Capsules

20-25°C; protect from moisture and light.221

Actions

  • Reduces peripheral vascular resistance and BP as a result of vasodilating effects;101 b produces both arterial and venous dilation.101

  • Effects appear to result from selective, competitive inhibition of α1-adrenergic receptors.b

  • Generally causes no change in heart rate, cardiac output, renal blood flow, and GFR.101 b

  • Binds to α-adrenergic receptors on the prostate capsule, prostate adenoma, and bladder trigone, resulting in decreased urinary outflow resistance in men.

  • May improve to limited extent the serum lipid profile (e.g., small increases in HDL and HDL/total cholesterol ratio; small decreases in LDL, total cholesterol, and triglyceride concentrations).153 161 c

  • Precise mechanism of action in PTSD not fully elucidated; however, norepinephrine and α1-adrenergic receptors play an important role in the pathophysiology of PTSD-associated nightmares, arousal, selective attention and vigilance.200 201 203 204 205 206 207 208 209 210 216 217 220 Prazosin is believed to help correct the effects of α1-adrenergic receptor hyperstimulation in PTSD and has also been shown to normalize the sleep cycle.200 203 205 206 211 220

Advice to Patients

  • Possible dizziness, lightheadedness or fainting, especially at initiation of therapy;101 b importance of avoiding driving or other hazardous tasks where injury could occur for 24 hours after the first dose or when dosage is increased.101

  • Importance of advising patient that alcohol use, hot weather, exercise, and standing for long periods of time may precipitate or exacerbate symptoms of dizziness, lightheadedness, or fainting, and to use caution during these situations.101

  • Importance of sitting or lying down when symptoms of lowered BP occur, and of rising carefully from a sitting or lying position.101 b

  • Possible drowsiness or somnolence; use caution when operating machinery or driving a motor vehicle until effects on individual are known.b

  • Importance of advising patients being considered for cataract surgery that they should inform their ophthalmologist of current or prior α1-blocker therapy, including prazosin.101 218

  • Importance of advising patients receiving prazosin for PTSD that the drug may help reduce nightmares and improve sleep and other symptoms; however, it does not cure PTSD and their nightmares, anxiety, and other PTSD-related symptoms may return if therapy is stopped.201 203 219

  • Importance of women informing clinicians if they are or plan to become pregnant or plan to breast-feed.101

  • Importance of informing clinicians of existing or contemplated concomitant therapy, including prescription and OTC drugs, as well as concomitant illnesses.101

  • Importance of informing patients of other important precautionary information.101 (See Cautions.)

Preparations

Excipients in commercially available drug preparations may have clinically important effects in some individuals; consult specific product labeling for details.

* available from one or more manufacturer, distributor, and/or repackager by generic (nonproprietary) name

Prazosin Hydrochloride

Routes

Dosage Forms

Strengths

Brand Names

Manufacturer

Oral

Capsules

1 mg (of prazosin)*

Minipress

Pfizer

Prazosin Hydrochloride Capsules

2 mg (of prazosin)*

Minipress

Pfizer

Prazosin Hydrochloride Capsules

5 mg (of prazosin)*

Minipress

Pfizer

Prazosin Hydrochloride Capsules

Comparative Pricing

This pricing information is subject to change at the sole discretion of DS Pharmacy. This pricing information was updated 02/2014. Actual costs to patients will vary depending on the use of specific retail or mail-order locations and health insurance copays.

Minipress 1MG Capsules (PFIZER U.S.): 60/$55.89 or 180/$161.22

Minipress 2MG Capsules (PFIZER U.S.): 60/$75.24 or 180/$214.97

Minipress 5MG Capsules (PFIZER U.S.): 60/$133.29 or 180/$374.06

Prazosin HCl 1MG Capsules (MYLAN): 60/$17.99 or 180/$37.97

Prazosin HCl 2MG Capsules (MYLAN): 60/$24.99 or 180/$53.97

Prazosin HCl 5MG Capsules (MYLAN): 60/$37.99 or 180/$104.96

AHFS DI Essentials. © Copyright, 2004-2014, Selected Revisions February 1, 2011. American Society of Health-System Pharmacists, Inc., 7272 Wisconsin Avenue, Bethesda, Maryland 20814.

† Use is not currently included in the labeling approved by the US Food and Drug Administration.

References

Only references cited for selected revisions after 1984 are available electronically.

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