This is an open-label (no placebo) study to see if the addition of Xyrem to a subject's PTSD medication regimen will be tolerated and possibly improve insomnia. Subjects will currently be taking at least a single psychotropic agent for the treatment of PTSD, (an SSRI). Dosing will be stable for at least 4 weeks and subjects will need to report continued insomnia despite treatment. They must also have failed at least two insomnia augmentations from separate drugs classes (benzodiazepine (temezapam, zolpidem, ect.), antihistime (quetiapine, mirtazapine, trazadone, etc.), dopamine antagonist (olanzapine, quetiapine, aripiprazole, etc.) to qualify for refractory insomnia.
Subjects will complete consenting process and attend a screening visit where they will be given a MINI psychiatric diagnostic evaluation to confirm PTSD, be given a Hamilton Anxiety, a Hospital Anxiety \& Depression Scale, PCL-C, Fatigue Severity Scale, Epworth Sleepiness Scale, Pittsburgh Sleep Quality Inventory, SF-12, and sleep diary evaluation to delineate current anxiety levels (secondary measure). Subjects will have to offer consent for the study team to contact their primary providers and retrieve all past and present records to show refractory history and lack of substance abuse. Subjects will undergo a brief physical exam and bloodwork and a sleep EEG will be ordered. Furthermore, a urine drug screen will be used to screen for current misuse. If subjects are taking sleeping agents, they will be appropriately washed out (tapered per cusual clinical practice and then drug free 5 times the drug's half life) prior to sleep EEG and prior to Xyrem start. In clinical practice, Xyrem use does not warrant blood monitoring, EEGs or EKGs per the FDA.
Assuming subject meets eligibility, they will start Xyrem per cataplexy dosing guidelines. Prior to titration, a 1-2 week washout of any sleeping agent will occur. Titration will then start with 2.25g at bedtime and then again 4 hours later. This drug may be flexibly increased to 4.5g (x2 doses) based upon tolerability and effectiveness. We will escalate dose if drug is toleratedbut without efficacy. Dosing will be increased if subjective sleep quantity/quality is still reported to be unchanged or if our rating scales indicate minimal to no change.
After screening visit 1 (eligibility, medical safety determination, washout, sleep EEG) subjects will return for baseline Visit 2 and start Xyrem.
They will be seen for Visit 3 after 7 days of treatment for rating scales and possible dose escalation to 6g/d.
They will be seen for Visit 4 after 14 days of treatment for rating scales and possible dose escalation to 7.5g/d.
They will be seen for Visit 5 after 21 days of treatment for rating scales and possible dose escalation to 9g/d.
They will be seen for Visit 6/termination after 28 days of treatment for rating scales, physical exam, lab work, sleep EEG.
Subjects will be called for final safety follow up one week later and 12 weeks later.
Again, liaison with the subject's provider will occur to discuss continuance of Xyrem. If provider agrees, then long term monitoring will be in the jurisdiction of this provider. If agreement is to NOT continue Xyrem, patient will be tapered or offered help in finding a clinician comfortable with the drug. There is no major issue in stopping this drug from a withdrawal point of view as it does not build up in the system over time in regards to dependence when used at bed time only. Insomnia will likely return and patient would go back to their usual treatment if desired and most likely their original level of insomnia.
Safety Measures The overall safety and tolerability of Xyrem will be assessed throughout the study by adverse event recording, clinical laboratory test results and physical exams. A Safety monitoring board will consist of the PI and two psychiatry attendings from University Hospital
