Randomized, Placebo-Controlled Trial of the Angiotensin Receptor Antagonist Losartan for Posttraumatic Stress Disorder

• Published in: Biological psychiatry (1969) Vol. 90; no. 7; pp. 473 - 481
• Main Authors: Stein, Murray B., Jain, Sonia, Simon, Naomi M., West, James C., Marvar, Paul J., Bui, Eric, He, Feng, Benedek, David M., Cassano, Paolo, Griffith, James L., Howlett, Jonathan, Malgaroli, Matteo, Melaragno, Andrew, Seligowski, Antonia V., Shu, I-Wei, Song, Suzan, Szuhany, Kristin, Taylor, Charles T., Ressler, Kerry J., Beg, Nuzhat, Sun, Xiaoying, Shaikh, Farah, Spangler, Patricia T., Dempsey, Catherine L., Eakley, Rachel, Kaufmann, Milissa L., Murphy, Beth L., Merker, Julia
• Format: Journal Article
• Language: English
• Published: United States Elsevier Inc 01.10.2021
• Subjects: ACE; Angiotensin; Angiotensin Receptor Antagonists; ARB; Double-Blind Method; Female; Humans; Hypertension; Losartan; Losartan - therapeutic use; Male; PTSD; Randomized controlled trial; Stress Disorders, Post-Traumatic - drug therapy; Treatment Outcome; Hypertension; PTSD; ARB; ACE; Losartan; Angiotensin; Randomized controlled trial
• ISSN: 0006-3223; 1873-2402
• DOI: 10.1016/j.biopsych.2021.05.012

Evidence-based pharmacological treatments for posttraumatic stress disorder (PTSD) are few and of limited efficacy. Previous work suggests that angiotensin type 1 receptor inhibition facilitates fear inhibition and extinction, important for recovery from PTSD. This study tests the efficacy of the angiotensin type 1 receptor antagonist losartan, an antihypertensive drug, repurposed for the treatment of PTSD. A randomized controlled trial was conducted for 10 weeks in 149 men and women meeting DSM-5 PTSD criteria. Losartan (vs. placebo) was flexibly titrated from 25 to 100 mg/day by week 6 and held at highest tolerated dose until week 10. Primary outcome was the Clinician-Administered PTSD Scale for DSM-5 (CAPS-5) change score at 10 weeks from baseline. A key secondary outcome was change in CAPS-5 associated with a single nucleotide polymorphism of the ACE gene. Additional secondary outcomes included changes in the PTSD Checklist for DSM-5 and the Patient Health Questionnaire-9, and proportion of responders with a Clinical Global Impressions–Improvement scale of “much improved” or “very much improved.” Both groups had robust improvement in PTSD symptoms, but there was no significant difference on the primary end point, CAPS-5 measured as week 10 change from baseline, between losartan and placebo (mean change difference, 0.9, 95% confidence interval, −3.2 to 5.0). There was no significant difference in the proportion of Clinical Global Impressions–Improvement scale responders for losartan (58.6%) versus placebo (57.9%), no significant differences in changes in PTSD Checklist for DSM-5 or Patient Health Questionnaire-9, and no association between ACE genotype and CAPS-5 improvement on losartan. At these doses and durations, there was no significant benefit of losartan compared with placebo for the treatment of PTSD. We discuss implications for failure to determine the benefit of a repurposed drug with strong a priori expectations of success based on preclinical and epidemiological data.