Zolpidem use and risk of suicide: A systematic review and meta-analysis

Neurotransmitter modulation of sleep-wake States: From molecular mechanisms to therapeutic potential

Sleep is one of the most fundamental physiological activities in humans and animals, and a normal sleep cycle is crucial for maintaining overall health. However, sleep disorders are increasingly becoming a major mental health issue affecting individuals and society, as well as a contributing factor to the onset of other diseases. Consequently, the development of novel therapeutic strategies for sleep disorders has emerged as a significant scientific challenge garnering widespread attention. Based on current research findings, focusing on neurotransmitters remains a promising approach for developing effective treatments. Neurotransmitters play a central role in regulating the sleep-wake cycle by precisely modulating the activity states of different brain regions. This review aims to elucidate the neural mechanisms underlying sleep initiation and function, thereby providing a comprehensive understanding of the complex nature of sleep as a physiological process. Furthermore, it seeks to uncover the potential pathological mechanisms of sleep disorders, offering a theoretical foundation and novel insights for precision medicine and drug development, ultimately reducing the negative impact of sleep disorders on individuals and society.

Treatment of Insomnia With Traditional Chinese Medicine Presents a Promising Prospect

Insomnia, a prevalent sleep disorder, significantly impacts global health. While Western medications provide temporary relief, their risks of dependency and cognitive impairment have spurred the search for safer alternatives. Traditional Chinese Medicine (TCM) offers a promising approach to treating insomnia by focusing on harmonizing the balance of Yin and Yang and the functions of internal organs. This review explores recent research advances in TCM for insomnia treatment, integrating classical theories with modern scientific understanding of key pathological mechanisms, including neurotransmitter regulation (GABA, monoamines), immune-inflammatory responses, the HPA axis, and interactions with the gut microbiota. Growing clinical evidence supports the effectiveness of classical TCM prescriptions and treatments like acupuncture in improving sleep quality, particularly when combined with Western medications to enhance efficacy and reduce dependency. However, TCM also has its limitations. Future research directions should focus on modernizing TCM applications, addressing comorbidities associated with insomnia, exploring the role of gut microbiota, and optimizing medicinal and edible homologous products. By integrating traditional knowledge with cutting-edge technologies, TCM holds great potential for advancing personalized and effective insomnia treatments globally.

Incidence of Adverse Effects and Misuse of Zolpidem

Study Objectives

Zolpidem is a widely prescribed medication for treating insomnia due to its effectiveness as a sedative-hypnotic. This study aimed to estimate the incidence of potential adverse effects associated with the use and misuse of zolpidem.

Methods

Retrospective cohort study. Participants were selected from consumers who had purchased zolpidem in a commercial pharmacy in Brazil and submitted an interviewed. Descriptive analysis was used to present the results. Pearson's chi-square tests were used to compare adverse reactions to zolpidem with categorical variables, and Student's t-tests were used to compare means. The significance level adopted was 5%.

Results

The study involved 65 participants, with a mean age of 52.7 years, 76.9% of whom were women. Of the total sample, 69.2% used zolpidem for the treatment of long-term insomnia, and 77.4% used it continuously. Among the interviewees, 55.4% reported experiencing adverse reactions, with amnesia, insomnia, and sleepwalking being the most reported. A statistically significant association was found between the occurrence of adverse reactions and continuous use (P value = 0.048), as well as among those with lower mean age (P value = 0.042).

Conclusion

Despite being a prescription-controlled medication, zolpidem was used excessively and inappropriately in the studied sample. Given the high prevalence of adverse effects identified in this study, the risk/benefit ratio of pharmacological treatments for insomnia warrants careful evaluation during prescription and dispensing. Incidence of adverse effects and misuse of zolpidem.

Insomnia in ambulatory care: A clinical review

PURPOSE

One-third to one-half of ambulatory care patients report insomnia. The objective of this clinical review is to detail the many causes and evidence-based treatment options for insomnia in outpatients and to recommend screening and summarize evidence for the place in therapy of prescription and nonprescription treatments.

SUMMARY

This work provides an overview of the literature on insomnia regarding causes, patient assessment, and nonpharmacological and pharmacological treatments. Patients who present with insomnia should be assessed for sleep apnea, restless legs syndrome, narcolepsy, and all contributing medications as well as medical, psychiatric, and substance use disorder diagnoses. The type of insomnia, namely difficulty falling asleep, difficulty maintaining sleep, and early morning awakening with resulting functional impairment, should be documented in addition to whether insomnia is short term or persistent. Cognitive behavioral therapy for insomnia (CBT-I) or digital CBT-I is first-line treatment for all patients with insomnia irrespective of the cause or type. Nonprescription treatments such as antihistamines or melatonin are for select populations. Prescription hypnotics are best utilized on an as-needed basis or for nightly use for less than 6 weeks. Z-hypnotics are safe and effective for insomnia in persons with depression or an anxiety disorder but should be avoided in older individuals or if there is respiratory or cognitive impairment. Orexin receptor antagonists are effective for sleep initiation and maintenance in healthy persons or if there is mild cognitive impairment, but they require further study in individuals with psychiatric and medical diagnoses. Trazodone is the most prescribed off-label treatment due to its efficacy for sleep initiation and maintenance and its lack of abuse potential.

CONCLUSION

Insomnia treatment should be guided by patient age, diagnoses, and type of insomnia. Pharmacological treatments should be used at the lowest effective dose for the shortest duration of time.

Associations of treatment with hypnotics with suicide and attempted suicide: A nationwide cohort study

BACKGROUND

Hypnotics have been linked to suicidal behaviors. While existing evidence has established findings of associations, more knowledge is needed regarding benzodiazepine (BZD) and non-benzodiazepine (n-BZD) hypnotics.

AIM

To examine whether individuals in treatment with hypnotics had higher rates of suicide and suicide attempts than those not in treatment.

METHODS

A longitudinal nationwide cohort design was applied to individual-level register data, including all individuals aged 15+ years who lived in Denmark from 1995 to 2021. Incidence rate ratios (IRR) for suicide and suicide attempts were estimated using Poisson regression models. Using the National Prescription Registry, individuals who redeemed prescriptions for hypnotics at pharmacies were identified. Death by suicide was identified in the Cause of Death Register.

RESULTS

A total of 7,311,630 individuals were observed over 122,681,369 person-years. In all, 678 males and 553 females died by suicide while in treatment with BZD, resulting in respective adjusted IRRs of 2.1 (95% CI: 1.9-2.4) and 2.6 (95% CI: 2.3-3.0), when compared to those not in treatment. A total of 1774 males and 1212 females died by suicide while in treatment with n-BZD and the adjusted IRRs were 3.4 (95% CI: 3.1-3.7) and 3.6 (95% CI: 3.4-3.9), respectively.

CONCLUSIONS

While confounding by indication is likely to be a major contributor, the fact that individuals in treatment with BZD or n-BZDs had higher rates of suicide and suicide attempts when compared to those not in treatment emphasizes the need to carefully monitor their mental state.

Neuroglia in suicide

Suicide is the worst outcome for many neuropsychiatric disorders having a high social and economic burden. There is a great need to determine the neurobiologic background of the etiopathogenesis and resilience toward suicide and to find novel pharmacologic strategies to treat suicidal behaviors. Neuroglia have been found to actively participate in the regulation of many cerebral functions, but it is debated whether these cells are structurally or functionally involved in the neuropathology of suicide, or merely follow the changes of comorbid psychiatric disorders. The purpose of this chapter is to review the scattered literature on the involvement of neuroglia in suicide and to describe how these cells might be responsive to the current pharmacologic interventions. We describe the different biological features of neuroglia in relation to suicide and the underlying psychiatric disorders, the molecular commonalities of neuroglial alterations in suicide across different psychiatric disorders, and the evidence for morphologic neuroglia changes in relation to the severity and resilience of suicide. Illuminating the mechanisms by which neuroglia are involved in suicide may ultimately lead to the development of suicide-related biomarkers and novel therapies for suicide prevention.

Pediatric suicide: Review of a preventable tragedy

Concepts of suicide are explored in this issue with a focus on suicide in children and adolescents. The epidemiology of pediatric suicide in the United States is reviewed; also, risk and protective factors, as well as prevention strategies, are discussed. Suicide in the pediatric athlete and the potential protective effect of exercise are examined. In addition, this analysis addresses the beneficial role of psychological management as well as current research on pharmacologic treatment and brain stimulation procedures as part of comprehensive pediatric suicide prevention. Though death by suicide in pediatric persons has been and remains a tragic phenomenon, there is much that clinicians, other healthcare professionals, and society itself can accomplish in the prevention of pediatric suicide as well as the management of suicidality in our children and adolescents.

GABAergic compounds for the treatment of alcohol use disorder

Decades of research have implicated the gamma-aminobutyric acid (GABA)ergic system as one of the main mediators of the behavioral effects of alcohol. Of importance, the addiction-related effects of alcohol also have been shown to be mediated in part by GABAergic systems, raising the possibility that pharmacotherapies targeting GABAergic receptors may be promising candidates for the treatment of alcohol use disorder (AUD). Alcohol modulates the activity of GABAA and GABAB receptors, and studies show that compounds targeting some of those receptors may decrease the addiction-related behavioral effects of alcohol. Specifically, drugs that share similar pharmacological properties with alcohol, such as positive allosteric modulators (PAMs) of GABAA and GABAB receptors, have been proposed as substitution therapies for AUD. Available evidence also suggests that negative allosteric modulators (NAMs) of GABAergic receptors may be potential therapeutics for AUD, although this effect is selective for specific receptor subtypes. Therefore, this Chapter reviews the available evidence on the use of GABAergic compounds for the treatment of AUD. Several GABAA and GABAB ligands show promising results, with a particularly positive therapeutic profile demonstrated for α5GABAA receptor NAMs, α4/6δGABAA receptor modulators (both positive and negative, including neurosteroids), and GABAB receptor PAMs. As newer and better GABAergic compounds become available, future research should focus on understanding how these ligands can modulate different clinical symptoms of AUD, with potential new areas of research encompassing alcohol withdrawal syndrome and AUD-related insomnia.

Evaluation of prescribing patterns of switching to and add-on lemborexant in patients treated with hypnotic medication: a nationwide claims database study in Japan

BACKGROUND

When considering changing hypnotic pharmacotherapy, lemborexant has attracted attention as a candidate due to its effectiveness and safety profile. However, few studies have investigated switching patterns in clinical practice.

RESEARCH DESIGN AND METHODS

We conducted a retrospective cohort study using a nationwide claims database. Patients prescribed a single hypnotic who either subsequently switched to (switching cohort) or were additionally prescribed (add-on cohort) lemborexant between July 2020 and December 2021 were identified. Proportion of successful switching was defined as remaining on lemborexant alone or without any hypnotic at 6 months after lemborexant initiation.

RESULTS

The success proportion was 70.1% in the switching cohort (n = 4,861) and 38.6% in the add-on cohort (n = 9,423). In the add-on cohort, the success proportion was lower in patients with a hypnotic history of ≥180 days (31.4%) and in patients whose prescribed hypnotic was a benzodiazepine or non-benzodiazepine (31.5% and 37.6%, respectively).

CONCLUSION

The proportion of successful switching was higher in patients who switched to lemborexant than in those who added lemborexant as a concomitant treatment. The lower success proportion in the add-on cohort might be related to clinically more severe insomnia, and/or a concomitant prescription of benzodiazepine or non-benzodiazepine, from which discontinuation may be challenging.

Sarcopenia adversely impacts clinical outcomes in patients undergoing pancreaticoduodenectomy: A systematic review and meta-analysis

BACKGROUND

Sarcopenia is a syndrome marked by a gradual and widespread reduction in skeletal muscle mass and strength, as well as a decline in functional ability, which is associated with malnutrition, hormonal changes, chronic inflammation, disturbance of intestinal flora, and exercise quality. Pancreatoduodenectomy is a commonly employed clinical intervention for conditions such as pancreatic head cancer, ampulla of Vater cancer, and cholangiocarcinoma, among others, with a notably high rate of postoperative complications. Sarcopenia is frequent in patients undergoing pancreatoduodenectomy. However, data regarding the effects of sarcopenia in patients undergoing pancreaticoduodenectomy (PD) are both limited and inconsistent.

AIM

To assess the influence of sarcopenia on outcomes in patients undergoing PD.

METHODS

The PubMed, Cochrane Library, Web of Science, and Embase databases were screened for studies published from the time of database inception to June 2023 that described the effects of sarcopenia on the outcomes and complications of PD. Two researchers independently assessed the quality of the data extracted from the studies that met the inclusion criteria. Meta-analysis using RevMan 5.3.5 and Stata 14.0 software was conducted. Forest and funnel plots were used, respectively, to demonstrate the outcomes of the sarcopenia group vs the non-sarcopenia group after PD and to evaluate potential publication bias.

RESULTS

Sixteen studies encompassing 2381 patients were included in the meta-analysis. The patients in the sarcopenia group (n = 833) had higher overall postoperative complication rates [odds ratio (OR) = 3.42, 95% confidence interval (CI): 1.95-5.99, P < 0.0001], higher Clavien-Dindo class ≥ III major complication rates (OR = 1.41, 95%CI: 1.04-1.90, P = 0.03), higher bacteremia rates (OR = 4.46, 95%CI: 1.42-13.98, P = 0.01), higher pneumonia rates (OR = 2.10, 95%CI: 1.34-3.27, P = 0.001), higher pancreatic fistula rates (OR = 1.42, 95%CI: 1.12-1.79, P = 0.003), longer hospital stays (OR = 2.86, 95%CI: 0.44-5.28, P = 0.02), higher mortality rates (OR = 3.17, 95%CI: 1.55-6.50, P = 0.002), and worse overall survival (hazard ratio = 2.81, 95%CI: 1.45-5.45, P = 0.002) than those in the non-sarcopenia group (n = 1548). However, no significant inter-group differences were observed regarding wound infections, urinary tract infections, biliary fistulas, or postoperative digestive bleeding.

CONCLUSION

Sarcopenia is a common comorbidity in patients undergoing PD. Patients with preoperative sarcopenia have increased rates of complications and mortality, in addition to a poorer overall survival rate and longer hospital stays after PD.

Innovative analysis of diazepam, zolpidem and their main metabolites in human urine by micelle-to-solvent stacking in capillary electrophoresis

Diazepam and zolpidem are the most widely used medications for managing insomnia. However, significant concerns regarding the potential risks of misuse and abuse problems arose in many literatures. While urine analysis is a valuable diagnostic tool, a challenge arises from the fact that some parent drugs may remain undetectable in urine. This necessitates concurrent monitoring of their metabolites. Here, we described an innovative on-line sample preconcentration technique known as micelle to solvent stacking (MSS) for the analysis of diazepam, zolpidem, and their main metabolites in urine. Several key parameters warrant further discussion to optimize the MSS model, enhancing its performance in terms of sensitivity and resolution. After optimizing the conditions, we conducted a validation test, achieving high correlation coefficients (greater than 0.9977) for intra-day and inter-day regression lines. Additionally, both the relative standard deviation (RSD) and relative error (RE) remained below 6.10% and 12.55%, respectively. The limits of detection (LODs, S/N = 3) for all five analytes ranged from 2.0 to 56 ng/mL. Compared to the conventional capillary zone electrophoresis method, this new approach exhibited remarkable sensitivity enhancements, ranging from 123 to 235-fold. Upon applying this method to actual urine samples from patients, we successfully detected nordiazepam, zolpidem, and its metabolites. This simple and sensitive approach has promising applications in supporting patient medication safety and bolstering forensic investigations.

Associations between insomnia medications and risk of death by suicide

PURPOSE

Insomnia is a modifiable risk factor for suicide often treated with medications. However, little is known about the associations between insomnia medications and risk of death by suicide. The purpose of this study is to model the comparative risk of suicide by each insomnia medication compared to zolpidem, a sedative-hypnotic approved for insomnia.

METHODS

First prescription fills of medications commonly used to treat insomnia were identified in electronic medical records. Date and cause of death were identified in death certificates. Cox proportional hazards models were used to analyze time from insomnia prescription to suicide.

RESULTS

More than 2 million patients filled a new insomnia prescription between 2005 and 2015, and 518 of them died by suicide within 12 months. Compared to zolpidem, the tricyclic antidepressants (amitriptyline, doxepin) were associated with a 64% lower risk of suicide (HR 0.36 (95% CI 0.22-0.66) and the sedating antihistamines (hydroxyzine, diphenhydramine) a 40% lower risk of suicide (HR 0.60 (0.41-0.89)). In contrast, the tetracyclic antidepressant (mirtazapine) was associated with a 62% higher risk of suicide (HR 1.62 (95% CI 1.10-2.38) compared to zolpidem.

CONCLUSION

Insomnia is a modifiable risk factor for suicide, yet many medications used to treat insomnia have never been tested for the indication in clinical trials. To define efficacy in the prevention of suicide, trials are warranted.

Prescription of Silexan Is Associated with Less Frequent General Practitioner Repeat Consultations Due to Disturbed Sleep Compared to Benzodiazepine Receptor Agonists: A Retrospective Database Analysis

The aim of the present study was to analyze the association between the prescription of Silexan and the recurrence of general practitioner (GP) repeat consultations because of disturbed sleep versus benzodiazepine receptor agonists including zolpidem, zopiclone, and zaleplon (Z-drugs). This retrospective cohort study was based on data from the IQVIA Disease Analyzer (DA) database. The study included adult patients treated by 1284 GPs in Germany with a documented sleep disorder and their first prescription of Silexan or Z-drug (prescription between January 2010 and October 2020). The recurrence of seeking medical advice because of sleep disorders in the 15-365 days after the first prescription was evaluated. Multivariate regression models were used, adjusted for age, sex, insurance status, and defined co-diagnoses. Data were available for 95,320 (Silexan: 5204; Z-Drug: 90,526) patients. In total, 15.6% of the Silexan patients and 28.6% of the Z-drug patients had a further documented GP consultation because of a sleep disorder. Silexan prescription was associated with significantly lower odds of recurrent sleep disorder diagnosis in the 15-365 days after the index date (Odds Ratio (OR): 0.56; 95% confidence intervals (CI): 0.51-0.60), although mental burden levels appeared higher in this group. Our study shows that the prescription of Silexan to adult patients consulting GPs for disturbed sleep results in less frequent repeat consultations than Z-drugs. This may support Silexan's role as an efficacious, self-enabling, well-tolerated, and sustained treatment option. Because Silexan is a proven anxiolytic, its impact in improving undiagnosed anxiety disorders may have had a lasting effect for certain patients.