Zolpidem-induced psychosis in an older woman

Association between GABA(A) receptor subunit gene cluster and zolpidem-induced complex sleep behaviors in Han Chinese

STUDY OBJECTIVES

To investigate and elucidate the role of GABA(A) receptor subunits, specifically the 2 genetic markers at the GABA(A) α1 and GABA(A) α6 receptors, in zolpidem-induced complex sleep behaviors (CSBs).

DESIGN

Genetic association study.

SETTING

Kaohsiung Medical University-affiliated hospitals, Kaohsiung, Taiwan.

PATIENTS

30 zolpidem-induced CSB subjects and 37 controls.

INTERVENTIONS

N/A.

MEASUREMENTS AND RESULTS

The χ(2) test demonstrated an association between the A15G variant at the GABA(A) α1 receptor subunit gene and zolpidem-induced CSBs (P = 0.007). The adjusted odds ratio of the GABA(A) α1 receptor subunit genotype for the risk of zolpidem-induced CSBs was approximately 10 (OR = 9.99, 95% CI = 1.82, 74.87; P = 0.013).

CONCLUSIONS

The finding reveals that the A15G variant at the GABA(A) α1 receptor subunit gene confers a high risk of zolpidem-induced CSBs and may be considered in clinical services.

Use of non-benzodiazepine hypnotics in the elderly: are all agents the same?

Sleep disorders, especially insomnia, are common in older adults. These disorders are frequently treated using non-benzodiazepine hypnotics. Nonetheless, there is a relative lack of data regarding the use of these agents in the elderly, and whether any of these medications is superior to any other in the class when used in the elderly is also unclear. In this article, we review, by way of the published literature, the pharmacodynamics, pharmacokinetics, drug interactions, efficacy and safety of zolpidem, zaleplon, zopiclone, eszopiclone and ramelteon in the elderly. Special emphasis is placed on identifying relevant differences between these medications when used in older adults with insomnia. Based primarily on data from placebo-controlled trials, the non-benzodiazepines reviewed were found to be most effective at improving sleep latency and sleep quality, and least effective at enhancing total sleep time. The efficacy of ramelteon was limited to improving sleep latency, while all other agents, especially at higher doses, were found to produce improvement in both sleep latency and some improvement in total sleep time. All of the medications were found to be well tolerated in the elderly. From pharmacokinetic and drug-drug interaction perspectives, zaleplon and ramelteon offer the advantage of not being primarily metabolised via the cytochrome P450 3A4 isoenzyme. In conclusion, based on relatively limited data, zopiclone, zolpidem, zaleplon, eszopiclone and ramelteon represent modestly effective and generally well tolerated treatments for insomnia in older adults. While some actual and potential differences exist among these medications, more comparative trials are needed.

Compulsive activity and anterograde amnesia after zolpidem use

BACKGROUND

Zolpidem is a selective GABAAalpha1 receptor modulator used for its hypnotic-sedative properties. Zolpidem has side effects that are similar but not identical to the benzodiazepines. We report the first cases of compulsive activity combined with anterograde amnesia after the use of zolpidem.

CASE REPORT

Three women experienced anterograde amnesia and compulsive repetitive behaviors after zolpidem use. These activities consisted of cleaning, shopping, and eating. These behaviors stopped after discontinuation of the zolpidem.

CONCLUSION

These reports demonstrate that compulsive activity combined with anterograde amnesia may be associated with the use of zolpidem. Physicians and pharmacists should be aware of this potential side effect.

Sleep in the Elderly: Burden, Diagnosis, and Treatment

Insomnia is commonly seen in elderly populations and is associated with numerous individual and socioeconomic consequences. Elderly patients are more likely to suffer from chronic insomnia characterized by difficulty maintaining sleep than difficulty initiating sleep. Management of insomnia in these patients requires very careful evaluation and exclusion of an underlying medical or psychiatric condition. Nonpharmacologic interventions in elderly patients, especially use of behavioral therapy, have demonstrated some success. Commonly prescribed medications have also been effective, though they have limitations. Newer agents currently under investigation for insomnia hold promise for good efficacy and safety in the elderly population. The following review presents clinical studies, survey results, and guidelines retrieved from peer-reviewed journals in the PubMed database using the search terms elderly, temazepam, trazodone, zolpidem, zaleplon, insomnia, and prevalence and the dates 1980 to 2003. In addition, newer research with emerging agents has been included for completeness.

Delirium associated with zolpidem

OBJECTIVE

To report a case of an elderly woman sustaining an episode of delirium after one dose of zolpidem.

CASE SUMMARY

An 86-year-old white woman was admitted to the hospital for headaches and diplopia. On hospital day 3, the patient received zolpidem 5 mg and, approximately two hours later, became restless, disoriented, and physically agitated. She was treated with haloperidol and was restrained for her safety. The patient's symptoms resolved by day 5, and she had no recollection of the incident. No rechallenge was attempted.

DISCUSSION

Pharmacokinetic factors may play an important role in zolpidem-induced adverse drug reactions. Elderly women can achieve up to a 63% higher serum concentration than men. The patient in our report had factors such as age, gender, and hypoalbuminemia, which may have increased the maximum concentration and the AUC of zolpidem and possibly increased her risk of an adverse reaction.

CONCLUSIONS

This case, along with previous reports, warrants the cautious use of zolpidem. Clinicians should be aware that a majority of these reactions occur in women. It appears that the reactions are concentration dependent, therefore, dosage reductions should be made in elderly patients and those with hepatic insufficiency.

Treatment of insomnia in hospitalized patients

OBJECTIVE

To provide recommendations for the short-term management of insomnia in hospitalized patients and review patient assessment, nonpharmacologic treatment modalities, and selection of hypnotic medications.

DATA SOURCES

Review articles and primary literature representative of current knowledge regarding the treatment of insomnia were identified by MEDLINE search (1966-January 2001). Search terms included insomnia (sleep initiation and maintenance disorders), benzodiazepines, zaleplon, zolpidem, and trazodone.

DATA SYNTHESIS

Literature regarding the management of insomnia in hospitalized patients is limited; therefore, data pertinent to the treatment of ambulatory patients must be extrapolated to the inpatient setting. When evaluating insomnia in hospitalized patients, it seems reasonable to obtain a thorough history and physical examination to identify potential underlying etiologies. Treatment of these underlying etiologies should be considered. When the use of a sedative-hypnotic agent is necessary, medication and dose selection should be based on the pharmacokinetic and adverse effect profiles of each agent. Patent-specific characteristics should also be considered to provide effective treatment while minimizing adverse effects.

CONCLUSIONS

Nonpharmacologic approaches to the treatment of insomnia should be considered for hospitalized patients. When sedative-hypnotic medications must be administered, the pharmacokinetic profile of intermediate-acting benzodiazepines (e.g., lorazepam, temazepam) makes them good first-line agents. Zaleplon and zolpidem are also attractive hypnotic agents; however, they are typically reserved for second-line therapy due to cost. Trazodone may be an alternative for patients unable to take benzodiazepines.

Central nervous system side effects associated with zolpidem treatment

Zolpidem is one of the newer medications developed for the treatment of insomnia. It is an imidazopyridine agent that is an alternative to the typical sedative-hypnotic agents. Zolpidem use is gaining favor because of its efficacy and its side effect profile, which is milder and less problematic than that of the benzodiazepines and barbiturates used to treat insomnia. Still, side effects are not uncommon with zolpidem use. We report a series of cases in which the patients developed delirium, nightmares and hallucinations during treatment with zolpidem. We will review its pharmacology, discuss previous reports of central nervous system side effects, examine the impact of drug interactions with concurrent use of antidepressants, examine gender differences in susceptibility to side effects, and explore the significance of protein binding in producing side effects.