Gender influences on efficacy and safety of sublingual zolpidem tartrate for middle-of-the-night awakening in insomnia

Sex bias persists in surgical research: A 5-year follow-up study

BACKGROUND

Federal initiatives have recently addressed the sex bias that exists in biomedical and clinical research. However, improvement to the inclusion of sex as a biological variable remains unknown.

METHODS

We performed a 5-year follow-up study of all clinical and biomedical research articles published in 5 surgical journals from January 1, 2017, through December 31, 2018. Human, animal, and cell subjects were analyzed for study/subject type, sex of participants, sex matching, and sex-based data reporting, analysis, and discussion.

RESULTS

Comparing 2017 to 2018 with 2011 to 2012, slightly more articles reported the sex of the human studied (87% vs 83%; P = .001). Inclusion of both sexes remained high (94% vs 95%; P = .22), but sex-based data reporting (36% vs 38%; P = .17), analysis (35% vs 33%; P = .39), and discussion of results (10% vs 23%; P < .0001) remained unchanged or worsened. Regarding animal research, the number of articles that stated the sex studied remained unchanged (79% vs 78%; P = .67); if stated, slightly more included both sexes (7% vs 3%; P = .002). Regarding cell research, fewer articles reported the sex of the cells studied (5% vs 24%; P = .0001); if stated, more articles included both sexes, but the difference did not reach statistical significance (25% vs 7%; P = .34). Sex matching remained poor with only 50% of human, 4% of animal, and 9% of cell studies matching the inclusion of both sexes by at least 50%.

CONCLUSION

Sex bias persists in surgical research. The majority of articles failed to report, analyze, or discuss results based on sex, which will negatively affect clinical translatability and outcomes of evidence-based medicine.

Sublingual and oral zolpidem for insomnia disorder: a 3-month randomized trial

Objective:

To evaluate the safety and efficacy of a 5 mg sublingual dose of zolpidem, compared to a 10 mg oral dose, at bedtime and “as needed” following middle-of-the-night awakenings.

Methods:

Participants were randomized into an oral group (oral zolpidem 10 mg and sublingual placebo at bedtime and “as-needed”) and a sublingual group (oral placebo and sublingual zolpidem 5 mg at bedtime and “as-needed”). Participants underwent medical evaluation, polysomnography, the psychomotor vigilance test, and completed questionnaires.

Results:

Of 85 patients, 67 met the criteria for insomnia (48±10 years; 79% women) and were randomized. Of these, 46 completed 92±5 days of treatment. Mild-to-moderate adverse events were reported by 25% of the participants, including headache, sleepiness, and dizziness. Both treatments decreased middle-of-the-night awakenings by an average of -3.1±2.3 days/week and increased total sleep time by 1.5 hours. Changes in sleep quality and insomnia severity scores were also favorable and comparable between groups: variation depended on continuation of treatment. Regarding PSG findings, sleep latency decreased more in the sublingual group than the oral group (-14±42 vs. 10±29 min; p = 0.03). The psychomotor vigilance test showed minor residual effects 30 minutes after awakening, which reversed after 2 hours.

Conclusions:

The safety and efficacy of both zolpidem formulations are comparable. The sublingual 5 mg dose induced sleep more rapidly.

Clinical trial registration:

NCT01896336

Zolpidem and Gender: Are Women Really At Risk?

BACKGROUND

In 2013 the Food and Drug Administration (FDA) claimed the existence of new data showing women to be at risk for excessive daytime sedation and impaired driving proficiency following bedtime doses of zolpidem. The putative explanation was the reduced metabolic clearance of zolpidem and higher morning blood concentrations in women compared to men. The FDA acted to reduce the recommended dosage for women down to 50% of the dose for men. No other regulatory agency worldwide has taken similar action.

METHODS

Gender effects on zolpidem pharmacokinetics, pharmacodynamics, adverse effects, clinical efficacy, and driving performance were evaluated through a further analysis of data from a previous study, together with a literature review.

RESULTS

Women had on average 35% lower apparent clearance of zolpidem than men (236 vs 364 mL/min, P < 0.001). This difference was not explained by body weight. In some laboratory studies, women had greater functional impairment than men taking the same dose, but in all studies active drug was not distinguishable from placebo at 8 hours after oral dosage. On-the-road driving studies likewise showed no evidence of driving impairment in men or women at 8 hours after 10 mg of oral immediate-release zolpidem. No clinical trial demonstrated a gender-related difference in clinical efficacy or adverse reactions, and there was no evidence of a particular risk to women.

CONCLUSIONS

Dosage reduction in women is not supported by available scientific evidence, and may in fact lead to underdosing and the consequent hazard of inadequately treated insomnia.

Zolpidem prescribing practices before and after Food and Drug Administration required product labeling changes

Background:

Women have higher morning serum zolpidem concentrations than men after taking an evening dose, potentially leading to increased risk of harm. On 19 April 2013, the United States Food and Drug Administration required labeling changes for zolpidem, recommending an initial dose of no greater than 5 mg (immediate release) or 6.25 mg (controlled release) per night in women.

Objectives:

The primary objective of this study was to compare prescribing practices before and after the 2013 zolpidem labeling change. A secondary objective was to evaluate serious adverse events potentially related to zolpidem.

Methods:

Electronic medical records of adults receiving care through the University of Colorado Health system were accessed for study inclusion if patients were provided a first-time prescription for zolpidem either prior to or after the Food and Drug Administration labeling change. Patients were randomly chosen from eight strata based on age, gender, and date of zolpidem initiation (before/after the labeling change). Demographic and zolpidem prescribing data were collected. Low-dose zolpidem was considered 5 mg (immediate release) or 6.25 mg (controlled release) daily or less. Documentation of potentially related serious adverse events within the patients’ records was also evaluated.

Results:

A total of 400 patients were included in the study. The overall percentage of patients prescribed low-dose zolpidem increased from 44% to 58% after the labeling change (p = 0.0020). In a pre-specified subgroup analysis, the percentage of patients prescribed low-dose zolpidem increased in all groups, including young men (38%–50%, p = 0.23), elderly men (34%–40%, p = 0.53), and elderly women (60%–74%, p = 0.14), but the change was only significant in young women (42%–70%, p = 0.0045).

Conclusion:

After Food and Drug Administration–mandated labeling changes for zolpidem in 2013, the percentage of overall patients in our health system, and specifically young women, with initial prescriptions for low-dose zolpidem significantly increased as compared to before the labeling change.