Zolpidem-Associated Parasomnia with Serious Self-Injury: A Shot in the Dark

Zolpidem for Insomnia: A Double-Edged Sword. A Systematic Literature Review on Zolpidem-Induced Complex Sleep Behaviors

BACKGROUND

Being a nonbenzodiazepine, zolpidem is believed to have a favorable side-effect profile and is widely prescribed for insomnia. However, in the past few years, numerous neuropsychiatric adverse reactions, particularly complex sleep behaviors (CSBs), have been reported with zolpidem.

OBJECTIVE

To conduct a systematic review of zolpidem-associated CSBs.

DATA SOURCES

An electronic search was conducted using MEDLINE, Embase, PubMed, and Cochrane database of systematic reviews to extract relevant articles till July 2020.

STUDY ELIGIBILITY CRITERIA

Any type of literature article (case report, case series, and observational or interventional study) reporting CSBs associated with zolpidem.

RESULTS

In this review, we present aggregate summarized data from 148 patients presenting with zolpidem-induced CSBs (79 patients from 23 case reports and 5 case series; 69 patients out of 1454 taking zolpidem [4.7%] from three observational clinical studies). Various types of CSBs associated with zolpidem were reported, most common being sleepwalking/somnambulism and sleep-related eating disorder. On causality assessment, around 88% of cases were found to have a probable association with zolpidem.

LIMITATIONS

Extraction of data from observational studies and spontaneous reports, due to nonavailability of any randomized controlled trials relevant to the study objective.

CONCLUSION AND IMPLICATION OF KEY FINDINGS

Zolpidem-induced CSBs, although not very common, may develop when the drug is used at therapeutic doses for insomnia. Doctors need to be alert to monitor such adverse effects of zolpidem and exercise caution while prescribing it.

Impetuous suicidality with zolpidem use: a case report and minireview

Zolpidem is a clinically effective hypnotic medication for treating chronic insomnia. In the last decade, there has been increasing documentation of altered consciousness and behavioral changes following zolpidem administration. This report presents a case of a probable zolpidem induced suicide attempt and highlights similar studies of suicidal thoughts and behaviors of other patients that have taken the drug. We examine zolpidem and other treatments for insomnia, including the FDA approved hypnotics and frequently prescribed off-label medications, in terms of prescribing practices and adverse effects, especially altered consciousness and risk of suicide. Parallels are identified between the untoward activating side effects of zolpidem and its off-label use for patients in persistent vegetative states. We hypothesize that similar to the proposed mechanism in which the wakefulness promoted by zolpidem in vegetative patients is mediated by disruption of GABAergic tone in neurodormant brain regions, there may occur in patients with parasomnias interference of GABA activity in brain regions that maintain a high level of inhibitory regulation. Dosing recommendations are offered together with the FDA Safety Announcement addressing dose reductions for women due to possible carry-over effects the morning after ingesting zolpidem.

Suicidality in sleep disorders: prevalence, impact, and management strategies

Sleep disturbances are associated with suicide-related thoughts and behaviors, and the incidence of sleep concerns and suicide has increased recently in the US. Most published research exploring the sleep-suicidality relation is focused on select sleep disorders, with few reviews offering a comprehensive overview of the sleep-suicidality literature. This narrative review broadly investigates the growing research literature on sleep disorders and suicidality, noting the prevalence of suicide ideation and nonfatal and fatal suicide attempts, the impact of several sleep disorders on suicide risk, and potential sleep-disorder management strategies for mitigating suicide risk. Aside from insomnia symptoms and nightmares, there exist opportunities to learn more about suicide risk across many sleep conditions, including whether sleep disorders are associated with suicide risk independently of other psychiatric conditions or symptoms. Generally, there is a lack of randomized controlled trials examining the modification of suicide risk via evidence-based sleep interventions for individuals with sleep disorders.

Medication induced sleepwalking: A systematic review

Medications that trigger sleepwalking may inadvertently put the patient at risk of injury to themselves and/or others, and contribute to poor treatment adherence. The aim of this study was to systematically review the literature to identify drugs that may increase the risk of sleepwalking. A search of CINAHL, EMBASE, PsycINFO, PubMed, and ScienceDirect was conducted with the keywords 'sleepwalking' OR 'somnambulism'. Of the original 83 sourced papers, 62 met the inclusion criteria and were subsequently included for review. Twenty-nine drugs, primarily in four classes-benzodiazepine receptor agonists and other gamma aminobutyric acid (GABA) modulators, antidepressants and other serotonergic agents, antipsychotics, and β-blockers-were identified as possible triggers for sleepwalking. The strongest evidence for medication-induced sleepwalking was for zolpidem and sodium oxybate. All other associations were based on case reports. This research highlights the importance of considering sleepwalking in risk profiles in clinical trials, particularly for drugs that enhance GABA activity at the GABA_A receptor, enhance serotonergic activity, or block the activity of noradrenaline at β receptors. The results also have implications for prescribers to consider sleepwalking as a potential adverse effect and ensure that: 1) the patient is educated about a safe sleep environment; 2) they are encouraged to report the onset or exacerbation of sleepwalking, and 3) alternative treatments are considered if sleepwalking occurs.