Dose-related illusions and hallucinations with zaleplon

Clinical safety and narcolepsy-like symptoms of dual orexin receptor antagonists in patients with insomnia: a systematic review and meta-analysis

STUDY OBJECTIVES

Dual orexin receptor antagonists (DORAs) are emerging treatments for insomnia. This meta-analysis study aimed to assess the safety of FDA-approved DORAs (suvorexant, lemborexant, and daridorexant), focusing on narcolepsy-like symptoms associated with these drugs.

METHODS

Five prominent databases were searched to identify randomized controlled trials (RCTs) on this topic. Primary safety outcomes included treatment-emergent adverse events (TEAEs), treatment-related TEAEs, TEAEs leading to discontinuation, and serious TEAEs. Excessive daytime sleepiness (EDS), sleep paralysis, and hallucinations were categorized as adverse events (AEs)-related narcolepsy-like symptoms.

RESULTS

Eleven RCTs with 7703 patients were included. DORAs were associated with a higher risk of TEAEs (risk ratio [RR], 1.09; 95% confidence interval [CI], 1.03 to 1.15) and treatment-related TEAEs (RR, 1.69; 95% CI: 1.49 to 1.92) when compared to placebo. The DORA group exhibited a significantly higher risk of EDS (RR, 2.15; 95% CI: 1.02 to 4.52) and sleep paralysis (RR, 3.40; 95% CI: 1.18 to 9.80) compared to the placebo group.

CONCLUSION

This meta-analysis achieved a comparative evaluation of the clinical safety and tolerability of FDA-approved DORAs for primary insomnia, specifically focusing on AEs-related narcolepsy-like symptoms. This study contributes to understanding the safety profile of FDA-approved DORAs for treating insomnia.

Study on the hypnotic effect of rare protopanaxadiol-type and protopanaxatriol-type ginsenosides

Ginsenosides, as major active components of ginseng, possess various pharmacological activities, including anti-tumor, anti-diabetic and hypotensive effects. However, the sedative and hypnotic effect of ginsenosides and the involved mechanism remain unclear. In the present study, the hypnotic effect of rare protopanaxadiol-type (PD) ginsenosides, consisting of Rg3, Rk1, Rg5, and protopanaxatriol-type (PT) ginsenosides, consisting of Rh1, Rk3, Rh4, was investigated and compared in rodent models through behavioral pharmacology methods. Both rare PD and PT ginsenosides decreased spontaneous locomotion activity in normal mice and reduced sleep latency, and extended sleep duration in pentobarbital-treated mice. Moreover, PD and PT ginsenosides attenuated the insomnia induced by caffeine in mice. These hypnotic effects of PD and PT ginsenosides were potentiated by 5-hydroxytryptophan (5-HTP), a precursor of serotonin, and inhibited by p-chlorophenylalanine (PCPA), a 5-HT synthesis inhibitor. Flumazenil (FLU, a specific gamma aminobutyric acid (GABA) antagonist) also impaired the hypnotic effect of both PD and PT ginsenosides. The aforementioned results indicated that PD and PT ginsenosides exhibit sedative and hypnotic activity, and PT ginsenosides show higher activity than PD ginsenosides at high doses (96 mg kg⁻¹). Furthermore, the bioactivity of these two types of ginsenosides might be mediated via the serotonergic and GABAergic systems.

Ginsenosides, as major active components of ginseng, possess various pharmacological activities, including anti-tumor, anti-diabetic and hypotensive effects.

Recorded atypical hallucinations in psychotic and affective disorders and associations with non-benzodiazepine hypnotic use: the South London and Maudsley Case Register

OBJECTIVES

Hallucinations are present in many conditions, notably psychosis. Although under-researched, atypical hallucinations, such as tactile, olfactory and gustatory (TOGHs), may arise secondary to hypnotic drug use, particularly non-benzodiazepine hypnotics ('Z drugs'). This retrospective case-control study investigated the frequency of TOGHs and their associations with prior Z drug use in a large mental healthcare database.

METHODS

TOGHs were ascertained in 2014 using a bespoke natural language processing algorithm and were analysed against covariates (including use of Z drugs, demographic factors, diagnosis, disorder severity and other psychotropic medications) ascertained prior to 2014.

RESULTS

In 43 339 patients with International Classification of Diseases, Tenth Edition schizophreniform or affective disorder diagnoses, 324 (0.75%) had any TOGH recorded (0.54% tactile, 0.24% olfactory, 0.06% gustatory hallucinations). TOGHs were associated with male gender, black ethnicity, schizophreniform diagnosis and higher disorder severity on Health of the National Outcome Scales. In fully adjusted models, tactile and olfactory hallucinations remained independently associated with prior mention of Z drugs (ORs 1.86 and 1.60, respectively).

CONCLUSIONS

We successfully developed a natural language processing algorithm to identify instances of TOGHs in the clinical record. TOGHs overall, tactile and olfactory hallucinations were shown to be associated with prior mention of Z drugs. This may have implications for the diagnosis and treatment of patients with comorbid sleep and psychiatric conditions.

Sleep disorders in the elderly: a growing challenge

In contrast to newborns, who spend 16-20 h in sleep each day, adults need only about sleep daily. However, many elderly may struggle to obtain those 8 h in one block. In addition to changes in sleep duration, sleep patterns change as age progresses. Like the physical changes that occur during old age, an alteration in sleep pattern is also a part of the normal ageing process. As people age, they tend to have a harder time falling asleep and more trouble staying asleep. Older people spend more time in the lighter stages of sleep than in deep sleep. As the circadian mechanism in older people becomes less efficient, their sleep schedule is shifted forward. Even when they manage to obtain 7 or 8 h sleep, they wake up early, as they have gone to sleep quite early. The prevalence of sleep disorders is higher among older adults. Loud snoring, which is more common in the elderly, can be a symptom of obstructive sleep apnoea, which puts a person at risk for cardiovascular diseases, headaches, memory loss, and depression. Restless legs syndrome and periodic limb movement disorder that disrupt sleep are more prevalent in older persons. Other common medical problems of old age such as hypertension diabetes mellitus, renal failure, respiratory diseases such as asthma, immune disorders, gastroesophageal reflux disease, physical disability, dementia, pain, depression, and anxiety are all associated with sleep disturbances.

Use of Medicines from the Group of Benzodiazepines in the Period of 2003-2013 Year in the Republic of Macedonia

AIM

The aim of this study was to analyze the use of benzodiazepines in the period of 2003-2013 year in the Republic of Macedonia (MKD).

METHOD

The study was cross sectional and analyzes the available data on the use of benzodiazepines in the country. This study used several sources of data: Statistical Reports of the United Nations regarding the consumption of psychotropic substances; data from the Ministry of Health associated with the use of benzodiazepines (BZD), derived from reports of Ministry of Health stakeholders; Data extracted from the database of the Ministry of Health in the electronic database "My term" and Analysis of reports of Health Insurance Fund.

RESULTS

The analysis for the period 2003-2013 showed that the most consumed drug in MKD from the group of BZD is Diazepam, with 54.8 and predominantly is use of diazepam of 5 mg with 59 %. According to the Health Insurance Fund, Diazepam is second most prescribed medicaments of all medicaments with marketing authorization in MKD.

CONCLUSIONS

The analysis shows that the use of BZD in MKD is particularly high. Limited number of studies was performed for this kind of drugs relating to their effects; differences in use between genders; adult population. There is need for additional focused research that will contribute to developing a full picture of the situation.

The clinical and forensic toxicology of Z-drugs

The Z-drugs zolpidem, zopiclone, and zaleplon were hailed as the innovative hypnotics of the new millennium, an improvement to traditional benzodiazepines in the management of insomnia. Increasing reports of adverse events including bizarre behavior and falls in the elderly have prompted calls for caution and regulation. Z-drugs have significant hypnotic effects by reducing sleep latency and improving sleep quality, though duration of sleep may not be significantly increased. Z-drugs exert their effects through increased γ-aminobutyric acid (GABA) transmission at the same GABA-type A receptor as benzodiazepines. Their pharmacokinetics approach those of the ideal hypnotic with rapid onset within 30 min and short half-life (1-7 h). Zopiclone with the longest duration of action has the greatest residual effect, similar to short-acting benzodiazepines. Neuropsychiatric adverse events have been reported with zolpidem including hallucinations, amnesia, and parasomnia. Poisoning with Z-drugs involves predominantly sedation and coma with supportive management being adequate in the majority. Flumazenil has been reported to reverse sedation from all three Z-drugs. Deaths from Z-drugs are rare and more likely to occur with polydrug overdose. Z-drugs can be detected in blood, urine, oral fluid, and postmortem specimens, predominantly with liquid chromatography-mass spectrometry techniques. Zolpidem and zaleplon exhibit significant postmortem redistribution. Zaleplon with its ultra-short half-life has been detected in few clinical or forensic cases possibly due to assay unavailability, low frequency of use, and short window of detection. Though Z-drugs have improved pharmacokinetic profiles, their adverse effects, neuropsychiatric sequelae, and incidence of poisoning and death may prove to be similar to older hypnotics.