Zolpidem-induced suicide attempt: a case report

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

INTRODUCTION

Zolpidem is one of the most commonly prescribed nonbenzodiazepine hypnotic drugs for insomnia. Published epidemiological studies linked zolpidem with the risk of suicide. However, to date, no meta-analysis investigated this association. Hence, we systematically reviewed and meta-analysed the current evidence from real-world studies reporting the risk of suicide with the use of zolpidem.

METHODS

Medline (Ovid), Embase (Ovid), and PsycINFO databases were searched from inception till June 2021 for real-world evidence studies reporting the risk of suicide with the use of zolpidem. The quality assessment of included studies was assessed using the New-Castle Ottawa Scale (NOS). Random-effect meta-analysis was performed using a generic inverse variance method.

RESULTS

This meta-analysis was based on four studies with 344,753 participants, of which 42,279 were zolpidem users. The methodological quality of all the included studies was of high quality. A significantly increased risk of suicide or suicide attempt was found in zolpidem users compared to non-users, with a pooled relative risk of 1.88 (95% CI: 1.54 - 2.30). Furthermore, an increased risk of suicidal death was observed in zolpidem users compared to non-users, with a pooled relative risk of 1.82 (95% CI: 1.43 - 2.30). Dose-response analysis also revealed a significantly increased risk of suicide in patients receiving ≥ 180cDDD (cumulative defined daily doses) of zolpidem (124 times), followed by 90-179cDDD (113 times) and <90cDDD (93 times) of zolpidem compared to non-users.

CONCLUSION

In conclusion, zolpidem use was associated with an increased risk of suicide or suicide attempt and suicidal death. Therefore, careful prescribing practices must be followed by considering the risk-benefit profile.

Risks of suicide attempts after prescription of zolpidem in people with depression: a nationwide population study in South Korea

OBJECTIVES

To investigate the association between zolpidem prescription and suicide attempts in people with depression.

METHODS

A nationwide, population-based electronic medical records database from the Health Insurance Review & Assessment Service of South was used to investigate the incidence rate ratios (IRRs) of suicide attempts and probable suicide attempts in people with depression before and after zolpidem prescription using self-controlled case series design.

RESULTS

In a total of 445 people who attempted suicide and 23 141 people who attempted probable suicide attempt, the IRRs of suicidal behavior during the risk periods before and after zolpidem prescription increased compared with those at the baseline. The IRRs gradually increased and peaked immediately before the prescription of zolpidem. The IRR was 70.06 (95% CI: 25.58-191.90) on day 2 before zolpidem prescription and 63.35 (95% CI: 22.99-174.59) on day 1 after zolpidem prescription in the suicide attempt group. The IRR was 24.07 (95% CI: 20.50-28.26) on the day before zolpidem prescription and 14.96 (95% CI: 12.21-18.34) on the day after zolpidem prescription in the probable suicide attempt group. The ratios declined eventually after zolpidem was prescribed.

CONCLUSIONS

Although zolpidem prescription was associated with an increased risk of suicide attempts in people with depression, the risk increased and peaked immediately before zolpidem prescription. The risk declined gradually thereafter. This result indicates that the risk of suicide attempts increases at the time of zolpidem prescription. However, zolpidem prescription does not contribute to additional increase in the risk of suicide attempts.

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.

Overdose and Alcohol Sensitive Immediate Release System (OASIS) for Deterring Accidental Overdose or Abuse of Drugs

Death from an accidental or intentional overdose of sleeping tablets has increased exponentially in the USA. Furthermore, the simultaneous consumption of sleeping tablets with alcoholic beverages not only intensifies the effect of sleeping tablets but also leads to blackouts, sleepwalking, and death in many cases. In this article, we proposed a unique and innovative technology to prevent multi-tablet and alcohol-associated abuse of sleeping tablet. Agonist- and antagonist-loaded polymeric filaments of appropriate Eudragit® polymers were prepared using hot melt extrusion. Metoprolol tartrate and hydrochlorothiazide were used as model drugs in place of zolpidem tartrate (agonist-BCS class I) and flumazenil (antagonist-BCS class IV), respectively. Crushed filaments were converted into a tablet with a novel rapidly soluble co-processed alkalizing agent. Dissolution studies of single tablet and multiple tablets (5) in fasted state simulated gastric fluid (FaSSGF) confirmed that the release of the agonist was significantly (p < 0.0001) reduced in multi-tablet dissolution. Furthermore, the release of antagonist was significantly higher when tablet was exposed to FaSSGF+20% ethanol and various alcoholic beverages. Thus, appropriate use of Eudragit® polymer's chemistry could help design a tablet to prevent the release of agonist in case of overdose and simultaneous release of antagonist when consumed with alcohol.

Prescription of Zolpidem and the Risk of Fatal Motor Vehicle Collisions: A Population-Based, Case-Crossover Study from South Korea

BACKGROUND

Zolpidem is one of the most frequently used hypnotics worldwide, but associations with serious adverse effects such as motor vehicle collisions have been reported.

OBJECTIVE

The objective of this study was to evaluate the association of fatal motor vehicle collisions with a prescription for zolpidem, considering the context of the motor vehicle collisions.

METHODS

We conducted a case-crossover study, where each case served as its own control, by linking data about fatal motor vehicle collisions from the Korean Road Traffic Authority between 2010 and 2014 with national health insurance data. The case period was defined as 1 day before the fatal motor vehicle collisions, and was matched to four control periods at 90-day intervals. Conditional logistic regression was performed to calculate the odds ratio for fatal motor vehicle collisions associated with zolpidem exposure, and odds ratios were adjusted for time-varying exposure to confounding medications. A stratified analysis was performed by age group (younger than 65 years or not), the Charlson Comorbidity Index, and whether patients were new zolpidem users.

RESULTS

Among the 714 subjects, the adjusted odds ratio for a fatal motor vehicle collision associated with a prescription for zolpidem the previous day was 1.48 (95% confidence interval 1.06-2.07). After stratification, a significantly increased risk was observed in subjects with a high Charlson Comorbidity Index (odds ratio 1.81; 95% confidence interval 1.16-2.84), the younger age group (odds ratio: 1.62; 95% confidence interval 1.03-2.56), and new zolpidem users (odds ratio 2.37; 95% confidence interval 1.40-4.00).

CONCLUSION

A prescription for zolpidem on the previous day was significantly related to an increased risk of fatal motor vehicle collisions in this population-based case-crossover study.

Hypnotic Medications and Suicide: Risk, Mechanisms, Mitigation, and the FDA

OBJECTIVE

Insomnia is associated with increased risk for suicide. The Food and Drug Administration (FDA) has mandated that warnings regarding suicide be included in the prescribing information for hypnotic medications. The authors conducted a review of the evidence for and against the claim that hypnotics increase the risk of suicide.

METHOD

This review focused on modern, FDA-approved hypnotics, beginning with the introduction of benzodiazepines, limiting its findings to adults. PubMed and Web of Science were searched, crossing the terms "suicide" and "suicidal" with each of the modern FDA-approved hypnotics. The FDA web site was searched for postmarketing safety reviews, and the FDA was contacted with requests to provide detailed case reports for hypnotic-related suicide deaths reported through its Adverse Event Reporting System.

RESULTS

Epidemiological studies show that hypnotics are associated with an increased risk for suicide. However, none of these studies adequately controlled for depression or other psychiatric disorders that may be linked with insomnia. Suicide deaths have been reported from single-agent hypnotic overdoses. A separate concern is that benzodiazepine receptor agonist hypnotics can cause parasomnias, which in rare cases may lead to suicidal ideation or suicidal behavior in persons who were not known to be suicidal. On the other hand, ongoing research is testing whether treatment of insomnia may reduce suicidality in adults with depression.

CONCLUSIONS

The review findings indicate that hypnotic medications are associated with suicidal ideation. Future studies should be designed to assess whether increases in suicidality result from CNS impairments from a given hypnotic medication or whether such medication decreases suicidality because of improvements in insomnia.

Eszopiclone-induced Parasomnia with Suicide Attempt: A Case Report

Eszopiclone is a benzodiazepine-like hypnotic that is commonly prescribed to treat insomnia. However, eszopiclone's efficacy has been questionable in several clinical trials, and its pharmacologic profile makes its effects on sleep and behavior difficult to predict. We report a case demonstrating an instance of eszopiclone-induced parasomnia involving paranoia and a suicide attempt in a patient taking eszopiclone. We explore possible biochemical explanations examining the pharmacologic profile of eszopiclone and its potential for drug-drug interactions, especially with concomitant administration of monoaminergic medications such as antidepressants. Caution should be exercised when prescribing these medications, and evidence-based treatments for insomnia (e.g., cognitive behavioral therapy, biofeedback, sedating antidepressants) should be considered prior to sedative-hypnotic administration.

Association Between Zolpidem and Suicide: A Nationwide Population-Based Case-Control Study

OBJECTIVE

To evaluate the association between zolpidem and the risk of suicide.

PATIENTS AND METHODS

In this nationwide case-control study, the case group comprised 2199 people who committed suicide or were hospitalized due to suicide attempt between January 1, 2002, and December 31, 2011. To create a control group, we randomly selected 10 people matched to each case according to age, sex, urbanization, and occupation. We measured the risk of suicide/suicide attempt in association with zolpidem exposure by using adjusted odds ratios (ORs) and assessed the dose-response effect of zolpidem.

RESULTS

After adjustment for potential confounders such as the comorbidities of schizophrenia, major depression, bipolar disorder, anxiety, insomnia, substance use, and other mental disorders, the Charlson comorbidity index, and use of benzodiazepine or antidepressants, zolpidem exposure was found to be significantly associated with the risk of suicide/suicide attempt with an OR of 2.08 (95% CIs, 1.83-2.36). The risk increased with the level of zolpidem use. The ORs (95% CIs) for cumulative defined daily doses of less than 90, 90 to 179, and 180 mg or more were 1.90 (1.65-2.18), 2.07 (1.59-2.67), and 2.81 (2.33-3.38), respectively (for trend, P<.001). Subgroup analyses showed that the exposure to zolpidem consistently increased the OR in different age groups, sex, urbanization level, occupation, mental disorders, and Charlson comorbidity index levels and in groups of people with or without the presence of insomnia.

CONCLUSION

This study demonstrated a significant association between using zolpidem and suicide or suicide attempt in people with or without comorbid psychiatric illnesses (all P<.05).

[Evaluation of the conservability of zolpidem and zaleplon in the hepatic tissue]

This paper reports the experimental data on the conservability of zolpidem and zalepion in the samples of the cadaveric liver tissue stored under different conditions. The authors describe the method that includes isolation of the substances of interest from the hepatic tissue by means of acetone extraction, their solvent and chromatographic purification, and subsequent identification with the help of the spectrophotometric technique. It is shown that zolpidem and zaleplon remain in the cadaveric hepatic tissue within 6 months after intoxication regardless of temperature which makes possible their detection, isolation, and identification by the proposed method.