Clinically important drug interactions with zopiclone, zolpidem and zaleplon

Investigating the potential of highly porous zopiclone-loaded 3D electrospun nanofibers for brain targeting via the intranasal route

Nanofibers (NFs) have proven to be very attractive tool as drug delivery plateform among the different plethora of nanosystems, owing to their unique features. They exhibit two- and three-dimensional structures some of which mimic structural environment of the body tissues, in addition to being safe, efficacious, and biocompatible drug delivery platform. Thus, this study embarked on fabricating polyvinyl alcohol/chitosan (PVA/CS) electrospun NFs encapsulating zopiclone (ZP) drug for intranasal brain targeted drug delivery. Electrospun NFs were optimized by adopting a three factor-two level full factorial design. The independent variables were: PVA/CS ratio (X1), flow rate (X2), and applied voltage (X3). The measured responses were: fiber diameter (Y1,nm), pore size (Y2,nm) and ultimate tensile strength (UTS,Y3,MPa). The selected optimum formula had resulted in NFs diameter of 215.90 ± 15.46 nm, pore size 7.12 ± 0.27 nm, and tensile strength around 6.64 ± 0.95 MPa. In-vitro biodegradability testing confirmed proper degradation of the NFs within 8 h. Moreover, swellability and breathability assessment revealed good hydrophilicity and permeability of the prepared NFs. Ex-vivo permeability study declared boosted ex-vivo permeation with an enhancement factor of 2.73 compared to ZP suspension. In addition, optimized NFs formula significantly reduced sleep latency and prolonged sleep duration in rats compared to IV ZP drug solution. These findings demonstrate the feasibility of employing the designed NFs as an effective safe platform for intranasal delivery of ZP for insomnia management.

Orexin dual receptor antagonists, zolpidem, zopiclone, eszopiclone, and cognitive research: A comprehensive dose-response meta-analysis

Background

About one-third of adults have trouble sleeping, ranging from occasional difficulty to chronic insomnia, along with difficulty maintaining sleep. Many studies reported that the long-term use of hypnotics can cause brain dysfunction and damage cognition.

Objective

The objective of the study is to evaluate whether low, medium, and high doses of orexin dual receptor antagonists (DORA), zopiclone (ZOP), eszopiclone (ESZ), and zolpidem (ZST) can impair cognition.

Methods

From the beginning through September 20, 2022, PubMed, Embase, Scopus, the Cochrane Library, and Google Scholar were searched. Randomized controlled trials (RCTs) assessing the therapeutic effects of DORA, eszopiclone, and zopiclone for sleep and cognitive function were included. The primary outcomes were indices related to the cognitive profile, including memory, alertness, execution and control function, and attention and orientation. The secondary outcomes were indices related to sleep and adverse events. The standard mean difference (SMD) was generated for continuous variables. Certain data were captured from figures by GetData 2.26 and analyzed using RStudio 4.2.

Results

Finally, a total of 8,702 subjects were included in 29 studies. Compared with the placebo, the DSST (Digit Symbol Substitution Test) scores of low, medium, and high doses of DORA were SMD = 0.77; 95% CI: 0.33-1.20; SMD = 1.58; 95% CI: 1.11-2.05; and SMD = 0.85; 95% CI: 0.33-1.36, respectively. The DSST scores of zolpidem at low, medium, and high doses were SMD = -0.39; 95% CI: 0.85-0.07; SMD = -0.88, 95% CI: -2.34-0.58; and SMD = -0.12, 95% CI: -0.85-0.60, respectively. Zopiclone's DSST scale score was SMD = -0.18; 95% CI: -0.54-0.18. In addition, the total sleep time (TST) of low, medium, and high doses of DORA was SMD = 0.28, 95% CI: -0.15-0.70; SMD = 1.36, 95% CI: 0.87-1.86; and SMD = 2.59, 95% CI: 1.89-3.30, respectively. The TST of zolpidem with low, medium, and high doses was SMD = 1.01, 95% CI: 0.18-1.83; SMD = 1.94, 95% CI: 0.46-3.43; and SMD = 1.71, 95% CI: 0.86-2.56, respectively. The TST of low, medium, and high doses of eszopiclone was relatively SMD = 2.03, 95% CI: -0.21-4.27; SMD = 2.38, 95% CI: 1.35-3.42; and SMD = 1.71, 95% CI: 0.60-2.82. Zopiclone's TST was SMD = 2.47, 95% CI: 1.36-3.58.

Conclusion

We recommend DORA as the best intervention for insomnia because it is highly effective in inducing and maintaining sleep without impairing cognition. Although zolpidem has a more pronounced effect on maintaining sleep, it is best to reduce its use because of its side effects. Eszopiclone and zopiclone improved sleep quality, but their safety in cognition remains to be verified.

Cod liver oil nano-structured lipid carriers (Cod-NLCs) as a promising platform for nose to brain delivery: Preparation, in vitro optimization, ex vivo cytotoxicity & in vivo biodistribution utilizing radioiodinated zopiclone

Nano-structured lipid carriers containing zopiclone were prepared as a targeted drug delivery system to convey zopiclone directly to brain via nasal route. Nano-structured lipid carriers were constructed adopting hot emulsification-ultrasonication method using palmitic acid in place of the solid lipid, cod liver oil as liquid lipid, and poloxamer 407 as a surfactant. A three-factor three-level central composite face-centered design was used to optimize the formulated nano-structured lipid carriers. The independent factors were lipid amount (X₁), surfactant amount (X₂), and sonication time (X₃). The examined responses were entrapment efficiency (EE,Y₁,%), particle size (PS,Y₂,nm), zeta potential(mV), polydispersity index(PDI,Y₃), in vitro release(Q8h,Y₄,%) and dissolution efficiency (DE,Y₅,%). The optimum formula showed high entrapment efficiency of 94.31% ± 2.44, in vitro drug release of 83.89% ± 1.77 with dissolution efficiency equals 88.63% ± 2.01, small particle size of 71.27 nm ± 13.57 and low polydispersity index 0.097 ± 0.15. In vivo biodistribution in mice was evaluated by a radiobiological technique using radioiodinated zopiclone([¹³¹I]iodo-ZP). Results revealed the superiority of the intranasal route to deliver zopiclone directly to brain faster and higher brain uptake (6.9 ± 1.02%ID/g at 5 min post-administration). The current study confirmed that intranasal administration of nano-structured lipid carriers had great potential as an effective tool for targeted brain zopiclone delivery for insomnia treatment.

Controllable Site-Selective Construction of 2- and 4-Substituted Pyrimido[1,2-b]indazole from 3-Aminoindazoles and Ynals

A straightforward and novel controllable site-selective construction of 2- and 4-substituted pyrimido[1,2-b]indazole from 3-aminoindazoles and ynals has been developed. The high regioselectivity of this reaction could be easily switched by converting different catalytic systems. In this way, a series of 2- and 4-substituted pyrimido[1,2-b]indazole derivatives were obtained in moderate to good yields. In addition, the photophysical properties of compound 3a prepared by the present method were discussed.

Cu-Catalyzed Oxidative Dual Arylation of Active Alkenes: Preparation of Cyanoarylated Oxindoles through Denitrogenation of 3-Aminoindazoles

A novel and mild Cu-catalyzed oxidative dual arylation of carbon-carbon double bonds in acrylamides with 3-aminoindazoles is proposed for the synthesis of cyanoarylated oxindoles. Notably, 3-aminoindazoles are employed as efficient arylating agents via the cleavage of two C-N bonds. This oxidative dual arylation of active alkenes involves a radical process and undergoes a sequence of 3-aminoindazole oxidation, two-C-N-bond cleavage, cyanoaryl radical addition, and intramolecular cyclization.

Pharmacological Interactions between the Dual Orexin Receptor Antagonist Daridorexant and Ethanol in a Double-Blind, Randomized, Placebo-Controlled, Double-Dummy, Four-Way Crossover Phase I Study in Healthy Subjects

BACKGROUND

Daridorexant (ACT-541468) is a potent dual orexin receptor antagonist under development for the treatment of sleep disorders. Concomitant intake of ethanol and hypnotics has been shown to result in additive/supra-additive depression of the central nervous system, resulting in pronounced sedation.

OBJECTIVE

The aim of this study was to evaluate the pharmacokinetic (PK) and pharmacodynamic (PD) interactions between ethanol and daridorexant.

METHOD

This was a single-center, double-blind, placebo-controlled, randomized, four-way crossover study conducted in 19 healthy male/female subjects. Subjects received the following four treatments: ethanol with daridorexant, daridorexant alone, ethanol alone, and placebo. Daridorexant 50 mg and the matching placebo were administered as single oral tablets. Ethanol was infused intravenously and clamped at a level of 0.6 g/L for 5 h. The PK of ethanol and daridorexant were assessed and a battery of PD tests performed.

RESULTS

Concomitant administration of ethanol prolonged the time to reach maximum plasma concentrations (t_max) of daridorexant (median difference 1.25 h). No other relevant PK interactions were observed. Coadministration with ethanol produced a numerically greater impairment on saccadic peak velocity, body sway, visual analog scale (VAS) alertness, VAS alcohol intoxication, smooth pursuit, and adaptive tracking compared with daridorexant alone. All treatments were generally well tolerated without serious adverse events (AEs). The most commonly reported treatment-emergent AEs following coadministration of daridorexant and ethanol included somnolence, headache, fatigue, sudden onset of sleep, and dizziness.

CONCLUSIONS

Apart from a shift in t_max, no relevant changes in PK parameters were observed following coadministration of daridorexant and ethanol. The coadministration led to reinforced drug actions that were, at most, indicative of infra-additive effects on certain PD markers. Patients will be advised not to consume ethanol with daridorexant.

CLINICAL TRIALS REGISTRATION NUMBER

NCT03609775 (ClinicalTrials.gov Identifier).

Relationship between plasma exposure of zolpidem and CYP2D6 genotype in healthy Korean subjects

Zolpidem, a widely prescribed hypnotic agent, is extensively metabolized by cytochrome P450 (CYP) 3A4, and CYP2C9, CYP1A2 and CYP2D6 are also involved in the metabolism of zolpidem. The aim of the study was to investigate the effects of CYP2D6 genotypes on the exposure of zolpidem. The healthy male volunteers were divided into three different genotype groups (CYP2D6*wt/*wt [*wt = *1 or *2], CYP2D6*wt/*10, and CYP2D6*10/*10). Each subject received a single oral dose of zolpidem 5 mg with or without a steady-state concentration of clarithromycin (a potent inhibitor of CYP3A4), and plasma concentrations of zolpidem were measured up to 12 h after zolpidem dosing by using liquid chromatography-tandem mass spectrometry method. When zolpidem was administered alone, the exposure of zolpidem (the total areas under the curve and the mean peak plasma concentrations) was not significantly different among three different genotype groups. Even with the steady-state concentration of clarithromycin, a potent CYP3A4 inhibitor, there were no significant differences in the exposure of zolpidem in relation to CYP2D6 genotypes.

Drug Interactions of Psychiatric and COVID-19 Medications

INTRODUCTION

Coronavirus disease 2019 (COVID-19) has become a pandemic with 1771514 cases identified in the world and 70029 cases in Iran until April 12, 2020. The co-prescription of psychotropics with COVID-19 medication is not uncommon. Healthcare providers should be familiar with many Potential Drug-Drug Interactions (DDIs) between COVID-19 therapeutic agents and psychotropic drugs based on cytochrome P450 metabolism. This review comprehensively summarizes the current literature on DDIs between antiretroviral drugs and chloroquine/hydroxychloroquine, and psychotropics, including antidepressants, antipsychotics, mood stabilizers, and anxiolytics.

METHODS

Medical databases, including Google Scholar, PubMed, Web of Science, and Scopus were searched to identify studies in English with keywords related to psychiatric disorders, medications used in the treatment of psychiatric disorders and COVID-19 medications.

RESULTS

There is a great potential for DDIs between psychiatric and COVID-19 medications ranging from interactions that are not clinically apparent (minor) to those that produce life-threatening adverse drug reactions, or loss of treatment efficacy. The majority of interactions are pharmacokinetic interactions via the cytochrome P450 enzyme system.

CONCLUSION

DDIs are a major concern in the comorbidity of psychiatric disorders and COVID-19 infection resulting in the alteration of expected therapeutic outcomes. The risk of toxicity or lack of efficacy may occur due to a higher or lower plasma concentration of medications. However, psychiatric medication can be safely used in combination with COVID-19 pharmacotherapy with either a wise selection of medication with the least possibility of interaction or careful patient monitoring and management.

Use of alcohol as a sleep aid, unhealthy drinking behaviors, and sleeping pill use among women veterans

OBJECTIVES

Sleep complaints, such as insomnia and sleep disturbances caused by posttraumatic stress disorder (PTSD), are more common among women veterans than nonveteran women. Alcohol use among some women may be partially motivated by the desire to improve sleep. This study evaluated rates of alcohol use as a sleep aid among women veterans and explored the relationship between alcohol use to aid sleep and drinking frequency and sleeping pill use.

DESIGN AND SETTING

National cross-sectional population-based residential mail survey on sleep and other symptoms.

PARTICIPANTS

Random sample of women veteran VA users who completed a postal survey (N = 1533).

INTERVENTIONS

None.

MEASUREMENTS

The survey included demographics, Insomnia Severity Index, Primary Care PTSD screen, and items on alcohol use frequency (days/week), use of prescription or over-the-counter sleep medications, and use of alcohol as a sleep aid (yes/no for each item) over the past month.

RESULTS

A total of 14.3% of respondents endorsed using alcohol to aid sleep. Logistic regression models showed more severe insomnia (odds ratio [OR] = 1.03; 95% confidence interval [CI]: 1.01-1.06) and PTSD (OR = 2.11; 95% CI: 1.49-2.97) were associated with increased odds of using alcohol to aid sleep. Alcohol use to aid sleep was associated with increased odds of daily drinking (OR = 8.46; 95% CI: 4.00-17.87) and prescription (OR = 1.79; 95% CI: 1.34-2.38) and over-the-counter sleep aid use (OR = 1.54; 95% CI: 1.12-2.11).

CONCLUSIONS

Insomnia and PTSD may increase risk for using alcohol as a sleep aid, which may increase risk for unhealthy drinking and for mixing alcohol with sleep medications. Findings highlight the need for alcohol use screening in the context of insomnia and for delivery of cognitive-behavioral therapy for insomnia to women veterans with insomnia.

Trends in Prescribed Central Nervous System Depressant Medications Among Adults Who Regularly Consume Alcohol: United States 1999 to 2014

BACKGROUND

Although the risks of using central nervous system depressant (CNS-D) medications with alcohol are well documented, little is known about trends in prescribed use of these medications among individuals who regularly consume alcohol (i.e., trends in "concurrent use"). We examined changes in the prevalence of prescribed CNS-D medications among individuals who drank alcohol on 52 or more occasions in the past year ("regular drinking"). CNS-D medications included sedative-hypnotics (subclassified as anxiolytics or sleep medications) and opioids.

METHODS

We used 8 cross-sectional cycles of the National Health and Nutrition Examination Survey (1999-2000 to 2013-2014) from participants aged 20 and older (n = 37,709). We used log-binomial regression to examine (i) prevalence trends of prescribed CNS-D medication use, (ii) trend differences by drinking status, and (iii) correlates of CNS-D medication use.

RESULTS

Among those who drink regularly, the relative annual increase in prevalence of sedative-hypnotic use was 5.3% (95% CI: 2.7 to 7.9): Anxiolytic and sleep medication use increased annually by 3.7% (95% CI: 0.8 to 6.7) and 11.2% (95% CI: 6.5 to 16.0), respectively. Opioid use trends among those who drink regularly were not statistically significant but were nonlinear. Differences in CNS-D medication trends between those who drink regularly and those who drink infrequently/abstain were not statistically significant. Those who drink regularly were less likely than those who drink infrequently/abstain to use opioids (adjusted relative risk [ARR]: 0.69, 95% CI: 0.60 to 0.78) and anxiolytics (ARR: 0.71, 95% CI: 0.61 to 0.81), but not sleep medications (ARR: 1.04, 95% CI: 0.80 to 1.35). Those aged 40 and older were 2 to 5 times as likely as those aged 20 to 29 to use sedative-hypnotics.

CONCLUSIONS

Among those who drink regularly, the prevalence of prescribed sedative-hypnotic use increased and prescribed opioid use remained common. These trends indicate that a substantial portion of the population is at risk of alcohol-related adverse drug reactions-particularly those aged 40 and older.

Perioperative Management of the Orthopaedic Patient and Alcohol Use, Abuse, and Withdrawal

Alcohol is one of most commonly abused substances in the United States, and it has contributed to a growing epidemic of medical ailments, including cirrhosis, neurologic and psychosocial disorders, impairment to fertility, and cancer. Moreover, acute and chronic alcohol use represent a significant risk factor for orthopaedic injury and postoperative complications. Yet, relatively little is known about the clinical implications of alcohol abuse in common orthopaedic procedures. Acute withdrawal from alcohol is potentially fatal, particularly in the orthopaedic inpatient whose abstinence is mandated by the hospital setting. The aim of this review is to address the screening, diagnostic, and therapeutic tools available to appropriately manage acute alcohol withdrawal in the orthopaedic inpatient. The influence of chronic alcohol consumption on bone metabolism, fracture healing, and surgical fixation will also be reviewed because this information may guide surgical decision making.

Oxidant-controlled divergent transformations of 3-aminoindazoles for the synthesis of pyrimido[1,2-b]-indazoles and aromatic nitrile-derived dithioacetals

An oxidant-controlled divergent reactivity of 3-aminoindazoles is presented, which enables the [3 + 3] annulation and C–H arylation of ketene dithioacetals in disparate pathways to assemble pyrimido[1,2-b]-indazoles and aromatic nitrile-derived dithioacetals.

Simulated Microgravity Altered the Metabolism of Loureirin B and the Expression of Major Cytochrome P450 in Liver of Rats

Loureirin B (LB) is the marker compound of dragon blood (DB), which exhibits great potentials in protecting astronauts' health against radiation and simulated microgravity (SM). Pharmacokinetics of LB is reported to be significantly altered by SM. Here, we investigated key metabolic features of LB in rat liver microsome (RLM) and the effects of SM on LB metabolism as well as on expression of major hepatic cytochrome P450 (CYP450) isoforms. Ten metabolites were tentatively identified based on fragmentation pathways using LC-MS/MS method and elimination kinetics of LB followed a typical Michaelis-Menten equation (V max was 1.32 μg/min/mg and K m was 13.33 μg/mL). CYP1A2, CYP2C11, CYP2D1, and CYP3A2 were involved in the metabolism of LB and the relative strength was: CYP3A2 > CYP2C11 > CYP2D1 > CYP1A2. Comparative studies suggested that elimination of LB in RLM was remarkably increased by 3-day and 14-day SM, and the generation of identified metabolites was affected as well. Additionally, 3-day and 14-day SM showed obvious regulatory effects on the expression of major CYP450 isoforms, which might contribute to the increased elimination of LB. The data provided supports for the application of DB as a protective agent and the reasonable use of current medications metabolized by hepatic CYP450 in space missions.

Paradoxical insomnia in a patient taking zopiclone

We present a case of a man aged 20 years who was diagnosed with a major depressive disorder and was started on escitalopram and zopiclone. The patient had a significant response to escitalopram except that he developed severe insomnia which dramatically resolved following discontinuation of zopiclone. The patient was recommenced on low dose of zopiclone and unfortunately redeveloped moderate insomnia. The patient was thoroughly investigated and zopiclone was determined to have paradoxically caused the insomnia.

MEDICAL COMORBIDITY AND COMPLICATIONS

Like their peers in the general youth population, youth with chronic medical conditions (YCMC) are at risk for substance use, including nonmedical use of prescription medications. However, given dangerous disease-substance interactions, the stakes for detecting and intervening on substance use are perhaps even higher for YCMC. Given the risk for nonadherence with chronic disease management, it is incumbent on primary care providers, specialty providers, and behavioral health specialists to be vigilant in asking about substance use and providing brief counseling and referral to substance use treatment when appropriate.

Analysis and prediction of drug-drug interaction by minimum redundancy maximum relevance and incremental feature selection

Drug-drug interaction (DDI) defines a situation in which one drug affects the activity of another when both are administered together. DDI is a common cause of adverse drug reactions and sometimes also leads to improved therapeutic effects. Therefore, it is of great interest to discover novel DDIs according to their molecular properties and mechanisms in a robust and rigorous way. This paper attempts to predict effective DDIs using the following properties: (1) chemical interaction between drugs; (2) protein interactions between the targets of drugs; and (3) target enrichment of KEGG pathways. The data consisted of 7323 pairs of DDIs collected from the DrugBank and 36,615 pairs of drugs constructed by randomly combining two drugs. Each drug pair was represented by 465 features derived from the aforementioned three categories of properties. The random forest algorithm was adopted to train the prediction model. Some feature selection techniques, including minimum redundancy maximum relevance and incremental feature selection, were used to extract key features as the optimal input for the prediction model. The extracted key features may help to gain insights into the mechanisms of DDIs and provide some guidelines for the relevant clinical medication developments, and the prediction model can give new clues for identification of novel DDIs.

Efficacy and safety of pharmacotherapy in cancer-related psychiatric disorders across the trajectory of cancer care: a review

At least 25-30% of patients with cancer and an even higher percentage of patients in an advanced phase of illness meet the criteria for a psychiatric diagnosis, including depression, anxiety, stress-related syndromes, adjustment disorders, sleep disorders and delirium. A number of studies have accumulated over the last 35 years on the use of psychotropic drugs as a pillar in the treatment of psychiatric disorders. Major advances in psycho-oncology research have also shown the efficacy of psychotropic drugs as adjuvant treatment of cancer-related symptoms, such as pain, hot flushes, pruritus, nausea and vomiting, fatigue, and cognitive impairment. The knowledge about pharmacokinetics and pharmacodynamics, clinical use, safety, side effects and efficacy of psychotropic drugs in cancer care is essential for an integrated and multidimensional approach to patients treated in different settings, including community-based centres, oncology, and palliative care. A search of the major databases (MEDLINE, Embase, PsycLIT, PsycINFO, the Cochrane Library) was conducted in order to summarize relevant data concerning the efficacy and safety of pharmacotherapy for cancer-related psychiatric disorders in cancer patients across the trajectory of the disease.

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.

A review of the interplay between tuberculosis and mental health

AIMS

Tuberculosis and mental illness share common risk factors including homelessness, HIV positive serology, alcohol/substance abuse and migrant status leading to frequent comorbidity. We sought to generate a comprehensive literature review that examines the complex relationship between tuberculosis and mental illness.

METHODS

A literature search was conducted in MedLine, Ovid and Psychinfo, with further examination of the references of these articles. In total 316 articles were identified. It was not possible to conduct a formal meta-analysis due to the absence of randomised controlled data.

RESULTS

Rates of mental illness of up to 70% have been identified in tuberculosis patients. Medications used in the treatment of common mental illnesses, such as depression, may have significant interactions with anti-tuberculosis agents, especially isoniazid and increasingly linezolid. Many medications used in the treatment of tuberculosis can have significant adverse psychiatric effects and some medications such as rifampicin may reduce the effective doses of anti-psychotics y their enzyme induction actions. Treatment with agents such as cycloserine has been associated with depression, and there have been reported cases of psychosis with most anti-tuberculous agents. Mental illness and substance abuse may also affect compliance with treatment, with attendant public health concerns.

CONCLUSIONS

As a result of the common co-morbidity of mental illness and tuberculosis, it is probable that physicians will encounter previously undiagnosed mental illness among patients with tuberculosis. Similarly, psychiatrists are likely to meet tuberculosis among their patients. It is important that both psychiatrists and physicians are aware of the potential for interactions between the drugs used to treat tuberculosis and psychiatric conditions.

Dynamics and Kinetics of a Modified-Release Formulation of Zolpidem: Comparison With Immediate-Release Standard Zolpidem and Placebo

Modified-release (MR) zolpidem was developed to maintain effective plasma concentrations during the 3- to 6-hour post-dosage interval, corresponding to the middle portion of the typical sleep interval. Modified-release zolpidem (12.5 mg), standard immediate-release (IR) zolpidem (10 mg), and placebo were compared in a double-blind, single-dose, 3-way crossover daytime study of healthy volunteers (n = 70 completers). Effect areas for electroencephalographic beta amplitude during 0 to 8 hours and 3 to 6 hours after dosage were greater for MR compared to IR (P < .001). The digit-symbol substitution test and sedation rating scales behaved similarly. MR and IR did not differ in effects at 8 hours post-dosage nor in halflife or clearance. Time of peak plasma concentration (tmax) was significantly longer for MR (2.4 vs 2.0 hours, P < .004), and dose-normalized peak plasma concentration (Cmax) was lower (12.2 vs 14.0 ng/mL/mg, P < .001). MR zolpidem also had greater area under the plasma concentration curve (AUC) during the 3- to 6-hour interval (P < .001). Thus, MR zolpidem produces sustained plasma levels compared to IR, with resulting enhancement of pharmacodynamic effects in the 3- to 6-hour post-dosage interval.

Clinical implications and management of drug-drug interactions between antiretroviral agents and psychotropic medications

Medications used in the treatment of human immunodeficiency virus (HIV) often have drug-drug interactions which complicate treatment of psychiatric illnesses in HIV-infected patients. Protease inhibitors (PIs) and non-nucleoside reverse transcriptase inhibitors (NNRTIs) are the two classes of HIV medications most likely to be involved with interactions, with the majority occurring via the cytochrome P450 (CYP450) system. These interactions can result in either increased or decreased exposure to psychotropic and antiretroviral medications, often requiring dosage adjustments and increased monitoring. This article reviews some of the major drug interactions with antiretroviral agents.

Dual orexin receptor antagonism by almorexant does not potentiate impairing effects of alcohol in humans

The orexin system plays a pivotal role in the regulation of the sleep/wake state. Almorexant is a selective, orally available dual orexin receptor antagonist. This study evaluated the pharmacokinetic (PK) and pharmacodynamic (PD) interactions between almorexant (200 mg p.o.) and alcohol (0.6 g/L i.v. ethanol clamp for 5 h) using various cognitive and psychomotor performance tests in healthy subjects (n=20; 10 males and 10 females) in a 4-way crossover study. No effect of almorexant on ethanol PK was observed. The effects of ethanol on the PK of almorexant were limited, its exposure (AUC) increased by 21%; the median difference in tmax was 1.2 h; t1/2 and Cmax of almorexant were unchanged. Almorexant showed decreases in adaptive tracking performance, saccadic peak velocity, and subjective alertness as assessed by visual analog scale (VAS) of Bond and Lader, but had no or small effects on smooth pursuit eye movements, body sway, VAS for alcohol intoxication, and a memory test. Almorexant administered together with ethanol showed additive effects for adaptive tracking performance, saccadic peak velocity, subjective alertness and, possibly, calmness, but not on body sway, smooth pursuit, VAS for alcohol intoxication, or memory testing. To conclude, administration of almorexant together with ethanol was associated with additive effects for some of the measured cognitive and psychomotor performance tests. No indications of synergistic effects of almorexant and ethanol for any measured variable were observed.

Pharmacokinetic interactions of almorexant with midazolam and simvastatin, two CYP3A4 model substrates, in healthy male subjects

PURPOSE

Pre-clinical experiments have shown that almorexant, a dual orexin receptor antagonist, is able to inhibit cytochrome P450 3A4 (CYP3A4). Therefore, a study was conducted to investigate the effects of multiple-dose almorexant on the pharmacokinetics of midazolam and simvastatin, two CYP3A4 model substrates.

METHODS

Fourteen healthy male subjects were enrolled in an open-label, randomized, two-way crossover study. Treatment period A consisted of a single oral dose of 2 mg midazolam on day 1 and 40 mg simvastatin on day 3. In treatment period B, subjects received 200 mg almorexant once daily for 9 days together with a single oral dose of midazolam on day 7 and simvastatin on day 9.

RESULTS

Concomitant administration of midazolam with almorexant at steady-state levels, achieved within 4-5 days, resulted in an increase of 1.2-fold [90 % confidence interval (CI) 1.0-1.4], 1.4-fold (90 % CI 1.2-1.6), and 1.3-fold (90 % CI 1.2-1.4) in the maximum plasma concentration (C(max)), area under the concentration-time curve from time 0 to infinity (AUC(0-∞)), and terminal half-life (t(1/2)), respectively, of midazolam; the time to peak plasma concentration (t(max)) was unchanged. Whereas C(max) and t(max) were not influenced by almorexant, the AUC(0-∞) of hydroxy-midazolam increased by 1.2-fold (90 % CI 1.1-1.4) and the t(1/2) by 1.3-fold (90 % CI 1.0-1.5). Concomitant administration of simvastatin with almorexant at steady-state resulted in an increase of 2.7-fold (90 % CI 2.0-3.7) and 3.4-fold (90 % CI 2.6-4.4) in C(max) and AUC(0-∞), respectively, for simvastatin; the t(1/2) and t(max) were unchanged. The C(max) and AUC(0-∞) of hydroxyacid simvastatin both increased by 2.8-fold, with 90 % CIs of 2.3-3.5 and 2.2-3.5, respectively; the t(max) increased by 2 h and the t(1/2) was unchanged. The urinary 6-β-hydroxycortisol/cortisol ratio was unaffected by almorexant.

CONCLUSIONS

Our results suggest that the observed interaction was caused by the inhibition of CYP3A4 activity, most probably at the gut level.

Zolpidem for insomnia

INTRODUCTION

The imidazopyridine derivative zolpidem , which acts as a benzodiazepine (BZ) receptor agonist, is the most widely prescribed hypnotic drug in the US.

AREAS COVERED

This review addresses the neuroreceptor properties of zolpidem; clinical pharmacokinetics, pharmacodynamics and drug interactions; efficacy as a hypnotic; adverse effects; tolerance, dependence and withdrawal; relation to motor vehicle accidents and complex sleep behaviors; and new dosage forms.

EXPERT OPINION

Approved doses of zolpidem (10 mg for adults, 5 mg for the elderly) are consistently effective in reducing sleep latency and consequently increasing sleep duration in patients with insomnia. However, favorable effects on sleep maintenance are observed less consistently. Residual daytime effects are unlikely with recommended doses, and provided that at least 8 h elapse prior to arising. Hypnotic efficacy is maintained with repeated nightly use, and the risk of rebound insomnia is low. Dependence and abuse of zolpidem are no more likely to occur than with typical benzodiazepines. Newly available novel dosage forms of zolpidem have increased therapeutic options for patients with insomnia variants such as sleep maintenance insomnia and middle-of-the-night awakening.

Clinical relevance of disturbances of sleep and vigilance in major depressive disorder: a review

OBJECTIVE

The primary objective of this article is to provide a concise review of the clinical relevance of sleep and vigilance in major depressive disorder.

DATA SOURCES

PubMed was reviewed (1990-2009) and English-language articles were identified using the key words sleep and depression and sleep and antidepressants. Secondary searches included articles cited in sources identified by the primary search.

STUDY SELECTION

The narrative review provides brief descriptions of the normal physiology of sleep and changes associated with depression, as well as the impact of various treatments on these processes.

DATA SYNTHESIS

Although it has long been known that sleep disturbances are an important characteristic of depression, relatively few studies have been conducted with the newer-generation antidepressants. Neither of the most widely used classes of antidepressants, the selective serotonin reuptake inhibitors and the serotonin-norepinephrine reuptake inhibitors, have particularly beneficial effects on sleep and, among the medications that reliably improve sleep efficiency, including mirtazapine and the tricyclic antidepressants, problems with daytime sedation can offset therapeutic benefit. Despite relatively widespread use, trazodone has not been demonstrated to be an effective and safe hypnotic in patients taking other antidepressants. For many patients, ongoing concomitant treatment with benzodiazepines and related drugs is the preferred option, again without convincing empirical support of longer-term efficacy. Among newer and investigational antidepressants, agomelatine shows promise with respect to both overall safety and effects on insomnia, although possible negative effects on liver function warrant further study.

CONCLUSIONS

Sleep disturbances are a significant aspect of depressive syndromes, and relief of insomnia remains an important unmet need in antidepressant therapeutics. Development of a well-tolerated antidepressant medication that rapidly improves sleep maintenance without daytime sedation is a priority for drug development.

Medication effects on sleep

The understanding of the neuropharmacologic reciprocal interactions between the sleep and wake cycles has progressed significantly in the past decade. It was also recently appreciated that sleep disruption or deprivation can have adverse metabolic consequences. Multiple medications have a direct or indirect impact on sleep and the waking state. This article reviews how commonly prescribed medications can significantly affect the sleep-wake cycle.

Propofol reduces the distribution and clearance of midazolam

BACKGROUND

Midazolam, at sedative levels, increases blood propofol concentrations by 25%. We evaluated the reverse interaction and determined the influence of propofol on the pharmacokinetics of midazolam.

METHODS

Eight healthy male volunteers were studied on 2 occasions in a random crossover manner. During session A, volunteers received midazolam 0.035 to 0.05 mg x kg(-1) IV for 1 minute followed by an infusion of 0.035 to 0.05 mg x kg(-1) x h(-1) for 59 minutes. During session B, in addition to this midazolam infusion scheme, a target-controlled infusion of propofol (constant C(T): 0.6 or 1.0 microg x mL(-1)) was given from 15 minutes before the start until 6 hours after termination of the midazolam infusion. Arterial blood samples for propofol and midazolam concentration analysis were taken until 6 hours after termination of the midazolam infusion. Nonlinear mixed-effect models examining the influence of propofol and hemodynamic variables on midazolam pharmacokinetics were constructed using Akaike's information-theoretic criterion for model selection.

RESULTS

In the presence of a mean blood propofol concentration of 1.2 microg x mL(-1), the plasma midazolam concentration was increased by 26.9% + or - 9.4% compared with midazolam given as a single drug. Propofol (C(blood): 1.2 microg x mL(-1)) reduced midazolam central volume of distribution from 5.37 to 2.98 L, elimination clearance from 0.39 to 0.31 L x min(-1), and rapid distribution clearance from 2.77 to 2.11 L x min(-1). Inclusion of heart rate further improved the pharmacokinetic model of midazolam.

CONCLUSIONS

Propofol reduces the distribution and clearance of midazolam in a concentration-dependent manner. In addition, inclusion of heart rate as a covariate improved the pharmacokinetic model of midazolam predominantly through a reduction in the intraindividual variability.

Clinical evaluation of zaleplon in the treatment of insomnia

Zaleplon is a pyrazolopyrimidine hypnotic used for the treatment of insomnia. Zaleplon binds preferentially at the α1β2γ2 subunit of gamma aminobutyric acid type A (GABAA) receptors in the central nervous system, and has a half-life of about one hour. Efficacy studies show that zaleplon is a suitable hypnotic for sleep initiation purposes. However, because of its short half-life, zaleplon is less effective in sleep maintenance when compared with other hypnotics. Nevertheless, zaleplon does increase total sleep time. No rebound effects are observed after treatment discontinuation. The use of zaleplon is relatively safe. Adverse effects are mild and of short duration. No important interactions have been reported, and there is no evidence of abuse potential. Relative to benzodiazepine hypnotics, the biggest advantage of zaleplon is that current evidence suggests it does not produce residual next-day effects. As early as four hours after intake of zaleplon, no effects on cognitive, memory, psychomotor performance, and the ability to drive a car have been reported. Future studies should confirm these findings, and comparisons with new nonbenzodiazepine hypnotics should determine the importance of zaleplon in the future treatment of insomnia.

SFINX-a drug-drug interaction database designed for clinical decision support systems

OBJECTIVE

The aim was to develop a drug-drug interaction database (SFINX) to be integrated into decision support systems or to be used in website solutions for clinical evaluation of interactions.

METHODS

Key elements such as substance properties and names, drug formulations, text structures and references were defined before development of the database. Standard operating procedures for literature searches, text writing rules and a classification system for clinical relevance and documentation level were determined. ATC codes, CAS numbers and country-specific codes for substances were identified and quality assured to ensure safe integration of SFINX into other data systems. Much effort was put into giving short and practical advice regarding clinically relevant drug-drug interactions.

RESULTS

SFINX includes over 8,000 interaction pairs and is integrated into Swedish and Finnish computerised decision support systems. Over 31,000 physicians and pharmacists are receiving interaction alerts through SFINX. User feedback is collected for continuous improvement of the content.

CONCLUSION

SFINX is a potentially valuable tool delivering instant information on drug interactions during prescribing and dispensing.

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.

Effects of three cytochrome P450 inhibitors, ketoconazole, fluconazole, and paroxetine, on the pharmacokinetics of lasofoxifene

AIMS

Two studies were conduced to assess the effects of ketoconazole, a CYP3A4/5 inhibitor; fluconazole, a CYP2C9 inhibitor; and paroxetine, a CYP2D6 inhibitor, on lasofoxifene pharmacokinetics.

METHODS

The first parallel group study was conducted in 45 healthy postmenopausal women (15 per group) to compare the pharmacokinetics of a single dose of lasofoxifene (0.25 mg) administered alone and in combination with ketoconazole (400 mg daily x 20 days) or fluconazole (400 mg daily x 20 days). Lasofoxifene was administered on day 2 and blood samples were collected serially for up to 456 h postdose (20 days). The second study enrolled 20 healthy postmenopausal women (10 per group) to compare the pharmacokinetics of a single dose of lasofoxifene (0.25 mg) alone and in combination with paroxetine (30 mg qd x 21 days). Lasofoxifene was given on day 8 of paroxetine treatment and blood samples were collected serially for up to 336 h postdose.

RESULTS

All subjects completed the study and the treatments were well tolerated. Lasofoxifene C(max) and AUC ratios [90% confidence interval (CI)] with/without ketoconazole were 111% (98.4, 127) and 120% (105, 136), respectively, and were 91.3% (80.3, 104) and 104% (91.4, 118), respectively, with/without fluconazole. Lasofoxifene C(max) and AUC ratios (90% CI) with/without paroxetine were 118% (95.4, 146) and 135% (120, 152), respectively.

CONCLUSIONS

Coadministration of potent inhibitors of CYP3A4/5 and CYP2D6, but not CYP2C9, resulted in a moderate increase in lasofoxifene exposure. No dosage adjustment should be required when lasofoxifene is coadministered with ketoconazole, fluconazole, paroxetine or other agents that inhibit these CYP enzymes.

Evidence of the principle of similitude in modern fatal iatrogenic events

Samuel Hahnemann attributed fundamental importance to the principle of similitude, promoting it to a 'natural law'. Observing that enantiopathic or allopathic treatment produced enduring aggravation of the disease symptoms after a brief and transitory initial relief, he systematised homeopathic treatment, prescribing substances that provoke similar symptoms in healthy individual. Based on clinical and experimental observations, he anticipated the concept of homeostasis, dividing the effects of substances into: primary action of the medicine followed by secondary action or reaction of the organism. This reaction, known as the rebound effect or paradoxical action by modern pharmacology, used to awake the curative response of the body when the principle of similitude is applied, is responsible for several iatrogenic diseases when used on the basis of the principle of contraries. This study discusses the role of this paradoxical reaction of the organism in the fatal side effects of four important drugs, used according to the model of enantiopathic treatment of the symptoms. I present evidence relating to acetylsalicylic acid, rofecoxib, antidepressants and long-acting bronchodilators. The consequences of the allopathic treatment could be decreased if health professionals valued homeostasis, minimising the rebound effect of the organism by gradual suspension of palliative drugs.

Secondary insomnia in the primary care setting: review of diagnosis, treatment, and management

INTRODUCTION

Insomnia is associated with a number of medical and psychiatric disorders, including chronic pain and clinical depression. Until recently, it was assumed that effective treatment of the underlying medical condition would also correct the sleep disturbance. However, some evidence indicates that treatment of secondary or comorbid insomnia should be considered separately from, and perhaps in addition to, optimizing treatment of the primary condition.

METHODS

This article reviews the extant literature to examine the impact of secondary and comorbid insomnia on the patient, and on healthcare economics, in the primary care setting, and discusses current diagnostic and treatment approaches. A MEDLINE search was performed for literature published from 1980 to 2005, and retrieved randomized, controlled clinical trials and key review articles for the conditions most often accompanied by secondary insomnia: depression, chronic pain, and menopause/perimenopause. The search terms included those for commonly used pharmacologic treatments and behavioral therapy.

RESULTS

Due to the paucity of clinical trial data in secondary insomnia patients, physicians have had to rely on evidence derived from primary insomnia trials. These data indicate that hypnotic medications are effective in treating sleep onset insomnia. However, few of these agents are effective against the most commonly occurring insomnia symptom - poor sleep maintenance - and many are associated with problematic residual sedation. Nevertheless, the cost of not treating these insomnia symptoms is often greater than the treatment inadequacies. Physicians should thus consider treating what they perceive as secondary insomnia with one of the available forms of therapy.

CONCLUSION

Patients experiencing sleep problems associated with a potential medical or psychiatric primary condition would likely benefit from increased physician awareness of secondary insomnia and the subsequent increased attention to diagnosing and treating this prevalent condition. Recommendations for managing secondary or comorbid insomnia in the primary care setting are discussed.

A double-blind, placebo- and flurazepam-controlled investigation of the residual psychomotor and cognitive effects of modified release zolpidem in young healthy volunteers

Short-acting hypnotic drugs, such as zolpidem, have minimal residual effects but may not provide optimal efficacy throughout the night for all insomnia patients. A modified-release formulation of zolpidem, zolpidem-MR, has been developed to overcome this limitation. This was a phase I, double-blind, 3-way crossover, placebo-controlled study to investigate the residual psychomotor and cognitive effects of a single oral dose of zolpidem-MR 12.5 mg in 18 healthy young adults. Flurazepam 30 mg was used as a positive control. No comparison with standard immediate-release zolpidem was made. Five neuropsychological tests and 2 subjective tests were performed 8 hours after dosing. The safety of zolpidem-MR was also investigated. Performance on the Critical Flicker Fusion Frequency test, Choice Reaction Time, Immediate and Delayed Word Recall, and the Compensatory Tracking Task was significantly impaired by flurazepam but not by zolpidem-MR (with the exception of the Compensatory Tracking Task) or placebo. No significant effects were observed on the Digit Symbol Substitution Test. The Leeds Sleep Evaluation Questionnaire showed that both drugs improved the ease of getting to sleep and perceived quality of sleep, whereas only flurazepam significantly impaired the ease of awakening. Neither drug scored significantly better than placebo on the Bond and Lader contentedness scale, but both induced a significant difference in calmness; only flurazepam significantly reduced alertness. The safety profile of zolpidem-MR was comparable to placebo. In conclusion, the study showed the good tolerance of zolpidem-MR in terms of residual neuropsychological effects as well as a beneficial effect on sleep quality in young healthy adults.