Effects of zolpidem withdrawal

The Z-category hypnotics are promoted for their relative safety. However, this view is challenged by the emerging clinical evidence in the form of zolpidem related intoxication delirium and seizures, and dependence and complicated withdrawal. We report the case of a zolpidem-naive alcohol-dependent inpatient that, while undergoing alcohol de-addiction, was prescribed zolpidem for insomnia and zolpidem withdrawal delirium during taper-off. He was successfully detoxified for alcohol, treated for delirium and put on disulfiram prophylaxis.

The case highlights the need for being cautious while using zolpidem for insomnia in alcohol dependent subjects. Efficacy and a better safety profile make it a popular alternative to benzodiazepines. AM, a year-old was admitted for alcohol de-addiction. He had a history of alcohol dependence for 12 years and dysthymia for 7 years. Off and on, he was on escitalopram mg for past one year.

At admission day 1all his physical parameters were within normal limits except for bilateral fine tremors of hands post-detoxification diagnosed by neurologist as essential tremors and a mild hepatomegaly with fatty change on ultrasound. For persisting sleep initiation disturbance, he was prescribed zolpidem 10 mg on day 13, increased to 15 mg and 20 mg on days alprazolam and amphetamine salts and 18, respectively.

Persistence of sleep problems led to addition of mirtazapine 7. On day 36, about 20 hours after the last dose of zolpidem, he was observed to be pacing in the ward and misrecognizing the treating staff. He became agitated, refused medication, and soiled his clothes. He was disorientated to time and place, and refused to change soiled clothes. His delirium rating scale score was He was afebrile with normal respiratory rate. Neurological and fundus zolpidem withdrawal were normal.

Arterial blood gas analysis, ECG, full zolpidem withdrawal count, blood sugar, serum electrolytes, liver function test, blood urea, serum zolpidem withdrawal, and urine analysis were within normal limits. Over next 24 hours, his condition persisted despite haloperidol being increased from 0. A review of medication over past 72 hours revealed an inconsistency between the zolpidem withdrawal order and the actual administration of zolpidem.

On day 24, zolpidem prescription was written in two brand names and either one was to be administered depending on availability. The nurse, however, administered both the brands concurrently resulting in doses of 25 mg and 20 mg instead of 10 zolpidem withdrawal and 5 mg on days 28 to 32, respectively. After this discovery, lorazepam 1 mg twice daily b. Over next two days, delirium zolpidem withdrawal of effects completely.

After proper relapse prevention counseling, AM was zolpidem withdrawal on disulfiram and later discharged. The causation of delirium in the index case could be considered from various angles. One, the possibility as an adverse drug reaction of escitalopram, propranolol, zolpidem, and mirtazapine is unlikely as the patient was on these medications for weeks without any abrupt dose change except for zolpidem.

Two, pharmacodynamic interaction between escitalopram and mirtazapine causing delirium is easily ruled out as there were no concurrent symptoms suggestive of serotonin syndrome. Three, zolpidem is highly plasma-protein bound Four, medications zolpidem withdrawal and mirtazapine that are substrates zolpidem effects withdrawal of or inhibitors of zolpidem-metabolizing hepatic cytochrome P 3A4 isozyme may raise plasma zolpidem levels.

Both these possibilities are unlikely as the delirium occurred during weaning-off and not with peak dose of zolpidem. The index case was what is the lowest dose of valium available slightly higher than recommended dosages mg vs mg daily for 18 days, and had shown no evidence of developing dependence on zolpidem.

Long-term alcohol use had possibly caused structural or receptor level neuronal changes rendering the index case susceptible to even smaller alterations in zolpidem dose and resulting in delirium. Also, the index case had none of the predisposing factors such as acute hospitalization, older age, female gender, and hepatorenal dysfunction, that could lead to higher than optimal drug plasma levels even at recommended dose-range; thus, increasing the risk of an adverse event.

Instead, the temporal relation between symptom onset after abrupt dose reduction, failure of the trial of low dose haloperidol, and an almost zolpidem withdrawal response to lorazepam strongly implicate zolpidem as the cause of delirium. This case highlights the risk of prescription of zolpidem in dual diagnosis patients "effects of zolpidem withdrawal" multiple medications. Xanax and trying to get pregnant re-emphasizes the merits of strict adherence to recommended doses and to the time-tested practice of gradual taper-off.

Lastly, it reinforces the sanctity of medical charting and prescription writing so as to minimize the prescription errors. National Center for Biotechnology InformationU. Journal List Indian J Pharmacol v. MattooNavendu Gaurand Partha P. Find effects by Partha P. Surendra Kumar Mattoo, E-mail: This is an open-access article distributed under the terms of the Creative Commons Attribution-Noncommercial-Share Alike 3.

Abstract The Z-category hypnotics are promoted for their relative safety. Adverse drug reactions, alcohol dependence, delirium, insomnia, zolpidem. Case Report AM, a year-old was admitted for alcohol de-addiction. Open in a separate window. Discussion The causation of delirium in the index case could be considered from various angles. Footnotes Source of Support: Central nervous system side effects associated with zolpidem treatment.

Evidence of what is a medication called soma abuse and dependence: Br J Clin Pharmacol. Aggarwal Zolpidem withdrawal, Sharma DD. J Neuropsychiatry Clin Neurosci. Validation of the Delirium Rating Scale-revised Langtry HD, Benfield P. A review of its pharmacodynamic and pharmacokinetic properties and therapeutic potential.

American Psychiatric Press; Diagnostic and Statistical Manual of Mental Disorders. A method for estimating the probability of adverse drug reactions. Zolpidem dependence case series: Kovacic P, Somanathan R. Zolpidem, a clinical hypnotic that affects electronic transfer, alters synaptic activity through potential GABA receptors in the nervous system without significant free radical generation.

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