Zolpidem precautions

List of precautions
General Severe anaphylactic and anaphylactoid reactions Abnormal thinking and behavioral changes Withdrawal effects CNS depressant effects Special populations Laboratory tests
 * Decreased behavioral inhibition
 * Visual and auditory hallucinations
 * Complex behaviors
 * Neuro-psychiatric symptoms
 * Additive effects
 * Elderly and/or debilitated patient population
 * Patients with concomitant illness
 * Patients with compromised respiratory functions
 * Patients with renal impairment
 * Depression
 * Pediatric patients
 * Monitoring
 * Interference with laboratory tests

General
Because sleep disturbances may be the presenting manifestation of a physical and/or psychiatric disorder, symptomatic treatment of insomnia should be initiated only after a careful evaluation of the patient. The failure of insomnia to remit after 7 to 10 days of treatment may indicate the presence of a primary psychiatric and/or medical illness that should be evaluated. Worsening of insomnia or the emergence of new thinking or behavior abnormalities may be the consequence of an unrecognized psychiatric or physical disorder. Such findings have emerged during the course of treatment with sedative/hypnotic drugs, including Zolpidem tartrate tablets. Because some of the important adverse effects of Zolpidem tartrate tablets appear to be dose related, it is important to use the smallest possible effective dose, especially in the elderly. Return to top

Severe anaphylactic and anaphylactoid reactions
Rare cases of angioedema involving the tongue, glottis or larynx have been reported in patients after taking the first or subsequent doses of sedative-hypnotics, including Zolpidem tartrate tablets. Some patients have had additional symptoms such as dyspnea, throat closing or nausea and vomiting that suggest anaphylaxis. Some patients have required medical therapy in the emergency department. If angioedema involves the throat, glottis or larynx, airway obstruction may occur and be fatal. Patients who develop angioedema after treatment with Zolpidem tartrate tablets should not be rechallenged with the drug. Return to top

Decreased behavioral inhibition
A variety of abnormal thinking and behavior changes have been reported to occur in association with the use of sedative/hypnotics. Some of these changes may be characterized by decreased inhibition (eg, aggressiveness and extroversion that seemed out of character), similar to effects produced by alcohol and other CNS depressants. Return to top

Visual and auditory hallucinations
Visual and auditory hallucinations have been reported as well as behavioral changes such as bizarre behavior, agitation and depersonalization. In controlled trials, <1% of adults with insomnia who received Zolpidem reported hallucinations. In a clinical trial, 7.4% of pediatric patients with insomnia associated with attention-deficit/hyperactivity disorder (ADHD), who received Zolpidem reported hallucinations. Return to top

Complex behaviors
Complex behaviors such as “sleep-driving” (i.e., driving while not fully awake after ingestion of a sedative-hypnotic, with amnesia for the event) have been reported with Zolpidem tartrate tablets use. These events can occur in sedative-hypnotic-naive as well as in sedative-hypnotic-experienced persons. Although behaviors such as “sleep-driving” may occur with Zolpidem tartrate tablets alone at therapeutic doses, the use of alcohol and other CNS depressants with Zolpidem tartrate tablets appears to increase the risk of such behaviors, as does the use of Zolpidem tartrate tablets at doses exceeding the maximum recommended dose. Due to the risk to the patient and the community, discontinuation of Zolpidem tartrate tablets should be strongly considered for patients who report a “sleep-driving” episode. Other complex behaviors (e.g., preparing and eating food, making phone calls, or having sex) have been reported in patients who are not fully awake after taking a sedative-hypnotic. As with “sleep-driving”, patients usually do not remember these events. Return to top

Neuro-psychiatric symptoms
Amnesia, anxiety and other neuro-psychiatric symptoms may occur unpredictably. In primarily depressed patients, worsening of depression, including suicidal thoughts and actions (including completed suicides), has been reported in association with the use of sedative/hypnotics. Return to top It can rarely be determined with certainty whether a particular instance of the abnormal behaviors listed above is drug induced, spontaneous in origin, or a result of an underlying psychiatric or physical disorder. Nonetheless, the emergence of any new behavioral sign or symptom of concern requires careful and immediate evaluation. Return to top

Withdrawal effects
Following the rapid dose decrease or abrupt discontinuation of sedative/hypnotics, there have been reports of signs and symptoms similar to those associated with withdrawal from other CNS-depressant drugs. Return to top

CNS depressant effects
Zolpidem tartrate tablets, like other sedative/hypnotic drugs, have CNS-depressant effects. Due to the rapid onset of action, Zolpidem tartrate tablets should only be ingested immediately prior to going to bed. Patients should be cautioned against engaging in hazardous occupations requiring complete mental alertness or motor coordination such as operating machinery or driving a motor vehicle after ingesting the drug, including potential impairment of the performance of such activities that may occur the day following ingestion of Zolpidem tartrate tablets. Return to top

Additive effects
Zolpidem tartrate tablets showed additive effects when combined with alcohol and should not be taken with alcohol. Patients should also be cautioned about possible combined effects with other CNS-depressant drugs. Dosage adjustments may be necessary when Zolpidem tartrate tablets are administered with such agents because of the potentially additive effects. Return to top

Elderly and/or debilitated patient population
Use in the elderly and/or debilitated patients: Impaired motor and/or cognitive performance after repeated exposure or unusual sensitivity to sedative/hypnotic drugs is a concern in the treatment of elderly and/or debilitated patients. Therefore, the recommended Zolpidem tartrate tablets dosage is 5 mg in such patients to decrease the possibility of side effects. These patients should be closely monitored. Return to top

Patients with concomitant illness
Use in patients with concomitant illness: Clinical experience with Zolpidem tartrate tablets in patients with concomitant systemic illness is limited. Caution is advisable in using Zolpidem tartrate tablets in patients with diseases or conditions that could affect metabolism or hemodynamic responses. Return to top

Patients with compromised respiratory functions
Although studies did not reveal respiratory depressant effects at hypnotic doses of Zolpidem tartrate tablets in normals or in patients with mild to moderate chronic obstructive pulmonary disease (COPD), a reduction in the Total Arousal Index together with a reduction in lowest oxygen saturation and increase in the times of oxygen desaturation below 80% and 90% was observed in patients with mild-to-moderate sleep apnea when treated with Zolpidem tartrate tablets (10 mg) when compared to placebo. However, precautions should be observed if Zolpidem tartrate tablets are prescribed to patients with compromised respiratory function, since sedative/hypnotics have the capacity to depress respiratory drive. Zolpidem tartrate tablets should be used with caution in patients with sleep apnea syndrome or myasthenia gravis. Post-marketing reports of respiratory insufficiency, most of which involved patients with pre-existing respiratory impairment, have been received. Return to top

Patients with renal impairment
Data in end-stage renal failure patients repeatedly treated with Zolpidem tartrate tablets did not demonstrate drug accumulation or alterations in pharmacokinetic parameters. No dosage adjustment in renally impaired patients is required; however, these patients should be closely monitored. A study in subjects with hepatic impairment did reveal prolonged elimination in this group; therefore, treatment should be initiated with 5 mg in patients with hepatic compromise, and they should be closely monitored. Return to top

Depression
As with other sedative/hypnotic drugs, Zolpidem tartrate tablets should be administered with caution to patients exhibiting signs or symptoms of depression. Suicidal tendencies may be present in such patients and protective measures may be required. Intentional over-dosage is more common in this group of patients; therefore, the least amount of drug that is feasible should be prescribed for the patient at any one time. Return to top

Pediatric patients
Safety and effectiveness of Zolpidem has not been established in pediatric patients. In an 8-week study in pediatric patients (aged 6-17 years) with insomnia associated with ADHD, Zolpidem did not decrease sleep latency compared to placebo. Hallucinations were reported in 7.4% of the pediatric patients who received Zolpidem; none of the pediatric patients who received placebo reported hallucinations. Return to top

Monitoring
There are no specific laboratory tests recommended to monitor Zolpidem levels. Return to top

Interference with laboratory tests
Zolpidem is not known to interfere with commonly employed clinical laboratory tests. In addition, clinical data indicate that Zolpidem does not cross-react with benzodiazepines, opiates, barbiturates, cocaine, cannabinoids, or amphetamines in two standard urine drug screens. Return to top