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• W1489388360 abstract "To the Editor: Zolpidem is an imidazopyridine hypnotic agent that binds selectively the benzodiazepine receptors type-1 while having lower affinity for a2-, a3-, and a5-subunit-containing receptors.1 Because of this selectivity, zolpidem presents lower abuse and dependence potential than benzodiazepines.2, 3 Zolpidem is one of the most prescribed drugs for the treatment of insomnia that is an extremely prevalent condition in elderly people. Although several cases of zolpidem abuse or dependence have been reported in the last decade, little has been discussed about addiction to this agent in older people. To our knowledge, only one case of an elderly woman dependent on zolpidem has been previously reported.3 The aim of this report is to present the case of a 78-year-old man who developed dependence on zolpidem. A 78-year-old man was admitted to the Third Psychiatric Department of AHEPA General Hospital, Thessaloniki, Greece, for detoxification of zolpidem. The patient had developed tolerance, abuse, and dependence on benzodiazepines that had been prescribed for him since the age of 53; his use had escalated to a minimum of 12 mg bromazepam daily. Five years before, the patient decided to stop taking bromazepam without asking for any medical help. He developed withdrawal symptoms and sleep disturbances for which he was prescribed zolpidem 10 mg that gradually escalated to 300 mg daily. When he did not take zolpidem, he felt incapable of managing his everyday difficulties and experienced anxiety, irritability, and insomnia. Even after taking zolpidem in supratherapeutic dosages, his insomnia resisted treatment. Before his admission, the patient had not undergone detoxification therapy. Detoxification was started with a diminished dose of zolpidem 200 mg, valproic acid 500 mg and mirtazapine 30 mg daily with a progressive reduction of zolpidem and a simultaneous increase of mirtazapine up to 45 mg and valproic acid up to 1,000 mg daily. Mirtazapine initially improved the patient's insomnia and restlessness, but soon the sedative effects of mirtazapine were not enough to control the symptoms of the reduction of zolpidem. On Day 26 of his hospitalization, zolpidem had been reduced to 70 mg daily, but the patient was persistently complaining of insomnia and was irritable and isolated. He was obsessively asking for higher dose of zolpidem or an extra dose of benzodiazepine. To control his severe insomnia and craving for zolpidem, quetiapine 50 mg at night was added and was titrated to 100 mg when zolpidem was stopped (Day 40). The patient was discharged with a prescription of mirtazapine 45 mg daily, valproic acid 1,000 mg daily, and quetiapine 100 mg every night, with no severe difficulties in sleeping and no craving for zolpidem. Three months after detoxification from zolpidem, he has had no relapse, he does not report a craving for zolpidem or for benzodiazepines, and he has not developed any tolerance to the sedative effect of mirtazapine and quetiapine. He occasionally has mild sleep difficulties and mild anxiety symptoms that he tolerates. Zolpidem was the first nonbenzodiazepine hypnotic that was widely used as first-line treatment for insomnia. Because it binds to benzodiazepine receptors, zolpidem may exhibit partial agonist properties that explain the lack of rebound insomnia, tolerance, dependence, and withdrawal symptoms of benzodiazepines.4 In clinical practice, it has been shown that, although zolpidem is a safe drug, there is some risk of abuse and dependence, usually related to long-term use of high doses, especially in patients with previous history of substance abuse or other psychiatric disease. This risk is notably lower than that with benzodiazepines.5 Insomnia and mood disorders have been suggested as other vulnerability factors.3 The elderly population seems to have a higher risk for zolpidem abuse or dependency, not only because of its high frequency of sleep and mood disorders, but also because of the reduction of the clearance of zolpidem. In elderly people, peak plasma concentrations are 50% higher,2, 5 which means that in elderly subjects, even with lower doses of zolpidem, phenomena of abuse or dependence can be observed. Quetiapine is an atypical antipsychotic known for its sedative effect and has been proposed as an alternative sedating agent with low abuse potential.6 In our patient, low-dose quetiapine was combined with mirtazapine, another agent with anxiolytic, sedative, and hypnotic properties because of its serotonin 2A and 2C antagonist and H1 antihistamine properties.4 In elderly patients, zolpidem should be prescribed with caution (lower-dose, short-duration of treatment), especially when they have a previous history of substance abuse, to avoid abuse or dependency. In such cases, drugs or combinations of drugs with low abuse or dependency potential could be used, as in this patient. Conflict of Interest: The authors have received support from various pharmaceuticals companies to participate in medical congresses. No other conflict of interest exists. Author Contributions: All listed authors have participated sufficiently and meet the criteria for authorship stated in the Uniform Requirements for Manuscripts Submitted to Biomedical Journals. Sponsor's Role: None." @default.
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• W1489388360 date "2009-10-01" @default.
• W1489388360 modified "2023-10-18" @default.
• W1489388360 title "Zolpidem Dependence in a Geriatric Patient: A Case Report" @default.
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• W1489388360 doi "https://doi.org/10.1111/j.1532-5415.2009.02473.x" @default.
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