Use Of Non-benzodiazepine Hypnotics Research Articles

A Case-Control Study of Accidental Falls During Surgical Hospitalizations.

Postoperative falls are preventable complications. The study aims were to describe the rate and circumstances surrounding postoperative falls and explore potential associations with patient and procedural characteristics with emphasis on the use of sedative medications. Medical records of hospitalized patients undergoing non-lower extremity surgery under general anesthesia from January 1, 2010, through April 30, 2018 were reviewed for falls within 72 postoperative hours. Perioperative use of sedatives, sleep aids, gabapentinoids, and opioids were abstracted. Each fall case was matched with two controls on age, sex, and procedure type. Descriptive statistics and multivariable analysis accounting for the matched design were performed. There were 343 falls among 200186 hospitalized surgical patients (incidence of 17.1 [95% CI: 15.4, 19.0] falls per 10000 procedures) with largest proportion of falls occurring on postoperative day 2 (n = 134, 39.1%). Most falls occurred in the general hospital wards (n = 304, 88.6%) and were unwitnessed (n = 186, 55.9%). The incidence of major injuries was 1.0 (95% CI: .1 - 3.6) per 100000 procedures. Home use of non-benzodiazepine hypnotics (odds ratio 2.68, 95% CI: 1.47, 4.88, P=.001) and blood transfusions were associated with increased fall risk. Hospital stay was longer in patients who fall (7 [4, 15] vs. 5 [3, 9] days, P < .001). The rate of postoperative falls in our institution was low and frequently unwitnessed. The use of non-benzodiazepine hypnotics is a modifiable risk factor associated with postoperative falls. Serious complications after falls were rare.

Non-benzodiazepine hypnotic use for sleep disturbance in people aged over 55 years living with dementia: a series of cohort studies.

Sleep disturbance affects around 60% of people living with dementia and can negatively affect their quality of life and that of their carers. Hypnotic Z-drugs (zolpidem, zopiclone and zaleplon) are commonly used to treat insomnia, but their safety and efficacy have not been evaluated for people living with dementia. To estimate the benefits and harms of Z-drugs in people living with dementia with sleep disturbance. A series of observational cohort studies using existing data from (1) primary care linked to hospital admission data and (2) clinical cohort studies of people living with dementia. Primary care study - Clinical Practice Research Datalink linked to Hospital Episode Statistics and Office for National Statistics mortality data. Clinical cohort studies - the Resource Use and Disease Course in Dementia - Nursing Homes (REDIC) study, National Alzheimer's Coordinating Centre (NACC) clinical data set and the Improving Well-being and Health for People with Dementia (WHELD) in nursing homes randomised controlled trial. Primary care study - 371 primary care practices in England. Clinical cohort studies - 47 nursing homes in Norway, 34 Alzheimer's disease centres in the USA and 69 care homes in England. Primary care study - NHS England primary care patients diagnosed with dementia and aged > 55 years, with sleep disturbance or prescribed Z-drugs or low-dose tricyclic antidepressants, followed over 2 years. Clinical cohort studies - people living with dementia consenting to participate, followed over 3 years, 12 years and 9 months, for REDIC, NACC and WHELD, respectively. The primary exposure was prescription or use of Z-drugs. Secondary exposures included prescription or use of benzodiazepines, low-dose tricyclic antidepressants and antipsychotics. Falls, fractures, infection, stroke, venous thromboembolism, mortality, cognitive function and quality of life. There were insufficient data to investigate sleep disturbance. The primary care study and combined clinical cohort studies included 6809 and 18,659 people living with dementia, with 3089 and 914 taking Z-drugs, respectively. New Z-drug use was associated with a greater risk of fractures (hazard ratio 1.40, 95% confidence interval 1.01 to 1.94), with risk increasing with greater cumulative dose (p = 0.002). The hazard ratio for Z-drug use and hip fracture was 1.59 (95% confidence interval 1.00 to 2.53) and for mortality was 1.34 (95% confidence interval 1.10 to 1.64). No excess risks of falls, infections, stroke or venous thromboembolism were detected. Z-drug use also did not have an impact on cognition, neuropsychiatric symptoms, disability or quality of life. Primary care study - possible residual confounding because of difficulties in identifying patients with sleep disturbance and by dementia severity. Clinical cohort studies - the small numbers of people living with dementia taking Z-drugs and outcomes not necessarily being measured before Z-drug initiation restricted analyses. We observed a dose-dependent increase in fracture risk, but no other harms, with Z-drug use in dementia. However, multiple outcomes were examined, increasing the risk of false-positive findings. The mortality association was unlikely to be causal. Further research is needed to confirm the increased fracture risk. Decisions to prescribe Z-drugs may need to consider the risk of fractures, balanced against the impact of improved sleep for people living with dementia and that of their carers. Our findings suggest that when Z-drugs are prescribed, falls prevention strategies may be needed, and that the prescription should be regularly reviewed. More research is needed on safe and effective management strategies for sleep disturbance in people living with dementia. This study is registered as European Union electronic Register of Post-Authorisation Studies (EU PAS) 18006. This project was funded by the National Institute for Health Research (NIHR) Health Technology Assessment programme and will be published in full in Health Technology Assessment; Vol. 25, No. 1. See the NIHR Journals Library website for further project information.

Association Between the Use of Non-benzodiazepine Hypnotics and Cognitive Outcomes: A Systematic Review.

Adverse effects of sedative-hypnotic medications on cognition are concerning. Past studies have examined benzodiazepine (BZD) use and cognitive outcomes; however, few studies have examined newer non-BZD hypnotic agents (nBHs; e.g. zolpidem). This systematic review examined observational studies assessing the association between nBH use and cognitive outcomes. Five studies met eligibility requirements and were included in the review. Most studies did not find an association between nBH use and dementia diagnosis; however, we found no studies assessing other cognitive outcomes such as cognitive performance (e.g., word recall tasks). Characterization of nBH use mostly consisted of incident new use; one study assessed nBH dosing; none examined duration of use. Studies included were of strong quality. This review found no association between nBH use and dementia diagnosis, although there is a need for more research on more cognitive outcomes and nBH use patterns.

Use of non-benzodiazepine hypnotics is associated with falls in nursing home residents: a longitudinal cohort study.

Falls and related injuries are common among older people, and several drug classes are considered to increase fall risk. This study aimed to investigate the association between the use of certain drug classes and falls in older nursing home residents in Sweden, and relate these to different age groups. Information on falls that occurred in the previous year and regular use of possible fall risk drugs including non-benzodiazepine hypnotics (zopiclone and zolpidem) was collected from 331 nursing home residents during 2008-2011. Over the following 6months, the occurrence of serious falls, requiring a physician visit or hospital care, was registered. Association between serious falls and drug use was compared between an older (≥ 85years) and a younger group. An increased fall risk (Downton Fall Risk Index ≥ 3) was found in 93% of the study subjects (aged 65-101years). Baseline data indicated an association between falls that occurred in the previous year and regular use of non-benzodiazepine hypnotics (p = 0.005), but not with the other studied drug classes. During the following 6months, an association between use of non-benzodiazepine hypnotics and serious falls in the older group (p = 0.017, odds ratio 4.311) was found. No association was found between the other studied drug classes and serious falls. These results indicate an association between falls and the use of non-benzodiazepine hypnotics, compounds that previously have been considered generally well-tolerated in older people. Caution is advocated when using non-benzodiazepine hypnotics regularly in older people living in nursing homes.

Recorded atypical hallucinations in psychotic and affective disorders and associations with non-benzodiazepine hypnotic use: the South London and Maudsley Case Register

ObjectivesHallucinations are present in many conditions, notably psychosis. Although under-researched, atypical hallucinations, such as tactile, olfactory and gustatory (TOGHs), may arise secondary to hypnotic drug use, particularly non-benzodiazepine hypnotics (‘Z drugs’). This retrospective case-control study investigated the frequency of TOGHs and their associations with prior Z drug use in a large mental healthcare database.MethodsTOGHs were ascertained in 2014 using a bespoke natural language processing algorithm and were analysed against covariates (including use of Z drugs, demographic factors, diagnosis, disorder severity and other psychotropic medications) ascertained prior to 2014.ResultsIn 43 339 patients with International Classification of Diseases, Tenth Edition schizophreniform or affective disorder diagnoses, 324 (0.75%) had any TOGH recorded (0.54% tactile, 0.24% olfactory, 0.06% gustatory hallucinations). TOGHs were associated with male gender, black ethnicity, schizophreniform diagnosis and higher disorder severity on Health of the National Outcome Scales. In fully adjusted models, tactile and olfactory hallucinations remained independently associated with prior mention of Z drugs (ORs 1.86 and 1.60, respectively).ConclusionsWe successfully developed a natural language processing algorithm to identify instances of TOGHs in the clinical record. TOGHs overall, tactile and olfactory hallucinations were shown to be associated with prior mention of Z drugs. This may have implications for the diagnosis and treatment of patients with comorbid sleep and psychiatric conditions.

Age, Sex, and Dose Effects of Nonbenzodiazepine Hypnotics on Hip Fracture in Nursing Home Residents

ObjectiveThe Food and Drug Administration recommends a reduced dose of nonbenzodiazepine hypnotics in women, yet little is known about the age-, sex-, and dose-specific effects of these drugs on risk of hip fracture, especially among nursing home (NH) residents. We estimated the age-, sex-, and dose-specific effects of nonbenzodiazepine hypnotics on the rate of hip fracture among NH residents. Design and SettingCase-crossover study in US NHs. ParticipantsA total of 691 women and 179 men with hip fracture sampled from all US long-stay NH residents. MeasurementsMeasures of patient characteristics were obtained from linked Medicare and the Minimum Data Set (2007–2008). The outcome was hospitalization for hip fracture with surgical repair. We estimated rate ratios (RRs) and 95% confidence intervals (CIs) from conditional logistic regression models for nonbenzodiazepine hypnotics (vs nonuse) comparing 0 to 29 days before hip fracture (hazard period) with 60 to 89 and 120 to 149 days before hip fracture (control periods). We stratified analyses by age, sex, and dose. ResultsThe average RR of hip fracture was 1.7 (95% CI 1.5–1.9) for any use. The RR of hip fracture was higher for residents aged ≥90 years vs <70 years (2.2 vs 1.3); however, the CIs overlapped. No differences in the effect of the hypnotic on risk of hip fracture were evident by sex. Point estimates for hip fracture were greater with high-dose versus low-dose hypnotics (RR 1.9 vs 1.6 for any use), but these differences were highly compatible with chance. ConclusionsThe rate of hip fracture in NH residents due to use of nonbenzodiazepine hypnotics was greater among older patients than among younger patients and, possibly, with higher doses than with lower doses. When clinicians are prescribing a nonbenzodiazepine hypnotic to any NH resident, doses of these drugs should be kept as low as possible, especially among those with advanced age.

Auricular acupuncture versus cognitive behavioural therapy in the discontinuation of hypnotic drug usage, and treatment effects on anxiety, depression and insomnia symptoms − a randomised controlled study

IntroductionThe interest in non-pharmacological interventions for insomnia disorder has increased. The aim was to assess the immediate treatment effects of auricular acupuncture (AA) and cognitive behavioural therapy for insomnia (CBT-i) regarding discontinuation of hypnotic usage and symptoms of anxiety, depression and insomnia. MethodProspective randomised controlled study. Fifty-seven participants (mean age 61 years (SD 8.6)) with insomnia disorder and long-term use of non-benzodiazepine hypnotics received group-treatment with AA or CBT-i.Pre- and post-treatment measures included symptoms of anxiety, depression and insomnia via self-report questionnaires: Hospital Anxiety and Depression scale (HAD-A, HAD-D) and Insomnia Severity Index (ISI). Other sleep parameters and hypnotic consumption were measured with a sleep diary. Linear mixed models were performed to examine treatment effect over time within and between the groups. ResultsSeventy-one percent of the AA participants and 84% of the CBT-i participants managed to discontinue their hypnotic drug consumption post-treatment. Symptoms of anxiety and depression decreased within the AA group (HAD-A (p<0.05), HAD-D (p<0.05)) and insomnia symptoms decreased within the CBT-i group (ISI (p<0.001)). The only between-group difference occurred in ISI (p<0.001), in favour of CBT-i. According to the within-group sleep diary results, the CBT-i group went to bed later (p<0.001), fell asleep quicker (p<0.05), increased their sleep efficiency (p<0.001) and self-rated sleep quality (p<0.05) post-treatment. ConclusionsBoth groups ended/maintained low hypnotic drug consumption post-treatment. Short-term reductions occurred in the AA group in anxiety and depression symptoms and in the CBT-i group regarding insomnia symptoms.

LO032: Use of pharmacological sleep aids among emergency medicine staff physicians in a Canadian tertiary-care setting: a web based survey

Introduction: Emergency medicine by its nature requires shift-work that often follows an erratic and unpredictable pattern. Faced with this ongoing challenge we hypothesized that many ED physicians may have taken steps to minimize their personal sleep deprivation through the use of a pharmacological sleep aid (PSA). The extent and nature of PSA use in this population is not well studied. We sought to describe the use of PSAs amongst practicing ED physicians in a Canadian tertiary-care setting. We also hoped to determine the specific substances being used, their frequency and predictive factors contributing to their use. Methods: A cross-sectional descriptive web-based survey was sent via e-mail to all practicing staff emergency physicians within the Calgary zone of Alberta Health Services. Participation was entirely voluntary and all responses were anonymous. Descriptive statistics were used to assess frequencies and summary measures. Logistic regression was used to explore associations between key variables. Results: Of the 198 eligible ED physicians, 144 (73%) completed the survey. 132 (92%) felt that shift-work negatively affected their ability to sleep and 121(84%) had experienced insomnia at some point in their medical career. 96(67%) ED physicians had used a PSA at some time in their career and 82(57%) were currently using a PSA with any frequency. The most frequent sleep aids currently being used were non-benzodiazepine hypnotics (65%), alcohol (31%) and melatonin (27%). 66(46%) respondents required a prescription for their PSA and 37(56%) of those had obtained a prescription from an ED physician colleague. Physician self-reporting of experience with insomnia was strongly associated with prior use of any PSA (OR 4.0; 95% CI 1.6-10.0) and prior use of non-benzodiazepine hypnotics (OR 14.4; 95% CI 3.2-64.2) There was no statistically significant association between current use of a PSA and physician age, physician gender, number of night shifts worked per month or co-habitation with children. None of the physicians who responded felt that their use of a PSA adversely affected their ability to provide quality patient care. Conclusion: Pharmacological sleep aid use among Canadian ED physicians may be more common than previously assumed. This could have implications for physician wellbeing and performance.

Acupuncture for Ischemic Stroke, Music for Anxiety in Mechanical Ventilation, Essential Fatty Acids for Depression, Mindfulness Meditation for Sleep in Older Adults, Tripterygium wilfordii for Rheumatoid Arthritis

The interest in non-pharmacological interventions for insomnia disorder has increased. The aim was to assess the immediate treatment effects of auricular acupuncture (AA) and cognitive behavioural therapy for insomnia (CBT-i) regarding discontinuation of hypnotic usage and symptoms of anxiety, depression and insomnia.Prospective randomised controlled study. Fifty-seven participants (mean age 61 years (SD 8.6)) with insomnia disorder and long-term use of non-benzodiazepine hypnotics received group-treatment with AA or CBT-i.Pre- and post-treatment measures included symptoms of anxiety, depression and insomnia via self-report questionnaires: Hospital Anxiety and Depression scale (HAD-A, HAD-D) and Insomnia Severity Index (ISI). Other sleep parameters and hypnotic consumption were measured with a sleep diary. Linear mixed models were performed to examine treatment effect over time within and between the groups.Seventy-one percent of the AA participants and 84% of the CBT-i participants managed to discontinue their hypnotic drug consumption post-treatment. Symptoms of anxiety and depression decreased within the AA group (HAD-A (p < 0.05), HAD-D (p < 0.05)) and insomnia symptoms decreased within the CBT-i group (ISI (p < 0.001)). The only between-group difference occurred in ISI (p < 0.001), in favour of CBT-i. According to the within-group sleep diary results, the CBT-i group went to bed later (p < 0.001), fell asleep quicker (p < 0.05), increased their sleep efficiency (p < 0.001) and self-rated sleep quality (p < 0.05) post-treatment.Both groups ended/maintained low hypnotic drug consumption post-treatment. Short-term reductions occurred in the AA group in anxiety and depression symptoms and in the CBT-i group regarding insomnia symptoms.

Abstract 5041: The effect of YOCAS©® Yoga on prescription sleep medication and over-the-counter sleep medication usage in cancer survivors with impaired sleep quality

Abstract Background: Impaired sleep quality (ISQ) is highly prevalent among cancer survivors; 30-90% of cancer survivors report some form of ISQ following treatment. Cancer survivors with ISQ are often provided with sleep medications, which fall into two classes: prescription sleep medications (PSM) or over-the-counter sleep medications (OSM). The most common PSM are non-benzodiazepine hypnotics (NBH), benzodiazepines (BENZO), and tricyclic antidepressants (TCA). PSM have an uncertain efficacy, carry a risk of dependency, and may cause deleterious side effects. OSM (usually diphenhydramine and doxylamine) are believed to be safer, but the user can develop tolerance and often report a “groggy” feeling the next day. The aim of this secondary data analysis is to examine the effect of YOCAS©® Yoga for ISQ in cancer survivors on PSM and OSM usage. We also examined the baseline association between PSM, sleep quality, and side effects. Methods: We previously conducted a RCT among 410 cancer survivors suffering from moderate to severe ISQ between 2 and 24 months after treatment. The YOCAS©® program consisted of breathing exercises, 16 Gentle Hatha and Restorative yoga postures, and meditation. Participants attended two 75-minute sessions per week for four weeks. At baseline, participants listed all current prescription sleep medications while also completing questionnaires on sleep quality and side effects commonly experienced by cancer survivors. ANCOVA models were used to calculate the difference between groups while controlling for age, gender, race, and baseline values (where appropriate). Results: Previously published results showed YOCAS©® Yoga significantly improved ISQ compared to the control group. At baseline, 26% and 13% of participants reported using PSM and OSM, respectively. PSM users had significantly worse sleep quality (PSQI score: PSM=10.5 vs. No PSM=8.6; p&amp;lt;0.001) and insomnia scores (ISI score: PSM=14.7 vs. No PSM=13.3; p&amp;lt;0.01) than non-PSM users at baseline. PSM users reported higher levels of fatigue (Multidimensional Fatigue Inventory: PSM=28.9 vs. No PSM=21.2; p&amp;lt;0.01) and memory problems (0-10 scale: PSM=3.7 vs. No-PSM=2.8; p&amp;lt;0.01). Yoga participants significantly reduced the weekly quantity of NBH (NBH: Yoga = -0.85 vs. Control = 0.26; p=0.047) and there was a significant trend for a reduction in the weekly quantity of OSM use in yoga participants compared to the control participants (OSM: Yoga = -1.46 vs. Control = -0.41; p=0.092). Conclusion: PSM use was associated with ISQ along with side effects such as fatigue and memory problems at baseline. YOCAS©® yoga significantly reduced the use of NBH, which is currently the most used PSM. There was also a trend towards the reduction of OSM use with yoga. Clinicians may consider prescribing alternative therapies for ISQ such as YOCAS©® yoga, which improve ISQ and reduce the dependency on certain sleep medications. Citation Format: Luke J. Peppone, Michelle Janelsins, Jonathan Friedberg, Mohamed Tejani, Charles Kamen, Marie Flannery, Anita Peoples, James Atkins, Marianne Melnik, Karen Mustian. The effect of YOCAS©® Yoga on prescription sleep medication and over-the-counter sleep medication usage in cancer survivors with impaired sleep quality. [abstract]. In: Proceedings of the 105th Annual Meeting of the American Association for Cancer Research; 2014 Apr 5-9; San Diego, CA. Philadelphia (PA): AACR; Cancer Res 2014;74(19 Suppl):Abstract nr 5041. doi:10.1158/1538-7445.AM2014-5041

Prevalence of potentially inappropriate medications and risk of adverse clinical outcome in a cohort of hospitalized elderly patients: results from the REPOSI Study.

Inappropriate prescribing is highly prevalent for older people and has become a global healthcare concern because of its association with negative health outcomes including ADEs, hospitalization and resource utilization. Beers' criteria are widely utilized for evaluating the appropriateness of medications, and an up-to-date version has recently been published. To assess the prevalence of patients exposed to PIMs at hospital discharge according to the 2003 and 2012 versions of Beers' criteria and to evaluate the risk of adverse clinical events, re-hospitalization and all-cause mortality at 3-month follow-up. This cross-sectional study was held in 66 Italian internal medicine and geriatric wards. The sample included 1380 inpatients aged 65years or older. Prescriptions of PIM were analysed at hospital discharge. We considered all patients with complete 3-month follow-up. The prevalence of patients receiving at least one PIM was 20·1% and 23·5% according to the 2003 and 2012 versions of the Beers' criteria, respectively. The 2012 Beers' criteria identified more patients with at least one PIM than the 2003 version, although a high percentage of those patients (72·2%) were also identified by the criteria updated in 2003. The main difference in the prevalence of patients receiving a PIM according to the two versions of Beers' criteria involved prescriptions of benzodiazepines for insomnia or agitation, chronic use of non-benzodiazepine hypnotics, prescription of antipsychotics in people with dementia and oral iron at dosage higher than 325mg/day. Prescription of PIMs was not associated with a higher risk of adverse clinical events, re-hospitalization and all-cause mortality at 3-month follow-up in both univariate and multivariate analysis, after adjusting for age, sex and CIRS comorbidity index. This study found no significant effect of inappropriate drug use according to Beers' criteria on health outcomes among older adults 3month after discharge. Even though these criteria have been suggested as helpful in promoting appropriate prescribing, reducing drug-related adverse events and associated healthcare costs, to date there is no clear evidence that their application can achieve objective and quantifiable improvements in clinical outcomes. A possible explanation is that both versions of the Beers' criteria have several recognized limitations, one of the main ones being the restricted availability of some drugs in Europe or their limited prescription in everyday clinical practice.

Retraction: Use of Non-benzodiazepine Hypnotics Is Associated with Decreased Risk of Coronary Artery Disease

Background It has been reported that the use of benzodiazepines (BDZs) is associated with an increased risk of coronary artery disease (CAD). However, it is still unclear whether or not non-BDZs use has the same adverse effect on the cardiovascular system. Methods We conducted a hospital-based case-control study with 864 CAD patients and 1,008 controls to explore the association between non-BDZs use and CAD risk in Chinese Han population. Results Non-BDZs use was found to be associated with a decreased risk of CAD (adjusted odds ratio, OR=0.73; 95% confidence interval, CI=0.54-0.98). Adjusted ORs were 0.91 (95% CI=0.63-1.32) for using non-BDZs 0 to 5 years, 0.64 (95% CI=0.38-0.97) for 5 to 10 years, and 0.42 (95% CI=0.18-0.85) for >10 years. The risk of CAD tended to decrease with an increase in duration of non-BDZs use (p<0.001 for trend). Conclusion Our study demonstrates that non-BDZs use is associated with a decreased risk of CAD. The potential cardiovascular protective mechanisms of non-BDZs should be investigated further.

Zolpidem induced delirium

Use of non-benzodiazepine hypnotics like zolpidem for insomnia has become a popular practice because of better safety profile and low abuse potential. However, neuropsychiatric side-effects such as headache, depression, memory deficits and abnormal dreams with zolpidem use have been reported. Delirum is a rare side-effect associated with zolpidem use. Here, we report a case of delirium, which occurred with a single dose of zolpidem. Clinicians prescribing zolpidem for insomnia should look into the risk factors/pre-disposing factors such as old age, female gender, substance abuse/dependence, systemic infections, psychiatric illness and multiple drug interactions. It is recommended to stick to the lowest dose possible whenever indicated.

Use of Non-benzodiazepine Hypnotics Is Associated with Decreased Risk of Coronary Artery Disease

It has been reported that the use of benzodiazepines (BDZs) is associated with an increased risk of coronary artery disease (CAD). However, it is still unclear whether or not non-BDZs use has the same adverse effect on the cardiovascular system. We conducted a hospital-based case-control study with 864 CAD patients and 1,008 controls to explore the association between non-BDZs use and CAD risk in Chinese Han population. Non-BDZs use was found to be associated with a decreased risk of CAD (adjusted odds ratio, OR=0.73; 95% confidence interval, CI=0.54-0.98). Adjusted ORs were 0.91 (95% CI=0.63-1.32) for using non-BDZs 0 to 5 years, 0.64 (95% CI=0.38-0.97) for 5 to 10 years, and 0.42 (95% CI=0.18-0.85) for >10 years. The risk of CAD tended to decrease with an increase in duration of non-BDZs use (p<0.001 for trend). Our study demonstrates that non-BDZs use is associated with a decreased risk of CAD. The potential cardiovascular protective mechanisms of non-BDZs should be investigated further.

Heart Failure with Sunitinib; Prolonged QT Interval, Syncope, and Delirium with Galantamine; Memantine-Induced Hepatitis; Cabergoline-Associated Erythema Nodosum; “Sleep Driving” and the Use of Nonbenzodiazepine Hypnotics; Atypical Fractures in Postmenopausal Women Taking Alendronate; Drug-Related Problems in Patients with Human Immunodeficiency Virus

The purpose of this feature is to heighten awareness of specific adverse drug reactions (ADRs), discuss methods of prevention, and promote reporting of ADRs to the Food and Drug Administration's (FDA) medWatch program (800-FDA-1088). If you have reported an interesting preventable ADR to medWatch, please consider sharing the account with our readers.

Use of Non-Benzodiazepine Hypnotics in the Elderly

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.