A Case of Zolpidem Dependence Successfully Detoxified with Gabapentin

By Fernandes, Wenona; Pereira, Yvonne et al. | Indian Journal of Psychiatry, July-September 2013 | Go to article overview

A Case of Zolpidem Dependence Successfully Detoxified with Gabapentin


Fernandes, Wenona, Pereira, Yvonne, Tereza, Salvador O', Indian Journal of Psychiatry


Byline: Wenona. Fernandes, Yvonne. Pereira, Salvador. O' Tereza

An elderly female patient with Zolpidem dependence, who was successfully detoxified using Gabapentin is reported. Gabapentin may be considered as an alternative in the detoxification of non-benzodiazepine hypnotics.

Introduction

Zolpidem is a short acting, non benzodiazepine hypnotic, a member of the imidazopyridine class. Its mechanism of action shares much in common with benzodiazepines as it is active at the central benzodiazepine receptors (sometimes called the omega 'w' receptors). [sup][1] This receptor is a sub-unit of the GABA-A receptor and Zolpidem binds preferentially to the w1 receptor. Therefore, it has been proposed that it lacks benzodiazepine like side effects, having minimum abuse and dependence potential. [sup][2] This selectivity for w1 receptors however is lost at higher than standard hypnotic dosages, and thus Zolpidem acts like any other benzodiazepine. [sup][3],[4] The tolerance producing potential of Zolpidem was found to be the same as that of benzodiazepines and tolerance was found to develop in some people in just a few weeks, at doses of 30-120 mg above the recommended dose. [sup][5]

Various cases of Zolpidem dependence have been reported. However, till date, there is no consensus as regards the medication to be used in the detoxification.

We present a case report of an elderly female patient who developed dependence to Zolpidem over a period of 8 months and was successfully detoxified with Gabapentin.

Case Report

Mrs. M.C., 72-year-old female, received a prescription for Tab Zolpidem 10 mg per day as a treatment for insomnia. She gradually increased the number of tablets and would take Zolpidem even during the day as it increased her efficiency to carry out work done earlier. Over an 8 month period, the use escalated to 300 mg per day following which she was noted to be sleeping most of the time during the day, and would not attend to her routine household chores. If she was denied the tablets, she would become irritable on minimal provocation, would complain of feeling weak, along with decreased energy and ability to carry out work done earlier and would also develop tremulousness of hands and feet along with craving for Tab. Zolpidem. In view of the above symptoms, patient was taken to a private psychiatrist. She was initiated on 6 mg of Tab Clonazepam per day and the dose of Zolpidem was reduced to 150 mg per day over a period of 28 days. However, the craving persisted and hence she was referred to this hospital.

On mental status examination at admission, patient was found to be anxious with increased psychomotor activity, ill-sustained concentration, and dysphoric mood along with tremors of outstretched hands.

On physical examination, no gross abnormality was noted except for pallor and blood pressure of 180/110 mm Hg. Routine blood investigations and chest X-ray were within normal limits. ECG showed evidence of right bundle branch block.

She was started on a daily dose of Cap Gabapentin which was initiated at 300 mg one in the morning and two tablets at night, and gradually increased by 100 mg every fifth day to the dose of 1200 mg per day and Tab Zolpidem was reduced by 15 mg every third day. Patient was successfully detoxified over a period of 30 days. At discharge, the dose of Gabapentin was reduced to 600 mg per day which was tapered over a month. The patient was followed up after a fortnight of stopping Tab Gabapentin and was found to be asymptomatic.

Discussion

During the last decade, non BZD hypnotic, Zolpidem was considered to be a novel solution for the treatment of insomnia as it was suggested that it maintained the beneficial characteristics of BZDs as far as the reduction of sleep latency and sleep maintenance are considered, without having their side effects.

It was suggested that Zolpidem lacked anxiolytic, anticonvulsant, and muscle relaxant action and hardly caused memory impairment and more importantly minimal abuse and dependence potential. …

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