Infrequent: constipation, dysphagia, flatulence, gastroenteritis. Gastrointestinal system: Frequent: hiccup. Rare: enteritis, eructation, esophagospasm, gastritis, hemorrhoids, intestinal obstruction, rectal hemorrhage, tooth caries.
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 [see Drug Abuse and Dependence (9) ]
Musculoskeletal system: Infrequent: arthritis. Rare: arthrosis, muscle weakness, sciatica, tendinitis.
Visual and auditory hallucinations have been reported as well as behavioral changes such as bizarre behavior, agitation and depersonalization. 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. 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.
Adverse events are further classified within body system categories and enumerated in order of decreasing frequency using the following definitions: frequent adverse events are defined as those occurring in greater than 1/100 subjects; infrequent adverse events are those occurring in 1/100 to 1/1,000 patients; rare events are those occurring in less than 1/1,000 patients.
Indications and Usage ( 1 ) 03/2007 Warnings and Precautions ( 5 ) 03/2007.
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. These events can occur in sedative-hypnotic-naive as well as in sedative-hypnotic-experienced persons. Amnesia, anxiety and other neuro-psychiatric symptoms may occur unpredictably. 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. In primarily depressed patients, worsening of depression, including suicidal thinking, has been reported in association with the use of sedative/hypnotics. As with "sleep-driving", patients usually do not remember these events. 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.
Tablets are not scored. The 10 mg tablets are white, round, film-coated, debossed with "ZIM" on one side and "10" on the other side. Zolpidem tartrate tablets 5 mg are pink, round, film-coated, debossed with "ZIM" on one side and "5" on the other side.
Some patients have required medical therapy in the emergency department. Patients who develop angioedema after treatment with zolpidem tartrate tablets should not be rechallenged with the drug. Some patients have had additional symptoms such as dyspnea, throat closing or nausea and vomiting that suggest anaphylaxis. 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. If angioedema involves the throat, glottis or larynx, airway obstruction may occur and be fatal.
Updated May 9, 2007.
The total zolpidem tartrate tablet dose should not exceed 10 mg per day.
Data from a clinical study in which selective serotonin reuptake inhibitor- (SSRI) treated patients were given zolpidem revealed that four of the seven discontinuations during double-blind treatment with zolpidem (n=95) were associated with impaired concentration, continuing or aggravated depression, and manic reaction; one patient treated with placebo (n =97) was discontinued after an attempted suicide.
Pediatric patients: Safety and effectiveness of zolpidem has not been established in pediatric patients. Hallucinations were reported in 7.4% of the pediatric patients who received zolpidem; none of the pediatric patients who received placebo reported hallucinations [see Use in Specific Populations: Pediatric Use (8.4) ]. 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.
During longer-term treatment (28 to 35 nights) with zolpidem at doses up to 10 mg, the most commonly observed adverse events associated with the use of zolpidem and seen at statistically significant differences from placebo-treated patients were dizziness (5%) and drugged feelings (3%). Most commonly observed adverse events in controlled trials : During short-term treatment (up to 10 nights) with zolpidem tartrate tablets at doses up to 10 mg, the most commonly observed adverse events associated with the use of zolpidem and seen at statistically significant differences from placebo-treated patients were drowsiness (reported by 2% of zolpidem patients), dizziness (1%), and diarrhea (1%).
Post-marketing reports of respiratory insufficiency, most of which involved patients with pre-existing respiratory impairment, have been received. 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. Caution is advisable in using zolpidem tartrate tablets in patients with diseases or conditions that could affect metabolism or hemodynamic responses. No dosage adjustment in renally impaired patients is required; however, these patients should be closely monitored. Use in patients with concomitant illness: Clinical experience with zolpidem tartrate tablets in patients with concomitant systemic illness is limited. 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. 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. Data in end-stage renal failure patients repeatedly treated with zolpidem tartrate tablets did not demonstrate drug accumulation or alterations in pharmacokinetic parameters.
premarketing clinical trials discontinued treatment because of an adverse clinical event. Associated with discontinuation of treatment: Approximay 4% of 1,701 patients who received zolpidem at all doses (1.25 to 90 mg) in U.S. Events most commonly associated with discontinuation from U.S. trials were daytime drowsiness (0.5%), dizziness (0.4%), headache (0.5%), nausea (0.6%), and vomiting (0.5%).
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. These patients should be closely monitored. Therefore, the recommended zolpidem tartrate tablets dosage is 5 mg in such patients to decrease the possibility of side effects.
Skin and appendages: Infrequent: pruritus. Rare: acne, bullous eruption, dermatitis, furunculosis, injection-site inflammation, photosensitivity reaction, urticaria.
Rare: breast fibroadenosis, breast neoplasm, breast pain. Reproductive system: Infrequent: menstrual disorder, vaginitis.
Downward dosage adjustment may be necessary when zolpidem tartrate tablets are administered with agents having known CNS-depressant effects because of the potentially additive effects.
Immunologic system: Rare: abscess herpes simplex herpes zoster, otitis externa, otitis media.
Autonomic nervous system: Infrequent: increased sweating, pallor, postural hypotension, syncope. Rare: abnormal accommodation, altered saliva, flushing, glaucoma, hypotension, impotence, increased saliva, tenesmus.
Patients with hepatic insufficiency do not clear the drug as rapidly as normals. Elderly or debilitated patients may be especially sensitive to the effects of zolpidem tartrate tablets. An initial 5 mg dose is recommended in these patients.
Dose relationship for adverse events: There is evidence from dose comparison trials suggesting a dose relationship for many of the adverse events associated with zolpidem use, particularly for certain CNS and gastrointestinal adverse events.
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. Due to the rapid onset of action, zolpidem tartrate tablets should only be ingested immediay prior to going to bed. Zolpidem tartrate tablets, like other sedative/hypnotic drugs, have CNS-depressant effects. Dosage adjustments may be necessary when zolpidem tartrate tablets are administered with such agents because of the potentially additive effects. Patients should also be cautioned about possible combined effects with other CNS-depressant drugs. Zolpidem tartrate tablets showed additive effects when combined with alcohol and should not be taken with alcohol.
Central and peripheral nervous system: Frequent: ataxia, confusion, euphoria, insomnia, vertigo. Rare: abnormal gait, abnormal thinking, aggressive reaction, apathy, appetite increased, decreased libido, delusion, dementia, depersonalization, dysphasia, feeling strange, hypokinesia, hypotonia, hysteria, intoxicated feeling, manic reaction, neuralgia, neuritis, neuropathy, neurosis, panic attacks, paresis, personality disorder, somnambulism, suicide attempts, tetany, yawning. Infrequent: agitation, decreased cognition, detached, difficulty concentrating, dysarthria, emotional lability, hallucination, hypoesthesia, illusion, leg cramps, migraine, paresthesia, sleeping (after daytime dosing), speech disorder, stupor, tremor.
Use in 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.
Rare: acute renal failure, dysuria, micturition frequency, nocturia, polyuria, pyelonephritis, renal pain, urinary retention. Urogenital system: Infrequent: cystitis, urinary incontinence.
Rare: angina pectoris, arrhythmia, arteritis, circulatory failure, extrasystoles, hypertension aggravated, myocardial infarction, phlebitis, pulmonary embolism, pulmonary edema, varicose veins, ventricular tachycardia. Cardiovascular system: Infrequent: cerebrovascular disorder, hypertension, tachycardia.
Hematologic and lymphatic system: Rare: anemia, hyperhemoglo-binemia, leukopenia, lymphadenopathy, macrocytic anemia, purpura, thrombosis.
Revised: 5/2007. See 17 for PATIENT COUNSELING INFORMATION.
Rare: allergic reaction, allergy aggravated, anaphylactic shock, face edema, hot flashes, increased ESR, pain, restless legs, rigors, tolerance increased, weight decrease. Infrequent: edema, falling, fever, malaise, trauma. Body as a whole: Frequent: asthenia.
To provide a meaningful estimate of the proportion of individuals experiencing treatment-emergent adverse events, similar types of untoward events were grouped into a smaller number of standardized event categories and classified utilizing a modified World Health Organization (WHO) dictionary of preferred terms. The frequencies presented, therefore, represent the proportions of the 3,660 individuals exposed to zolpidem, at all doses, who experienced an event of the type cited on at least one occasion while receiving zolpidem. It is important to emphasize that, although the events reported did occur during treatment with zolpidem tartrate tablets, they were not necessarily caused by it. Adverse event incidence across the entire preapproval database: zolpidem tartrate tablets were administered to 3,660 subjects in clinical trials throughout the U.S., Canada, and Europe. All reported treatment-emergent adverse events are included, except those already listed in the table above of adverse events in placebo-controlled studies, those coding terms that are so general as to be uninformative, and those events where a drug cause was remote. Treatment-emergent adverse events associated with clinical trial participation were recorded by clinical investigators using terminology of their own choosing.
Liver and biliary system: Infrequent: abnormal hepatic function, increased SGPT. Rare: bilirubinemia, increased SGOT.
Zolpidem tartrate tablets are indicated for the short-term treatment of insomnia characterized by difficulties with sleep initiation. Zolpidem tartrate tablets have been shown to decrease sleep latency for up to 35 days in controlled clinical studies.
The clinical trials performed in support of efficacy were 4-5 weeks in duration with the final formal assessments of sleep latency performed at the end of treatment.
Rare: conjunctivitis, corneal ulceration, lacrimation abnormal, parosmia, photopsia. Infrequent: eye irritation, eye pain, scleritis, taste perversion, tinnitus. Special senses: Frequent: diplopia, vision abnormal.
Zolpidem tartrate tablets are contraindicated in patients with known hypersensitivity to zolpidem tartrate or to any of the inactive ingredients in the formulation.
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.
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( 1 ). Zolpidem tartrate tablets are indicated for the short-term treatment of insomnia characterized by difficulties with sleep initiation. Zolpidem tartrate tablets have been shown to decrease sleep latency for up to 35 days in controlled clinical studies.
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.
The dose of zolpidem tartrate tablets should be individualized.
The table includes only adverse events occurring at an incidence of at least 1% for zolpidem patients. The table is limited to data from doses up to and including 10 mg, the highest dose recommended for use. These trials involved patients with chronic insomnia who were treated for 28 to 35 nights with zolpidem at doses of 5, 10, or 15 mg. The following table was derived from a pool of three placebo-controlled long-term efficacy trials involving zolpidem tartrate tablets.
Respiratory system: Infrequent: bronchitis, coughing, dyspnea. Rare: bronchospasm, epistaxis, hypoxia, laryngitis, pneumonia.
Metabolic and nutritional: Infrequent: hyperglycemia, thirst. Rare: gout, hypercholesteremia, hyperlipidemia, increased alkaline phosphatase, increased BUN, periorbital edema.
Events reported by investigators were classified utilizing a modified World Health Organization (WHO) dictionary of preferred terms for the purpose of establishing event frequencies. Similarly, the cited frequencies cannot be compared with figures obtained from other clinical investigators involving related drug products and uses, since each group of drug trials is conducted under a different set of conditions. Adverse events observed at an incidence of ≥1% in controlled trials: The following tables enumerate treatment-emergent adverse event frequencies that were observed at an incidence equal to 1% or greater among patients with insomnia who received zolpidem tartrate tablets in U.S. The prescriber should be aware that these figures cannot be used to predict the incidence of side effects in the course of usual medical practice, in which patient characteristics and other factors differ from those that prevailed in these clinical trials. However, the cited figures provide the physician with a basis for estimating the relative contribution of drug and nondrug factors to the incidence of side effects in the population studied. placebo-controlled trials.
Worsening of insomnia or the emergence of new thinking or behavior abnormalities may be the consequence of an unrecognized psychiatric or physical disorder. 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. 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. 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. Such findings have emerged during the course of treatment with sedative/hypnotic drugs, including zolpidem tartrate tablets.
Zolpidem tartrate tablets are available in 5 mg and 10 mg strength tablets for oral administration.
Hypersensitivity to zolpidem tartrate or inactive ingredients ( 4.1 ).
The recommended dose for adults is 10 mg immediay before bedtime.
The table is limited to data from doses up to and including 10 mg, the highest dose recommended for use. The following table was derived from a pool of 11 placebo-controlled short-term U.S. efficacy trials involving zolpidem in doses ranging from 1.25 to 20 mg.
Events most commonly associated with discontinuation from these trials were daytime drowsiness (1.1%), dizziness/vertigo (0.8%), amnesia (0.5%), nausea (0.5%), headache (0.4%), and falls (0.4%). Approximay 4% of 1,959 patients who received zolpidem at all doses (1 to 50 mg) in similar foreign trials discontinued treatment because of an adverse event.
Serious adverse reactions including severe anaphylactic and anaphylactoid reactions, abnormal thinking and behavior, complex behaviors, withdrawal effects, amnesia, anxiety, other neuro-psychiatric symptoms and CNS-depressant effects have been reported with zolpidem.
5 mg and 10 mg tablets ( 3 ).
Monitoring : There are no specific laboratory tests recommended to monitor zolpidem levels.Zolpidem tartrate