Potentiating the Adverse Effects of Zolpidem in a Patient with Alcohol Dependence and SSRI use

Abstract

patients with liver or kidney pathology, resulting in the possibility of increased serum levels and subsequent toxicity [3]. In malnourished patients, hypoalbuminemia is common and can result in elevation of unbound drug concentration that may account for, or contribute to, zolpidem toxicity [5]. Others susceptible to toxicity are women, whose zolpidem plasma levels were noted to be 40% higher than men at equivalent doses, and those with concomitant selective serotonin reuptake inhibitor (SSRI) treatment which can displace zolpidem because of competing high protein affinity. Additionally, Kumar et al. noted the role of ethanol in reducing surface expression of the alpha-1 subunit containing GABA A receptors increasing susceptibility to delirium with even small alterations to zolpidem dose [6]. The following case report takes into account various vulnerabilities such as alcohol dependence, malnutrition and concomitant SSRI use. A 63 year old male was seen in a consultation with the Internal Medicine team for their observation of a psychotic process. This case highlights several risk factors associated with zolpidem toxicity. Case Subject Mr. S is a 63 year old Caucasian male, with a medical history of hypertension and depression, who presented to the emergency department at the request of family members following the development of auditory and visual hallucinations with paranoid delusions. Mr. S was admitted to the medical service with subsequent psychiatric consultation. Subsequent history did not suggest seizure disorder or other neurological illness. The patient did have a history of alcohol dependence with one episode of delirium tremens 4 years prior. Mr. S's spouse confirmed a history of alcohol dependence with an increase in drinking over the past 13 years after the unexpected death of a grandchild. Mr. S reported consuming approximately 1 pint (375ml) to 1 "fifth" (750ml) of vodka daily in 1-2 week blocks with interval periods of abstinence. His last drink of alcohol was 2-3 days prior to this hospitalization. Mr. S reported using chewing tobacco (3 packs every week) but denied any other substance use, including illicit drugs. Stressors identified were financial and marital stress lending to a recent diagnosis of depression treated with citalopram. No family history of depression or psychosis was identified.

Abrupt Withdrawal From Chronic High-Dose Zolpidem Use: A Case Report of Resulting Delirium

“…Innamuri et al discussed the management complexities of zolpidem dependence in 2023 [17]. Chopra et al highlighted the amplified adverse effects of zolpidem because of concurrent alcohol and SSRI use [18]. Mattoo, Gaur, and Das addressed zolpidem withdrawal delirium in 2011 [19], and Chate et al reported on zolpidem-induced delirium in 2013 [20].…”