Zolpidem Name of the medicinal product
Zolpitaj – 5 mg (Taj Pharma)
Zolpidem Tartrate Tablet IP – 5 mg
- Qualitative and quantitative composition
Each Film coated tablets contains:
Zolpidem Tartrate Tablet IP – 5 mg
Colours:Titanium dioxide IP
For the full list of excipients, see section 6.1.
- Pharmaceutical form
Film coated tablets for oral administration.
- Clinical particulars
4.1 Therapeutic indications
Zolpidem Tartrate (Zolpitaj) is indicated for the short-term treatment of insomnia in adults in situations where the insomnia is debilitating or is causing severe distress for the patient.
4.2 Posology and method of administration
The treatment should be taken in a single intake and not be re-administered during the same night.
The recommended daily dose for adults is 10 mg to be taken immediately at bedtime. The lowest effective daily dose of zolpidem tartrate should be used and must not exceed 10 mg.
The duration of treatment should usually vary from a few days to two weeks with a maximum of four weeks including tapering off where clinically appropriate.
Treatment should be as short as possible. It should not exceed four weeks including the period of tapering off. In certain cases extension beyond the maximum treatment period may be necessary; if so, extension beyond the maximum treatment period should not take place without re-evaluation of the patient’s status, since the risk of abuse and dependence increases with the duration of treatment (see section 4.4).
Zolpidem Tartrate (Zolpitaj) is not recommended for use in children and adolescents below 18 years of age, due to a lack of data to support use in this age group. The available evidence from placebo-controlled clinical trials is presented in section 5.1.
Elderly or debilitated patients may be especially sensitive to the effects of zolpidem tartrate therefore a 5 mg dose is recommended. These recommended doses should not be exceeded.
As clearance and metabolism of zolpidem tartrate is reduced in hepatic impairment, dosage should begin at 5 mg in these patients with particular caution being exercised in elderly patients. In adults (under 65 years) dosage may be increased to 10 mg only where the clinical response is inadequate and the drug is well tolerated.
Zolpidem must not be used in patients with severe hepatic impairment as it may contribute to encephalopathy (see section 4.3).
Method of administration
- Zolpidem tartrate is contraindicated in patients with a hypersensitivity to zolpidem tartrate or any of the excipients listed in section 6.1.
- Obstructive sleep apnoea.
- Myasthenia gravis.
- Severe hepatic insufficiency.
- Acute and/or severe respiratory depression.
In the absence of data, zolpidem tartrate should not be prescribed for children or patients with psychotic illness.
4.4 Special warnings and precautions for use
The cause of insomnia should be identified wherever possible and the underlying factors treated before a hypnotic is prescribed. The failure of insomnia to remit after a 7 – 14 day course of treatment may indicate the presence of a primary psychiatric or physical disorder, and the patient should be carefully re-evaluated at regular intervals.
Next-day psychomotor impairment
Like other sedative/hypnotic drugs, Zolpidem Tartrate (Zolpitaj) has CNS-depressant effects. The risk of next-day psychomotor impairment, including impaired driving ability, is increased if:
- zolpidem tartrate is taken within less than 8 hours before performing activities that require mental alertness (see section 4.7);
- a dose higher than the recommended dose is taken;
- zolpidem tartrate is co-administered with other CNS depressants or with other drugs that increase the blood levels of zolpidem tartrate, or with alcohol or illicit drugs (see section 4.5).
Zolpidem tartrate should be taken in a single intake immediately at bedtime and not be re-administered during the same night.
Specific patient groups
As hypnotics have the capacity to depress respiratory drive, precautions should be observed if Zolpidem Tartrate (Zolpitaj) is prescribed to patients with compromised respiratory function.
See section 4.2.
See section 4.2 for dose recommendations.
Risk from concomitant use of opioids:
Concomitant use of Zolpidem Tartrate (Zolpitaj) and opioids may result in sedation, respiratory depression, coma and death. Because of these risks, concomitant prescribing of sedative medicines such as benzodiazepines or related drugs such as Zolpidem Tartrate (Zolpitaj) with opioids should be reserved for patients for whom alternative treatment options are not possible.
If a decision is made to prescribe Zolpidem Tartrate (Zolpitaj) concomitantly with opioids, the lowest effective dose should be used, and the duration of treatment should be as short as possible (see also general dose recommendation in section 4.2).
The patients should be followed closely for signs and symptoms of respiratory depression and sedation. In this respect, it is strongly recommended to inform patients and their environment to be aware of these symptoms (see section 4.5).
Use in patients with a history of drug or alcohol abuse:
Extreme caution should be exercised when prescribing for patients with a history of drug or alcohol abuse. These patients should be under careful surveillance when receiving zolpidem tartrate or any other hypnotic, since they are at risk of habituation and psychological dependence.
Hypnotics such as Zolpidem Tartrate (Zolpitaj) are not recommended for the primary treatment of psychotic illness.
Suicidal ideation, suicide attempt, suicide and depression:
Some epidemiological studies suggest an increased incidence of suicidal ideation, suicide attempt and suicide in patients with or without depression, and treated with benzodiazepines and other hypnotics, including zolpidem. However, a causal relationship has not been established.
As with other sedative/hypnotic drugs, zolpidem tartrate should be administered with caution in patients exhibiting symptoms of depression. Suicidal tendencies may be present therefore the least amount of Zolpidem Tartrate (Zolpitaj) that is feasible should be supplied to these patients to avoid the possibility of intentional overdose by the patient. Pre-existing depression may be unmasked during use of Zolpidem Tartrate (Zolpitaj). Since insomnia may be a symptom of depression, the patient should be re-evaluated if insomnia persists.
General information relating to effects seen following administration of benzodiazepines and other hypnotic agents which should be taken into account by the prescribing physician are described below.
Some loss of efficacy to the hypnotic effects of short-acting benzodiazepines and benzodiazepine-like agents like Zolpidem Tartrate (Zolpitaj) may develop after repeated use for a few weeks.
Use of zolpidem may lead to the development of abuse and/or physical and psychological dependence. The risk of dependence increases with dose and duration of treatment. The risk of abuse and dependence is also greater in patients with a history of psychiatric disorders and/or alcohol, substance or drug abuse. Zolpidem should be used with extreme caution in patients with current or a history of alcohol, substance or drug abuse or dependence.
If physical dependence is developed, a sudden discontinuation of treatment will be accompanied by withdrawal symptoms. These may consist of headaches, muscle pain, extreme anxiety, tension, restlessness, confusion and irritability. In severe cases the following symptoms may occur: derealisation, depersonalisation, hyperacusis, numbness and tingling of the extremities, hypersensitivity to light, noise and physical contact, hallucinations or epileptic seizures.
A transient syndrome whereby the symptoms that led to treatment with a benzodiazepine or benzodiazepine-like agent recur in an enhanced form may occur on withdrawal of hypnotic treatment. It may be accompanied by other reactions including mood changes, anxiety and restlessness.
It is important that the patient should be aware of the possibility of rebound phenomena, thereby minimising anxiety over such symptoms should they occur when the medicinal product is discontinued. Since the risk of withdrawal phenomena or rebound has been shown to be greater after abrupt discontinuation of treatment, it is recommended that the dosage is decreased gradually where clinically appropriate.
There are indications that, in the case of benzodiazepines and benzodiazepine-like agents with a short duration of action, withdrawal phenomena can become manifest within the dosage interval, especially when the dosage is high.
Benzodiazepines or benzodiazepine-like agents such as Zolpidem Tartrate (Zolpitaj) may induce anterograde amnesia. The condition occurs most often several hours after ingesting the product. In order to reduce the risk, patients should ensure that they will be able to have an uninterrupted sleep of 8 hours (see section 4.8).
Other psychiatric and “paradoxical” reactions:
Other psychiatric and paradoxical reactions like restlessness, exacerbated insomnia, agitation, irritability, aggression, delusion, anger, nightmares, hallucinations, psychosis, abnormal behaviour and other adverse behavioural effects are known to occur when using benzodiazepines or benzodiazepine-like agents. Should this occur, use of the product should be discontinued. These reactions are more likely to occur in the elderly.
Somnambulism and associated behaviours:
Sleep walking and other associated behaviours such as “sleep driving”, preparing and eating food, making phone calls or having sex, with amnesia for the event, have been reported in patients who had taken Zolpidem Tartrate (Zolpitaj) and were not fully awake. The use of alcohol and other CNS-depressants with Zolpidem Tartrate (Zolpitaj) appears to increase the risk of such behaviours, as does the use of Zolpidem Tartrate (Zolpitaj) at doses exceeding the maximum recommended dose. Discontinuation of Zolpidem Tartrate (Zolpitaj) should be strongly considered for patients who report such behaviours (for example, sleep driving), due to the risk to the patient and others (see sections 4.5 and 4.8).
Due to its pharmacological properties, zolpidem can cause drowsiness and a decreased level of consciousness, which may lead to falls and consequently to severe injuries.
4.5 Interaction with other medicinal products and other forms of interaction
Concomitant intake with alcohol:
The sedative effect may be enhanced when the product is used in combination with alcohol. This affects the ability to drive or use machines.
Take into account
Combination with CNS depressants:
Enhancement of the central depressive effect may occur in cases of concomitant use with antipsychotics (neuroleptics), hypnotics, anxiolytics/sedatives, antidepressant agents, narcotic analgesics, antiepileptic drugs, anaesthetics and sedative antihistamines. Therefore, concomitant use of Zolpidem Tartrate (Zolpitaj) with these drugs may increase drowsiness and next-day psychomotor impairment, including impaired driving ability (see sections 4.4 and 4.7). Also, isolated cases of visual hallucinations were reported in patients taking Zolpidem Tartrate (Zolpitaj) with antidepressants including bupropion, desipramine, fluoxetine, sertraline and venlafaxine.
Co-administration of fluvoxamine may increase blood levels of zolpidem tartrate, concurrent use is not recommended.
In the case of narcotic analgesics enhancement of euphoria may also occur leading to an increase in psychological dependence.
The concomitant use of sedative medicines such as benzodiazepines or related drugs such as Zolpidem Tartrate (Zolpitaj) with opioids increases the risk of sedation, respiratory depression, coma and death because of additive CNS depressant effect. The dosage and duration of concomitant use should be limited (see section 4.4).
CYP450 inhibitors and inducers:
Co- administration of ciprofloxacin may increase blood levels of zolpidem tartrate, concurrent use is not recommended.
Compounds which inhibit certain hepatic enzymes (particularly cytochrome P450) may enhance the activity of benzodiazepines and benzodiazepine-like agents.
Zolpidem tartrate is metabolised via several hepatic cytochrome P450 enzymes, the main enzyme being CYP3A4 with the contribution of CYP1A2. The pharmacodynamic effect of zolpidem tartrate is decreased when it is administered with a CYP3A4 inducer such as rifampicin and St. John’s Wort. St. John’s Wort has been shown to have a pharmacokinetic interaction with zolpidem. Mean Cmax and AUC were decreased (33.7 and 30.0% lower, respectively) for zolpidem administered with St. John’s Wort compared to zolpidem administered alone. Co-administration of St. John’s Wort may decrease blood levels of zolpidem, concurrent use is not recommended.
However when zolpidem tartrate was administered with itraconazole (a CYP3A4 inhibitor) its pharmacokinetics and pharmacodynamics were not significantly modified. The clinical relevance of these results is unknown. Co-administration of Zolpidem Tartrate (Zolpitaj) with ketoconazole (200 mg twice daily), a potent CYP3A4 inhibitor, prolonged Zolpidem Tartrate (Zolpitaj) elimination half-life, increased total AUC, and decreased apparent oral clearance when compared to Zolpidem Tartrate (Zolpitaj) plus placebo. The total AUC for Zolpidem Tartrate (Zolpitaj), when co-administered with ketoconazole, increased by a factor of 1.83 when compared to Zolpidem Tartrate (Zolpitaj) alone. A routine dosage adjustment of Zolpidem Tartrate (Zolpitaj) is not considered necessary, but patients, should be advised that use of Zolpidem Tartrate (Zolpitaj) with ketoconazole may enhance the sedative effects.
When zolpidem tartrate was administered with ranitidine, no significant pharmacokinetic interactions were observed.
4.6 Fertility, pregnancy and lactation
The use of zolpidem is not recommended during pregnancy.
Animal studies do not indicate direct or indirect harmful effects with respect to reproductive toxicity.
Zolpidem crosses the placenta.
A large amount of data on pregnant women (more than 1000 pregnancy outcomes) collected from cohort studies has not demonstrated evidence of the occurrence of malformations following exposure to benzodiazepines or benzodiazepine-like substances during the first trimester of pregnancy. However, certain case-control studies reported an increased incidence of cleft lip and palate associated with use of benzodiazepines during pregnancy.
Cases of reduced fetal movement and fetal heart rate variability have been described after administration of benzodiazepines or benzodiazepine-like substances during the second and/or third trimester of pregnancy.
Administration of zolpidem during the late phase of pregnancy or during labour has been associated with effects on the neonate, such as hypothermia, hypotonia, feeding difficulties (‘floppy infant syndrome’) and respiratory depression due to the pharmacological action of the product. Cases of severe neonatal respiratory depression have been reported.
Moreover, infants born to mothers who took sedative/hypnotic agents chronically during the latter stages of pregnancy may have developed physical dependence and may be at risk of developing withdrawal symptoms in the postnatal period. Appropriate monitoring of the newborn in the postnatal period is recommended.
If Zolpidem Tartrate (Zolpitaj) is prescribed to a woman of childbearing potential, she should be warned to contact her physician about stopping the product if she intends to become or suspects that she is pregnant.
Small quantities of zolpidem tartrate appear in breast milk. The use of zolpidem tartrate in nursing mothers is therefore not recommended.
4.7 Effects on ability to drive and use machines
Zolpidem Tartrate (Zolpitaj) has major influence on the ability to drive and use machines.
Vehicle drivers and machine operators should be warned that, as with other hypnotics, there may be a possible risk of drowsiness, prolonged reaction time, dizziness, sleepiness, blurred/double vision and reduced alertness and impaired driving the morning after therapy (see section 4.8). In order to minimise this risk a resting period of at least 8 hours is recommended between taking zolpidem tartrate and driving, using machinery and working at heights.
Driving ability impairment and behaviours such as ‘sleep-driving’ have occurred with zolpidem tartrate alone at therapeutic doses.
Furthermore, the co-administration of zolpidem tartrate with alcohol and other CNS depressants increases the risk of such behaviours (see sections 4.4 and 4.5). Patients should be warned not to use alcohol or other psychoactive substances when taking zolpidem tartrate.