Somnambulism due to probable interaction of valproic acid and zolpidem

OBJECTIVE: To report a case of somnambulism due to a probable interaction between valproic acid and zolpidem in a patient with no prior personal or family history of somnambulism. CASE SUMMARY: A 47-year-old white man with a history of bipolar disorder was being maintained on citalopram 40 mg once daily and zolpidem 5 mg at bedtime. During treatment, he developed manic symptoms and was started on adjunctive valproic acid therapy. Soon after this, he developed episodes of somnambulism, which stopped when valproic acid was discontinued. On rechallenge with valproic acid, somnambulism returned. DISCUSSION: To our knowledge, this is the first report in the literature describing a probable interaction between valproic acid and zolpidem leading to somnambulism. Even though valproic acid has been associated with sleep changes, there are no published reports of somnambulism with this agent. Zolpidem has been associated with somnambulism, but our patient did not experience this when he was on zolpidem monotherapy. However, within 2 days of starting adjunctive valproic acid, sleepwalking occurred. It stopped after valproic acid was withdrawn. On rechallenge with valproic acid, sleepwalking recurred. However, when zolpidem was discontinued and valproic acid was continued, somnambulism did not occur. An assessment on the Naranjo probability scale suggests probable pharmacokinetic or pharmacodynamic interactions between the 2 medications. CONCLUSIONS: Valproic acid and zolpidem are generally safe medications that are commonly prescribed and often used together. No interactions have been previously reported with combined use of valproic acid and zolpidem. This case suggests a probable interaction between these 2 agents that can have a serious consequence, somnambulism. This could be frightening to patients and put them in danger. Recognition of such interactions that place patients at risk for potentially serious adverse events is imperative for appropriate care.     

Gabapentin for treatment of behavioral and psychological symptoms of dementia

OBJECTIVE: To report the use of gabapentin in the treatment of behavioral and psychological symptoms of dementia (BPSD) and to review the available literature relating to the use of gabapentin in this population. CASE SUMMARY: A 62-year-old white man was admitted to the hospital due to a worsening state of confusion, anxiety, depressed mood, insomnia, and verbal and physical aggressiveness toward his wife. He had a past medical history significant for vascular dementia. He had been intolerant of or had failed to respond to numerous antidepressants, benzodiazepines, and neuroleptics. The addition of gabapentin to the patient's medication regimen resulted in reduced agitation, sexual inappropriateness, and lability. He was discharged to his home on a dose of gabapentin 300 mg three times daily. DATA SOURCES: A MEDLINE search (1966-August 2000) was performed to identify case reports and clinical trials discussing the efficacy of gabapentin in the treatment of BPSD. DISCUSSION: Gabapentin, like other anticonvulsants, has been used with success in several psychiatric illnesses. Available literature indicates that the drug may have some efficacy in the treatment of BPSD. It has a favorable adverse effect profile in the elderly, which makes it an attractive altemative to standard therapies, including benzodiazepines and neuroleptics. Optimal dosing remains unclear. CONCLUSIONS: This case suggests that gabapentin is a reasonable alternative therapy for patients whose behavioral symptoms do not respond to conventional agents.     

Treatment of insomnia in hospitalized patients.

OBJECTIVE: To provide recommendations for the short-term management of insomnia in hospitalized patients and review patient assessment, nonpharmacologic treatment modalities, and selection of hypnotic medications. DATA SOURCES: Review articles and primary literature representative of current knowledge regarding the treatment of insomnia were identified by MEDLINE search (1966-January 2001). Search terms included insomnia (sleep initiation and maintenance disorders), benzodiazepines, zaleplon, zolpidem, and trazodone. DATA SYNTHESIS: Literature regarding the management of insomnia in hospitalized patients is limited; therefore, data pertinent to the treatment of ambulatory patients must be extrapolated to the inpatient setting. When evaluating insomnia in hospitalized patients, it seems reasonable to obtain a thorough history and physical examination to identify potential underlying etiologies. Treatment of these underlying etiologies should be considered. When the use of a sedative-hypnotic agent is necessary, medication and dose selection should be based on the pharmacokinetic and adverse effect profiles of each agent. Patent-specific characteristics should also be considered to provide effective treatment while minimizing adverse effects. CONCLUSIONS: Nonpharmacologic approaches to the treatment of insomnia should be considered for hospitalized patients. When sedative-hypnotic medications must be administered, the pharmacokinetic profile of intermediate-acting benzodiazepines (e.g., lorazepam, temazepam) makes them good first-line agents. Zaleplon and zolpidem are also attractive hypnotic agents; however, they are typically reserved for second-line therapy due to cost. Trazodone may be an alternative for patients unable to take benzodiazepines.     

Hypnotics in Insomnia: The Experience of Zolpidem

PurposeOne of the most commonly prescribed medications to treat insomnia is zolpidem, a nonbenzodiazepine compound that is available as an immediate-release oral tablet formulation, an extended-release oral formulation, an oral spray formulation, and as sublingual formulations. The purpose of this review was to summarize the data currently available on the efficacy and safety of zolpidem in the treatment of insomnia among adults.MethodsPublished studies on the use of zolpidem in the treatment of insomnia were identified by using combinations of relevant search terms in PubMed and Google Scholar. Studies were included if they were placebo- or active comparator–controlled studies, with the exception of trials on the long-term use of zolpidem. Studies were limited to those conducted in adults. Studies were not included if the patient population was small, if the study was not designed or powered to assess the efficacy or safety of zolpidem, if insomniac patients had a medical condition in addition to insomnia (with the exception of comorbid depression or anxiety for studies on comorbid insomnia), or if zolpidem was given concomitantly with any other therapy (with the exception of selective serotonin reuptake inhibitors for studies on comorbid insomnia).FindingsTwenty-five studies designed to evaluate the efficacy of zolpidem in insomnia and 51 studies reporting the safety of zolpidem in insomnia were included in this review.ImplicationsThe studies discussed in this review report the efficacy and safety of zolpidem in both young adults and the elderly. It can be used for either bedtime or middle-of-the-night administration, over the short or long term, with minimal risk of withdrawal or abuse. The use of zolpidem is associated with rebound insomnia, complex sleep-related behaviors, and next-day residual effects (after middle-of-the-night dosing) on driving ability, memory, and psychomotor performance.     

Transient reversal of anoxic brain injury-related minimally conscious state after zolpidem administration: a case report

Shames JL, Ring H. Transient reversal of anoxic brain injury-related minimally conscious state after zolpidem administration: a case report.Zolpidem is a unique nonbenzodiazepine sedative hypnotic drug that selectively binds to omega-1 γ-aminobutyric acid receptors in the brain. Although used for years in Israel and abroad for insomnia, there have been periodic reports of unusual or remarkable neurologic effects in patients with various brain pathologies. Here, we report on a 50-year-old woman 18 months after severe anoxic brain injury in a minimally conscious state. Residual deficits included mutism, athetoid movements of the extremities, and complete dependence for all personal care. After the administration of 5 to 10mg of zolpidem, within 45 minutes, the patient’s condition improved markedly, including the cessation of athetoid movements, regained speaking ability, and ability to perform various tasks including self-feeding. These effects lasted 3 to 4 hours, after which the patient returned to her former state. This effect was repeatable on a daily basis. Existing evidence and possible mechanisms to explain zolpidem’s effects in brain injury are described.     

Survival with acute primary coronary artery dissection: A case report and review of the literature

Primary coronary artery dissection its a rare etiology of acute myocardial Infarction (AMI) that often has divestating consequences. We present the case of a 46-year-old side survivor of primary coronary artery dissection who was diagnosed angiographiically. He suffered a non-Q-wave MI but had no electrocardiographic (ECG) charges during his coarse. A review of the literature of primary coronary artery dissection, particularly those diagnosed antemortem, is provided.     

Levetiracetam‐induced aggression and acute behavioral changes: A case report and literature review

Levetiracetam is a second‐generation antiepileptic medication used to treat a wide range of partial and generalized seizure disorders. While Levetiracetam is generally well‐tolerated, mild mood‐related side effects (e.g., anxiety, agitation, and depression) have been observed in a minority of patients in the days following initiation of therapy or changes in dosing. The development of acute aggression requiring termination of Levetiracetam therapy has been rarely reported in the medical literature but poses a limiting effect on treatment options for refractory epilepsy in pediatric patients. In this report, we present a teenage male patient with a history of seizure disorder who developed sudden, severe behavioral abnormalities and aggression following increases in his Levetiracetam dosing. His symptoms resolved rapidly after return of his medication dosing to baseline, with no further sequelae noted. Our observations suggest that Levetiracetam remains a safe and effective first‐line antiepileptic whose adverse behavioral side effect profile can be properly managed with close patient monitoring and dose titration.     

Recurrent cholestasis due to ampicillin

OBJECTIVE: To present a single case of ampicillin-induced recurrent cholestasis and a literature review. CASE SUMMARY: A 23-year-old man was hospitalized due to recurrent and self-limited cholestatic symptoms. He had used ampicillin before each cholestatic attack. He became well clinically and biochemically each time after cessation of the drug. One year after his recovery and discontinuance of ampicillin, the patient has had no recurrence of cholestasis. An objective causality assessment revealed that the adverse drug reaction was probable. DISCUSSION: Ampicillin-related hepatotoxicity is very rare, with injury being mainly hepatocellular. To our knowledge, there is only 1 case report in the literature referring to chronic cholestatic-type hepatotoxicity related to ampicillin. CONCLUSIONS: Ampicillin, which is one of the most widely used antibiotics, may cause recurrent cholestatic hepatitis. Clinicians should be aware of this adverse effect, and it should be kept in mind during diagnostic workup of liver injury.     

Increased arousal in a patient with anoxic brain injury after administration of zolpidem

A 35-yr-old man sustained an anoxic brain injury resulting from cardiac arrest, with subsequent extreme lethargy and lack of response to stimuli. The patient's lethargy was unresponsive to trials of several medications in attempts to increase arousal. Administration of twice-daily zolpidem 8 mos after injury resulted in a dramatic increase in the level of alertness, including improved speech and gait. When the patient was not able to receive zolpidem for a brief period, the patient's lethargy returned, and he became bedbound until the medication was resumed.     

The choice to end life as a ventilator-dependent quadriplegic

A 17-year-old male sustained a C5/6 fracture dislocation and complete C5 quadriplegia in a diving accident. Three days later sensory and motor function deteriorated and he required mechanical ventilation. Surgical exploration found no cause and a fusion was done. Neurologic function stabilized after three weeks with a C1 sensory level, no neck movement, and slight weakness of the tongue. Patient and family were followed closely by the spinal cord injury rehabilitation team from onset of injury. The patient was transferred to the ventilator-dependent pediatric rehabilitation program after ten weeks. Bowel, bladder, skin, and nutritional management were stabilized and taught to his parents who remained with him constantly. Communication was achieved with a "talking tracheostomy." He learned to use "Sip-n-Puff" control for driving an electric wheelchair and for Morse code input to a computer. He was passive but cooperative during hospitalization. Eight months after injury he was discharged to his home, which had been modified to meet his needs. A computer word processor, environmental control unit, and modified van were obtained; nursing care was provided around the clock. The patient enrolled in a community college course. Soon after discharge he contacted an attorney to explore legal actions for ending his life, which he considered intolerable. After obtaining medical and psychiatric reports, a court order was issued, which established his legal competence and directed people taking care of him to follow his directions. A few weeks later, 25 months after his injury, he privately said goodbye to his family, asked to be disconnected from the ventilator, and died. Medical and legal issues raised by this case are discussed.     

Zolpidem, a valuable alternative to benzodiazepine hypnotics for chronic insomnia?

Sleep quality and anxiety levels were examined using questionnaires and polysomnographic recordings in 22 chronic insomnia patients who regularly used benzodiazepines to treat their sleeping problems. After abruptly discontinuing their benzodiazepine medication, patients were randomly allocated to receive either a placebo or zolpidem 10 mg for 1 week, after which they entered an open extension phase, receiving zolpidem 10 mg for 3 weeks. Subjectively, sleep quality was considered mediocre during the use of a benzodiazepine hypnotic. One week after the discontinuation, an increase in sleep latency was observed in the placebo group, whereas zolpidem induced a significant decrease in sleep latency. Deterioration of other sleep variables (probably rebound) was not suppressed by zolpidem. An explanation for this could be the selective pharmacological profile of zolpidem. Polysomnographic differences between placebo and benzodiazepine and between placebo and zolpidem were not reflected by the subjective data on sleep and anxiety. Changes of sleep structure caused by hypnotics seem not always to be felt as such by patients. After 3-4 weeks of zolpidem treatment, the percentage of non-rapid eye movement-4 sleep increased significantly, corresponding with a significant subjective improvement of sleep quality. This indicates that zolpidem may restore physiological sleep.     

Paradise lost - Reflexion of preterm birth from the perspective after a brain injury. A case study

This case study describes the history of an older person, born in 1942 preterminally, who suffered from a brain injury in 2005. Problems in rehabilitation elicited the search for a new meaning in life. In analysing and interpreting the brain injury, preterm birth played a crucial role. The theme of lifelong compensation of deficits, caused by preterm birth, gained new importance. The consequences of brain injury left unsuccessful his former modes of compensation. He was confronted with finding new strategies in order to counterbalance the growing decompensation. This report is based on and was developed through respect for the principles of user involvement in research.     

Exfoliative dermatitis. Erythroderma can be a sign of a significant underlying disorder

64-year-old man presented with a 3-week history of a diffuse, pruritic rash that had started on his trunk and then spread to his entire cutaneous surface, including the palms of his hands and soles of his feet. Physical examination revealed widespread fine scaling and diffuse erythema. Generalized lymphadenopathy was noted. No fever, hair loss, onycholysis, or nail shedding was detected. The patient had neither a personal history of skin disorders or, specifically, atopic eczema or psoriasis nor a family history of eczema or psoriasis. He also had no history of malignancy and was taking no medications. The patient's complete blood cell count with differential was unremarkable. He was treated with moisturizers, topical corticosteroids, and antihistamines and was advised to avoid possible irritants. One week later, the patient returned because of a worsening of his erythroderma. He also reported malaise and chills. Three 4-mm biopsy specimens were obtained from representative areas (ie, back, arm, and abdomen), and a 2-week course of oral corticosteroids was prescribed. The erythroderma greatly improved but worsened shortly after the steroid dose was tapered. The specimens showed psoriasiform hyperplasia with features suggestive of psoriasis vulgaris. The patient was treated with 25 mg of oral acitretin once a day. His erythroderma slowly resolved over 6 months, at which time the acitretin dose was tapered. The patient reported no recurrence of the erythroderma.     

Cognitive behavioral therapy for insomnia associated with traumatic brain injury: a single-case study

OBJECTIVE: To test the efficacy of a cognitive behavioral therapy (CBT) for insomnia with a patient with traumatic brain injury (TBI). DESIGN: Single-case study. SETTING: Outpatient rehabilitation center. PARTICIPANT: A man in his late thirties who sustained a moderate TBI in a motor vehicle crash and who developed insomnia. He complained of difficulties falling asleep and staying asleep, despite pharmacotherapy with zopiclone. INTERVENTIONS: Eight weekly individual CBT sessions. Treatment included stimulus control, sleep restriction, cognitive therapy, and sleep hygiene education. MAIN OUTCOME MEASURES: Sleep diary and polysomnography data. RESULTS: Sleep onset decreased from 47 to 18 minutes, and nocturnal awakenings dropped from 85 to 28 minutes on average at posttreatment. Sleep efficiency also increased substantially (58% to 83%). Polysomnography evaluations corroborated the diary data by showing a decrease in total time awake (63.2 to 26.3 min) and in the number of awakenings (21 to 7.5). The majority of gains were well maintained at 1- and 3-month follow-up assessments. CONCLUSIONS: These preliminary results suggest that sleep disturbances after TBI can be alleviated with a nonpharmacologic intervention. CBT for post-TBI insomnia is a promising therapeutic avenue deserving more scientific and clinical attention.     

Idarucizumab for a traumatic head injury patient taking dabigatran

Background

Dabigatran is one of the four drugs currently used as a direct oral anticoagulant in Japan. Idarucizumab, which specifically targets dabigatran, was recently approved in Japan. We present a case of intracranial hemorrhage in a traumatic brain injury patient taking dabigatran who was treated by administering idarucizumab.

Case presentation

A 72-year-old man was injured in a traffic accident and was transferred to our emergency room. On arrival, his Glasgow Coma Scale score was 14 (eye, 3; verbal, 5; motor, 6), and his other vital signs were stable. Computed tomography (CT) imaging on arrival showed a small intracranial hematoma. A second CT 3 h later revealed expansion of the hematoma. We received information that he was taking dabigatran only after the second CT. Idarucizumab was then promptly administered, and emergency craniotomy for hematoma removal was performed. There was no tendency for bleeding during the operation, and blood transfusion was not required during the perioperative period. Although the patient underwent additional surgery for subdural effusion and hydrocephalus, his postoperative course was uneventful. He was transferred to a rehabilitation hospital on postoperative day 102.

Conclusion

We managed a patient taking dabigatran who suffered traumatic intracranial hemorrhage by administering idarucizumab preoperatively without the need for blood transfusion perioperatively. We suggest that idarucizumab could be a potent therapeutic bridge to definitive surgical management in such patients with traumatic brain injury who are taking dabigatran.

     

Zolpidem-induced distortion in visual perception

OBJECTIVE: To describe a patient who developed visual perception distortion after a single dose of zolpidem. CASE SUMMARY: A 50-year-old Asian woman had been prescribed conjugated estrogen 1 tablet daily for hormone replacement therapy and tricalcium phosphate twice daily for osteoporosis. One day, she took zolpidem 10 mg for insomnia as well as acetaminophen 500 mg for headache at bedtime and began to have visual perception distortion (e.g., the shapes of objects were twisted, houses were crooked) within 20 minutes, lasting for approximately 30 minutes, and then her vision returned to normal. She only partially recalled the event. She had never taken zolpidem before, and she had not had any such disturbances in the past. DISCUSSION: There have been 21 case reports of zolpidem-related psychotic symptoms in the literature; however, the exact mechanism by which zolpidem may cause visual perception changes is undetermined. Many factors have been correlated with zolpidem-induced visual experiences, such as pharmacokinetic factors, gender, age, and hypoalbuminemia. This patient shared certain similarities such as gender, dosage, and time of onset and duration of adverse reactions. CONCLUSIONS: An objective causality assessment revealed that the zolpidem-induced visual perception distortion in this patient was probable. Clinicians should be aware of the potential for visual perception distortion, as this is an uncommon adverse effect.     

Midodrine for the management of orthostatic hypotension in patients with spinal cord injury: A case report

A 21-year-old man sustained anterior displacement and a burst fracture of C7 in a motor vehicle crash. He underwent anterior corpectomy, decompression, fusion of C6-T1 vertebrae, and halo placement. The American Spinal Injury Association grade of his spinal cord injury (SCI) was C6 C tetraplegia. Severe orthostatic hypotension in the upright position complicated the patient's rehabilitation program. Midodrine was prescribed, and other medications with possible adverse effects were adjusted. Significant improvement after taking midodrine was reflected in the orthostatic vital signs and symptoms, as well as in FIM instrument scores. Staff noted improvements with therapy participation and functional status. The patient tolerated the midodrine well and had no significant side effects.     

Lyme carditis: A rare presentation in an unexpected setting

A case is reported of a 27-year-old man who presented to an inner city trauma center after he had experienced several seizure-like episodes. He was diagnosed with Lyme carditis and required 6 weeks of treatment with intravenous ceftriaxone for complete resolution of his symptoms. The case is discussed along with a review of the literature.