Discharging Patients from Acute Settings with Ambien (Zolpidem)
Zolpidem can be prescribed at discharge from acute care settings for short-term insomnia management, but requires careful patient selection, appropriate dosing (5 mg for elderly/hepatically impaired, 10 mg for other adults), and should be limited to the lowest practical dose for brief duration (typically ≤4 weeks), with specific attention to contraindications and high-risk populations. 1
Key Safety Considerations Before Discharge
Absolute Contraindications and High-Risk Populations
Avoid prescribing zolpidem to patients with severe hepatic impairment, as it may precipitate hepatic encephalopathy and these patients cannot clear the drug as rapidly as those with normal hepatic function 1
Exercise extreme caution in patients with respiratory impairment including sleep apnea, COPD, or myasthenia gravis, as zolpidem can depress respiratory drive and postmarketing reports document respiratory insufficiency in patients receiving 10 mg 1
Do not routinely co-prescribe zolpidem with opioids or benzodiazepines at discharge, as combination therapy with sedative-hypnotics and opioids increases mortality risk 3- to 10-fold compared to opioids alone, and the FDA has issued a black box warning against this practice 2, 1
Prescribe the lowest number of tablets feasible for patients with depression, as worsening depression and suicidal thoughts/actions have been reported in depressed patients treated with sedative-hypnotics, and zolpidem use is associated with increased suicide attempts (OR 2.08; 95% CI 1.83-2.63) 1, 3
Dose Adjustments Required
Prescribe 5 mg (not 10 mg) for elderly patients and those with hepatic impairment to account for slower drug metabolism and reduced clearance 1, 3
Women require lower dosing considerations, as they demonstrate higher mean plasma concentrations than men after 8 hours (28 vs. 20 ng/mL for 10 mg immediate-release) 3
Discharge Documentation Requirements
Essential Medication Information
Perform thorough medication reconciliation to verify safety of zolpidem with existing medications, particularly checking for interactions with other CNS depressants, SSRIs, or respiratory depressants 4, 1
Document clear rationale for prescribing and specify duration of therapy (typically ≤4 weeks for short-term insomnia treatment) 1, 5
Cross-check home and hospital medications and document any changes with clear rationale, including information about medication sensitivities and adverse reactions 4
Patient Education Components
Provide written discharge instructions about complex sleep behaviors (sleepwalking, sleep-driving, preparing/eating food while asleep), as these can occur even at therapeutic doses and patients rarely remember verbal instructions 1, 2
Warn about next-day impairment risks, including drowsiness, dizziness, and decreased alertness that can impair driving and other activities requiring full alertness 1
Educate about CNS-related adverse effects (confusion, dizziness, daytime sleepiness), which comprise 80.8% of adverse drug reactions in patients aged 50 or older 3
Instruct patients to take zolpidem only when able to get 7-8 hours of sleep before needing to be active again 1
Common Pitfalls to Avoid
Prescribing Errors
Do not prescribe for longer than 4 weeks without reassessment, as current recommendations strongly favor limited duration use, though zolpidem shows minimal tolerance development compared to benzodiazepines 1, 6, 7
Do not assume all insomnia requires pharmacotherapy at discharge—consider whether non-pharmacological approaches and cognitive behavioral therapy should be the primary intervention 3, 6
Avoid prescribing to hospitalized patients at high fall risk, as zolpidem increases fall risk with OR of 4.28 (P<0.001) and hip fracture risk with RR of 1.92 (95% CI 1.65-2.24) 3
Monitoring and Follow-up
Schedule outpatient follow-up within 1-2 weeks to assess efficacy, adverse effects, and need for continued therapy 4, 8
Document the patient's level of understanding regarding proper use, timing of administration, and when to contact healthcare providers 4
Provide clear instructions for discontinuation to minimize withdrawal effects, as abrupt discontinuation can cause withdrawal symptoms and rebound insomnia (sleep onset latency increased by 13.0 minutes on first night; 95% CI 4.3-21.7) 1, 3
Special Populations
Pregnancy Considerations
- Zolpidem is FDA Category C and maternal exposure is associated with increased incidence of low birth weight (OR=1.39), preterm delivery (OR=1.49), small for gestational age babies (OR=1.34), and cesarean deliveries (OR=1.74), though congenital abnormalities were not significantly increased 3
Elderly Patients
- Zolpidem is considered a reasonable choice for elderly patients when dosed appropriately at 5 mg, as it has lower incidence of residual daytime sleepiness and fall risk compared to benzodiazepines, though caution remains warranted 3, 7
Advantages Supporting Discharge Prescribing
Zolpidem demonstrates favorable tolerability with low propensity for clinical residual effects, withdrawal, dependence, or tolerance when administered according to prescribing information 5, 7
Minimal next-day effects on cognition and psychomotor performance when administered at bedtime at recommended doses 7
Efficacy comparable to benzodiazepines (flunitrazepam, flurazepam, nitrazepam, temazepam, triazolam) and other nonbenzodiazepine hypnotics for short-term insomnia treatment 5, 7