Zolpidem Should NOT Be Prescribed to Patients with Sleepwalking
Do not prescribe Ambien (zolpidem) to a patient who reports sleepwalking—this is an absolute contraindication per FDA labeling and carries a boxed warning for complex sleep behaviors including sleepwalking that can result in serious injury or death. 1
FDA Boxed Warning and Contraindications
- Zolpidem carries an FDA boxed warning specifically for complex sleep behaviors including sleepwalking, sleep-driving, and other activities while not fully awake, which may result in serious injuries including death. 1
- The FDA drug label explicitly states to discontinue zolpidem immediately if a patient experiences a complex sleep behavior, and patients who have ever experienced such behaviors (including sleepwalking) after taking zolpidem should not take the medication. 1
- Patients with a history of sleepwalking are at significantly higher risk for these dangerous behaviors when taking zolpidem. 2
Evidence for Zolpidem-Induced Sleepwalking
- A systematic review identified zolpidem as having the strongest evidence among all medications for inducing sleepwalking, with the association occurring regardless of age, dose, medical history, or prior history of sleepwalking. 2
- The American Academy of Sleep Medicine guidelines specifically warn that benzodiazepine receptor agonists (BzRAs) including zolpidem have been associated with reports of disruptive sleep-related behaviors including sleepwalking, eating, driving, and sexual behavior. 3
- Multiple case reports and case series document zolpidem-triggered sleepwalking episodes, with some resulting in serious injuries. 4, 5
Clinical Implications and Alternative Management
- Instead of zolpidem, consider cognitive behavioral therapy for insomnia (CBT-I) as first-line treatment, which the VA/DoD guidelines recommend over pharmacologic therapy. 3
- If pharmacotherapy is necessary and the patient is unable or unwilling to receive CBT-I, consider low-dose doxepin (3-6 mg) or ramelteon (8 mg), which do not carry the same sleepwalking risk. 3
- The American Academy of Sleep Medicine recommends that patients should be cautioned about the potential for adverse sleep-related behaviors and the importance of allowing appropriate sleep time, using only prescribed doses, and avoiding combination with alcohol or other sedatives. 3
Important Caveats
- All patients prescribed any BzRA hypnotic must be educated about safe sleep environments and encouraged to report onset or exacerbation of sleepwalking immediately. 2
- The mechanism of zolpidem-induced sleepwalking may involve desensitization of GABAergic receptors, with particular risk when combined with selective serotonin reuptake inhibitors (SSRIs). 6
- Patients with underlying sleep disorders causing frequent arousals (such as restless legs syndrome or obstructive sleep apnea) may be at even higher risk for zolpidem-associated sleep-related eating and sleepwalking behaviors. 5