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11/16/23, 11:09 AM Realizeit for Student Drug Therapy Herbal Supplements Commonly Used to Reduce Anxiety and Insomnia Melatonin This hormone is produced by the pineal gland, an endocrine gland in the brain. Endogenous melatonin is derived from the amino acid tryptophan, w then enzymatically conver...

11/16/23, 11:09 AM Realizeit for Student Drug Therapy Herbal Supplements Commonly Used to Reduce Anxiety and Insomnia Melatonin This hormone is produced by the pineal gland, an endocrine gland in the brain. Endogenous melatonin is derived from the amino acid tryptophan, w then enzymatically converted to melatonin in the pineal gland. Exogenous preparations are produced synthetically and may contain other ingredien available. Recommended doses on product labels usually range from 0.3 to 5 mg. Melatonin influences sleep–wake cycles; it is released during sleep, and serum levels are very low during waking hours. Prolonged intake of exogen cycle. As a result, it is widely promoted for prevention and treatment of jet lag (considered a circadian rhythm disorder) and treatment of insomnia. I benzodiazepines in inducing sleep. In several studies of patients with sleep disturbances, those taking melatonin experienced modest improvemen Other studies suggest that melatonin supplements improve sleep in older adults with melatonin deficiency and decrease weight loss in people with needed to determine the effects of long-term use and the most effective regimen when used for jet lag. Melatonin supplements are contraindicated in patients with hepatic insufficiency because of reduced clearance. They are also contraindicated in pe disease, depression, or neurologic disorders. They should be used cautiously by people with renal impairment and those taking benzodiazepines o effects include altered sleep patterns, confusion, headache, hypothermia, pruritus, sedation, and tachycardia. Valerian This herb is a perennial flowering plant, and the root has been used for centuries as a treatment for anxiety and insomnia. It is believed that valerian brain, probably by inhibiting the transaminase enzyme that normally metabolizes GABA. Increasing GABA, an inhibitory neurotransmitter, results in is a lack of evidence to support the use of valerian for treating insomnia or anxiety. In a meta-analysis of 11 clinical trials, there was no significant d valerian and placebo. In addition, valerian was associated with a greater number of adverse events per person compared with placebo. A small clin anxiety compared to a placebo. Adverse effects with acute overdose or chronic use of valerian include blurred vision, cardiac disturbance, excitability, headache, hypersensitivity re risk of hepatotoxicity from overdosage and from using combination herbal products containing valerian. Valerian should not be taken by people wit liver damage) or by pregnant or breast-feeding women (effects are unknown). The herb should not be taken concurrently with any other sedatives, h because of the potential for additive CNS depression. Benzodiazepines Benzodiazepines are widely used for anxiety and insomnia and are also used for several other indications. These drugs have a wide margin of safety between therapeutic and toxic doses, and they are rarely fatal, even in overdose, unless combined with other CNS depressant drugs, such as alcohol. Practitioners have used benzodiazepines to manage the anxiety and hyperarousal caused by PTSD, but research does not support their efficacy. With the high prevalence of substance abuse in patients with PTSD, judicious monitoring and consideration of alternate drug therapy would enhance safety in patients with a history of substance use. In addition, limited data suggest that benzodiazepines may impair the therapeutic effects of certain behavioral therapies, such as exposure therapy. Benzodiazepines are Schedule IV drugs under the Controlled Substances Act. Drugs of abuse, they may cause physiologic dependence; therefore, withdrawal symptoms occur if these drugs are stopped abruptly. To avoid withdrawal symptoms, it is necessary to taper benzodiazepines gradually before discontinuing them completely. The Food and Drug Administration (FDA) has issued a Black Box Warning for the combined use of benzodiazepines and opioid analgesics. The risk of serious adverse reactions, including slowed or difficult breathing and deaths, has been reported. Although benzodiazepines are effective anxiolytics, long-term use is associated with concerns over tolerance, dependency, withdrawal, lack of efficacy for treating the depression that often accompanies anxiety disorders, and the need for multiple daily dosing with some agents. These drugs differ mainly in their plasma half-lives, production of active metabolites, and clinical uses. Diazepam (Valium) is the prototype benzodiazepine. Pharmacokinetics Diazepam has a long half-life (20–100 hours) if the contribution from metabolites is included. The drug requires 5 to 7 days to reach steadystate serum levels. It is well absorbed, highly lipid soluble, widely distributed in body tissues, and highly bound to plasma proteins (85%– 98%). The high lipid solubility allows the drug to easily enter the CNS and perform its actions. After IV injection, diazepam may act within 1 https://herzing.realizeithome.com/RealizeitApp/Student.aspx?Token=0Dn26kXyU%2f6F5gOCz4%2f2IfXgL26npJPT22aAWsq08u6Npe56xgiyh8MpUasnCQGXnd… 1/6 11/16/23, 11:09 AM Realizeit for Student to 5 minutes. However, the duration of action of a single IV dose is short (30–100 minutes). Thus, the pharmacodynamic effects (e.g., sedation) do not correlate with plasma drug levels because the drugs move in and out of the CNS rapidly. This redistribution allows a patient to awaken even though the drug may remain in the blood and other peripheral tissues for days or weeks before it is completely eliminated. Diazepam is mainly metabolized in the liver by the cytochrome P450 enzymes (CYP3A4 subgroup) and glucuronide conjugation. Metabolites are excreted through the kidneys. Action Diazepam enhances the inhibitory effect of GABA to relieve anxiety, tension, and nervousness and to produce sleep. The decreased neuronal excitability also accounts for its usefulness as a muscle relaxant, hypnotic, and anticonvulsant. Use Health care providers mainly use diazepam for antianxiety, hypnotic, and anticonvulsant purposes. They also give the drug for preoperative sedation, prevention of agitation and delirium tremens in acute alcohol withdrawal, and treatment of anxiety symptoms associated with depression, acute psychosis, or mania. Thus, patients often take it concurrently with antidepressants, antipsychotics, and mood stabilizers. However, use of diazepam contraindicates the use of some antidepressants. Experts do not advise using the drug for long periods, because it may cause excessive sedation and respiratory depression. Investigators have extensively studied diazepam, and it has more approved uses than other drugs in its class. Larger-than-usual doses may be necessary for patients who are severely anxious or agitated. Also, large doses are usually required to relax skeletal muscle, control muscle spasm, control seizures, and provide sedation before surgery, cardioversion, endoscopy, and angiography. When using benzodiazepines with opioid analgesics, it is important to reduce the analgesic dose initially and increase it gradually to avoid excessive CNS depression. Use in Children Prescribers often order diazepam for children with anxiety and sleepwalking or night terrors. Use of the drug requires caution. Children may be more sensitive to the effects of this drug, namely, mood and/or mental changes. They may have unanticipated or variable responses, including paradoxical CNS stimulation and excitement rather than CNS depression and calming. Children should take diazepam and other benzodiazepines only when clearly indicated, in the lowest effective dose, and for the shortest effective time. Diazepam should not be used in children younger than 1 month of age. Use in Older Adults In older adults, most benzodiazepines are metabolized more slowly, and half-lives are longer than in younger adults. Caution is necessary. The elderly may be sensitive to its effects, especially drowsiness, poor coordination, and mental and/or mood changes caused by the drug. Adverse effects may contribute to falls and other injuries unless patients are carefully monitored and safeguarded. It is important to make the initial dose of any antianxiety or sedative–hypnotic drug small and to increase doses gradually. Diazepam and other benzodiazepines may produce paradoxical excitement and aggression in adults older than 50 years of age who have a history of psychosis. Current studies suggest a relationship between benzodiazepine use and cognitive declines. Use in Patients With Renal or Hepatic Impairment In impaired renal excretion, active metabolites may accumulate, causing excessive sedation and respiratory depression. Hepatic impairment also rules out use of diazepam. Use in Patients With Critical Illness Antianxiety and sedative–hypnotic drugs are often useful in critically ill patients to relieve stress, anxiety, and agitation. Their calming effects decrease cardiac workload (e.g., heart rate, blood pressure, force of myocardial contraction, myocardial oxygen consumption) and respiratory effort. Additional benefits include improving tolerance of treatment measures (e.g., mechanical ventilation); keeping confused patients from harming themselves by pulling out IV catheters, feeding or drainage tubes, wound drains, and other treatment devices; and allowing more rest or sleep. In addition to sedation, the drugs often induce amnesia, which may be a desirable effect in the critically ill. Caution is necessary with the use of diazepam in patients with critical illness. Patients should provide a comprehensive list of all medications to their health care provider, including antiretrovirals, certain antibiotics, and blood pressure medications. Use of many drugs is a contraindication to taking diazepam. Use in Patients Receiving Home Care Most patients take diazepam at home, and the home care nurse shares the responsibility for teaching patients how to use the drug effectively and how to recognize medication responses that should be reported to the health care provider. Accurate dosing is vitally https://herzing.realizeithome.com/RealizeitApp/Student.aspx?Token=0Dn26kXyU%2f6F5gOCz4%2f2IfXgL26npJPT22aAWsq08u6Npe56xgiyh8MpUasnCQGXnd… 2/6 11/16/23, 11:09 AM Realizeit for Student important because underuse may cause the recurrence of the symptoms and overuse may cause toxicity, which may be life threatening. The nurse tells the patient and any caregivers that if symptoms of withdrawal or overdose develop, it is necessary to seek medical attention immediately. The nurse also monitors the patient’s response to the drug and any changes in the patient’s condition. Adverse Effects Both therapeutic effects and adverse effects of diazepam are more likely to occur after 2 or 3 days of therapy than initially. Such effects accumulate with chronic usage and persist for several days after the drug is discontinued. Many of the adverse effects associated with diazepam are related to its CNS depressant effects. They include drowsiness, problems with memory, confusion, disinhibition, depressed mood with or without suicidal ideation, slurred speech, dizziness, shallow breathing, restlessness, irritability, loss of bladder control, and diminished sexual interest. Other effects may include new or worsening seizures, nausea, constipation, drooling or dry mouth, mild skin rash, and itching. Diazepam and other benzodiazepines exert effects on the GABA receptors and can lead to overdose. Signs of overdose include blurred or double vision, labored breathing, weakness, stupor, and coma. Flumazenil is a benzodiazepine antagonist that interacts with the GABA receptors to reverse overdose. Contraindications Contraindications to diazepam include severe respiratory disorders, such as chronic obstructive pulmonary disease or sleep apnea, severe liver or kidney disease, hypersensitivity reactions, and a history of alcohol or other drug abuse. People with narrow-angle glaucoma or who are pregnant or breast-feeding should not take diazepam. The concurrent use of diazepam and any other CNS depressants warrants caution. Nursing Implications Preventing Interactions Smaller-than-usual doses of diazepam and other benzodiazepines may be necessary in patients receiving cimetidine or other drugs that decrease the hepatic metabolism of benzodiazepines. There are various preparations of diazepam, for both oral and parenteral use. The nurse adheres to the following guidelines: Ensure that the patient has swallowed sustained-release tablets whole. It is important not to chew these tablets. Ensure that the patient consumes the entire dose of medication. Do not abruptly withdraw the medication. This places the patient at risk for alterations in mood. Administer the intramuscular preparation in a large muscle. Inject it slowly and rotate injection sites. Administer the IV form undiluted IV push at a rate of 5 mg/minute. In children, inject it at a rate of 0.25 mg/kg over 3 minutes. Assessing for Therapeutic Effects The nurse observes for a relaxed, but easily aroused, appearance. The nurse interviews the patient to assess response to the medication. For example, the patient should verbalize that he or she feels less worried and more relaxed. Nonverbal behavior is important; response to the medication includes decreased heart rate and blood pressure and a relaxed posture. It is necessary to assess the level of drowsiness and sleep pattern. Assessing for Adverse Effects The nurse monitors the patient’s blood pressure. It is necessary to make sure that the patient does not experience paradoxical responses, which include anger, aggression, and hallucinations, to the diazepam. The nurse assesses for symptoms of diazepam dependence, overdose, and withdrawal. The presence of withdrawal symptoms when the drug is stopped indicates physical dependence, which is associated with longer use and higher doses. Common signs and symptoms of withdrawal include increased anxiety, psychomotor agitation, insomnia, irritability, headache, tremor, and palpitations. Less common but more serious signs include confusion, abnormal perception of movement, depersonalization, psychosis, and seizures. Symptoms usually occur 4 to 5 days after stopping a long-acting drug such as diazepam. Relief requires administration of a benzodiazepine. Patient Teaching Patient Teaching Guidelines for Benzodiazepines “Nerve pills” and “sleeping pills” can relieve symptoms temporarily, but they do not cure or solve the underlying problems. With rare exceptions, short-term use. For long-term relief, counseling or psychotherapy may be more beneficial because it can help you learn other ways to decrease y Try to identify and avoid factors that cause nervousness, such as caffeine-containing beverages and stimulant drugs. This may prevent or decrea drugs are used, these factors can cancel or decrease the drugs’ effects. Stimulant drugs include asthma and cold remedies and appetite suppre https://herzing.realizeithome.com/RealizeitApp/Student.aspx?Token=0Dn26kXyU%2f6F5gOCz4%2f2IfXgL26npJPT22aAWsq08u6Npe56xgiyh8MpUasnCQGXnd… 3/6 11/16/23, 11:09 AM Realizeit for Student Most pills to control anxiety belong to the same chemical group and have similar effects, including the ability to decrease nervousness, cause dro there is no logical reason to take a combination of the drugs for anxiety or to take one drug for daytime sedation and another for sleep. Xanax, A examples of this group, but there are several others as well. Inform all health care providers when taking a sedative-type medication, preferably by the generic and trade names. This helps avoid multiple pre and reduces the risk of serious adverse effects from overdose. Do not perform tasks that require alertness if drowsy from medication. The drugs often impair mental and physical functioning, especially during make routine activities potentially hazardous. Avoid smoking, ambulating without help, driving a car, operating machinery, bathing, and other pot may lead to falls or other injuries if undertaken while alertness is impaired. Avoid alcohol and other depressant drugs (e.g., OTC antihistamines and sleeping pills, narcotic analgesics, sedating herbs such as kava and vale melatonin) while taking any antianxiety or sedative–hypnotic drugs (except buspirone). An antihistamine that causes drowsiness is the active ingr Nytol, Sominex, Unisom) and in many pain reliever products with “PM” as part of their names (e.g., Tylenol PM). Because these drugs depress br combining them produces additive depression and may lead to excessive drowsiness, difficulty breathing, traumatic injuries, and other potentiall Store drugs safely, out of reach of children and adults who are confused or less than alert. Accidental or intentional ingestion may lead to serious drug container at the bedside, because a person sedated by a previous dose may take additional doses. Do not share these drugs with anyone else. These mind-altering, brain-depressant drugs should be taken only by those people for whom they ar Do not stop taking a diazepam-related drug abruptly. Withdrawal symptoms can occur. When being discontinued, dosage should be gradually re supervision of a health care provider. Follow instructions carefully about how much, how often, and how long to take the drugs. These drugs produce more beneficial effects and fewe smallest effective doses and for the shortest duration feasible in particular circumstances. Omit one or more doses if excessive drowsiness occu other adverse drug effects. Take oral benzodiazepines with a glass of water. Take them with food if stomach upset occurs. Take Xanax XR once daily, preferably in the morning. Take the tablet intact; do not crush, chew, or break it. Other Drugs in the Class Alprazolam (Xanax, Xanax XR) is administered orally to reduce anxiety and panic disorders. Elderly patients are more sensitive to the effects of the drug and may experience ataxia and oversedation. The immediate-release preparations can be given sublingually if the patient cannot swallow. Alprazolam is preferred over diazepam due to its immediate onset of action. Nonbenzodiazepine Sedative–Hypnotic Agents The nonbenzodiazepine sedative–hypnotics produce sleep. People may receive them prior to diagnostic or surgical procedures or take them nightly. This classification lacks a specific prototype, so each drug in the class will be discussed individually. In general, people should use sedative–hypnotics only when insomnia causes significant distress and resists management by nonpharmacologic means. The drugs are not indicated for occasional sleeplessness. The goal of treatment is to relieve anxiety or sleeplessness without permitting sensory perception, responsiveness to the environment, or alertness to drop below safe levels. The drugs of choice for most patients are the benzodiazepines and the nonbenzodiazepine hypnotics, eszopiclone, ramelteon, zaleplon, and zolpidem. However, for patients with insomnia associated with major depression, antidepressants are preferred. The use of sedative–hypnotics every night should not occur unless absolutely necessary. Intermittent administration helps maintain drug effectiveness and decreases the risks of drug abuse and dependence. It also decreases disturbances of normal sleep patterns. For chronic insomnia, only eszopiclone is recommended for long-term treatment (≤12 months). To restore the sleep-producing effect, administration of the hypnotic drug must be interrupted for 1 to 2 weeks. Patient Teaching Guidelines for Nonbenzodiazepine Sedative–Hypnotics Sleeping pills, like antianxiety drugs, can relieve symptoms temporarily, but they do not cure or solve the underlying problems. With rare exceptio for short-term use. For long-term relief, counseling or psychotherapy may be more beneficial because it can help you learn other ways to decrea Avoid alcohol and other depressant drugs (e.g., OTC antihistamines and sleeping pills, narcotic analgesics, sedating herbs such as kava and vale melatonin) while taking sedative–hypnotic drugs. An antihistamine that causes drowsiness is the active ingredient in OTC sleep aids (e.g., Compo pain reliever products with “PM” as part of their names (e.g., Tylenol PM). Because these drugs depress brain functioning when taken alone, com and may lead to excessive drowsiness, difficulty breathing, traumatic injuries, and other potentially serious adverse drug effects. Do not perform tasks that require alertness if drowsy from medication. The drugs often impair mental and physical functioning, especially during make routine activities potentially hazardous. Avoid smoking, ambulating without help, driving a car, operating machinery, bathing, and other pot may lead to falls or other injuries if undertaken while alertness is impaired. Store drugs safely, out of reach of children and adults who are confused or less than alert. Accidental or intentional ingestion may lead to serious drug container at the bedside, because a person sedated by a previous dose may take additional doses. Take nonbenzodiazepine hypnotics on an empty stomach, at bedtime, because fatty heavy meals delay onset of action. Do not take herbal supplements with nonbenzodiazepine sedative–hypnotics. Do not take most “sleeping pills” every night. Many sleeping pills lose their effectiveness in 2 to 4 weeks if taken nightly and cause sleep disturba therapy for insomnia is needed, eszopiclone and ramelteon are approved for long-term use. Use nondrug measures to promote relaxation, rest, and sleep when possible. Physical exercise, reading, craft work, stress management, and rela drug. Take sleeping pills just before going to bed so that you are lying down when the expected drowsiness occurs. https://herzing.realizeithome.com/RealizeitApp/Student.aspx?Token=0Dn26kXyU%2f6F5gOCz4%2f2IfXgL26npJPT22aAWsq08u6Npe56xgiyh8MpUasnCQGXnd… 4/6 11/16/23, 11:09 AM Realizeit for Student Do not take zolpidem concurrently with alcohol or other CNS depressant drugs because of increased risk of excessive sedation and respiratory d Prime zolpidem oral spray prior to initial use. Compress the container five times, hold the container upright, and aim it directly into the mouth. Report adverse effects such as hypersensitivity reactions, complex sleep-related behaviors, or thoughts of suicide to the prescriber. Eszopiclone Eszopiclone (Lunesta) is the first oral nonbenzodiazepine hypnotic to receive FDA approval for long-term use (≤12 months). During testing, researchers did not observe tolerance to the hypnotic benefits of the drug over a 6-month period. It increases total sleep time and reduces the amount of time needed to fall asleep. Studies show that eszopiclone does not reduce nighttime awakenings. The drug is a Schedule IV controlled substance. Supposedly, the hypnotic effect of eszopiclone is due to interaction with the GABAA receptor at a location close to or coupled with the benzodiazepine receptors. The drug is rapidly absorbed after oral administration, reaching peak plasma levels 1 hour after administration. It has a half-life of 6 hours. It is metabolized in the liver and eliminated primarily by the renal system. People should take eszopiclone immediately prior to going to bed due to its rapid onset of action. QSEN Alert: Safety It is important to instruct patients not to engage in any activities following the administration of the medication. Also, people should not take the medication following a high-fat meal, because the onset of action may be delayed by approximately 1 hour, or prior to bathing. In addition, geriatric people should not use the drug according to the Beers criteria. Adverse reactions to eszopiclone include behavioral changes such as reduced inhibition, aggression or bizarre behavior, worsening depression and suicidal ideation, hallucinations, and anterograde amnesia (short-term memory loss). A commonly reported reaction to the drug is an unpleasant taste. Contraindications include hypersensitivity reaction. Caution is necessary during pregnancy and lactation, in depression, and with impaired hepatic or respiratory function. Elderly patients, those with hepatic impairment or debilitating conditions, and those taking drugs that inhibit CYP3A4 enzymes (e.g., antidepressants, antifungals, erythromycin, grapefruit, protease inhibitors, others) require lower dosages to reduce adverse effects. People who take eszopiclone should not take alcohol or other CNS depressants to avoid additive effects. Ramelteon Ramelteon (Rozerem), a melatonin agonist, is used for the long-term treatment of insomnia characterized by difficulty with sleep onset. Unlike other nonbenzodiazepine hypnotics, which bind to GABAA receptors, ramelteon binds to melatonin receptors in the CNS. Stimulation of melatonin receptors by ramelteon, like endogenous melatonin, is thought to play a role in the maintenance of the circadian rhythm, which helps regulate the normal sleep–wake cycle. Ramelteon does not appear to cause rebound insomnia posttreatment. Because it does not produce physical dependence, ramelteon is not classified as a controlled substance. Ramelteon is rapidly absorbed orally, reaching peak plasma levels in about 45 minutes. Ramelteon is moderately protein bound (82%) and undergoes rapid hepatic first-pass metabolism by cytochrome P450 enzyme systems, including CYP3A4. Ramelteon is excreted primarily in the urine and does not accumulate in the body due to the short half-life of the drug (1–2.6 hours). Patients should avoid taking ramelteon with a high-fat meal because food may delay the onset of action. Common adverse effects of ramelteon include headache, fatigue, dizziness, nausea, diarrhea, arthralgia/myalgia, and taste changes. The drug may affect endocrine hormones, resulting in decreased testosterone levels, increased prolactin levels, and decreased cortisol levels. Contraindications include severe hepatic impairment if combined with fluvoxamine. Caution is warranted in depression or impaired respiratory function. People should not take ramelteon with alcohol because of resulting excessive sedation and respiratory depression. Tasimelteon (Hetlioz), a drug in the same class as ramelteon, has been approved for the treatment of non–24-hour sleep–wake disorder in adults, a circadian sleep–wake rhythm disorder that occurs primarily affecting blind individuals. Zaleplon Zaleplon (Sonata) is an oral, nonbenzodiazepine hypnotic approved for the short-term treatment (7–10 days) of insomnia. Overall, this drug is effective in helping people get to sleep and has several advantages as a hypnotic, including the rapid onset, absence of active metabolites, absence of clinically significant CYP450 drug interactions, rapid clearance from the body, and absence of major memory impairments. However, it may not increase total sleep time or decrease the number of awakenings during sleeping hours. https://herzing.realizeithome.com/RealizeitApp/Student.aspx?Token=0Dn26kXyU%2f6F5gOCz4%2f2IfXgL26npJPT22aAWsq08u6Npe56xgiyh8MpUasnCQGXnd… 5/6 11/16/23, 11:09 AM Realizeit for Student Zaleplon is well absorbed, but bioavailability is only about 30% because of extensive presystemic or first-pass hepatic metabolism. Onset of action is rapid, with a peak in 1 hour. A high-fat, heavy meal slows absorption and may reduce the drug’s effectiveness in inducing sleep. It is 60% bound to plasma proteins, and its half-life is 1 hour. The drug is metabolized mainly in the liver to inactive metabolites. The metabolites and a small amount of unchanged drug are excreted in the urine. Zaleplon apparently enhances the inhibitory effects of GABA, as do the benzodiazepines. A few studies indicate that it has abuse potential similar to that of the benzodiazepines; zaleplon is a Schedule IV controlled substance. No dosage adjustment with zaleplon is necessary in mild to moderate renal impairment. However, to reduce the risk of adverse effects, it is necessary to decrease the dosage in mild to moderate hepatic impairment and avoid using the drug in severe hepatic impairment. It is also important to decrease the dosage in older adults. Adverse effects associated with zaleplon include depression, drowsiness, nausea, dizziness, headache, hypersensitivity, impaired coordination, and short-term memory impairment. Contraindications include hypersensitivity reactions and lactation. Caution is warranted during pregnancy and in impaired hepatic or respiratory function. Use of zaleplon with alcohol or other CNS depressant drugs should not occur because of the increased risk of excessive sedation and respiratory depression. There is also a risk of increased serum zaleplon levels if people take the hypnotic concurrently with cimetidine. It is very important that patients taking zaleplon be taught about this interaction because cimetidine is available without prescription, and the patient may not inform the health care provider who prescribes zaleplon about taking cimetidine. Zolpidem Zolpidem (Ambien, Zolpimist) is a nonbenzodiazepine hypnotic that differs structurally from the benzodiazepines but produces similar effects. This drug is a Schedule IV drug approved for short-term treatment (7–10 days) of insomnia. It is well absorbed with oral administration and has a rapid onset of action, usually within 20 to 30 minutes. The half-life of zolpidem is 2.5 hours, and its hypnotic effects last 6 to 8 hours. A newer controlled-release form (Ambien CR) contains a rapid-releasing layer, which promotes falling asleep, and a slowreleasing layer, which promotes sleep all night. The drug is metabolized to inactive metabolites in the liver; these are then eliminated by renal excretion. Dosage reductions with zolpidem are not necessary in renal impairment, but this condition requires close monitoring. Increased bioavailability, peak plasma concentration, and half-life occur in older adults and in patients with impaired hepatic function. Thus, dosage reduction is essential for these groups. People should not take zolpidem concurrently with alcohol or other CNS depressant drugs because of the increased risk of excessive sedation and respiratory depression. Adverse effects of zolpidem include daytime drowsiness, dizziness, nausea, diarrhea, and anterograde amnesia. Hallucinations have been reported in some patients. Older adults may experience headache, somnolence, and dizziness. Caution is necessary with signs and symptoms of major depression because of increased risk of intentional overdose. Rebound insomnia may occur for a night or two after stopping the drug, and withdrawal symptoms may occur if it is stopped abruptly after approximately a week of regular use. https://herzing.realizeithome.com/RealizeitApp/Student.aspx?Token=0Dn26kXyU%2f6F5gOCz4%2f2IfXgL26npJPT22aAWsq08u6Npe56xgiyh8MpUasnCQGXnd… 6/6