In this case study, I highlight the clinical impact that the ciprofloxacin and zolpidem interaction can have on a patient. JS is a 58-year-old female with a history of insomnia and takes zolpidem 10 mg at bedtime every night. She has recently been diagnosed with a urinary tract infection. She has been prescribed ciprofloxacin.
Upon initiation of the ciprofloxacin, she notes an increased level of sedation and feels more confused in the morning. She attributes these symptoms to the urinary tract infection. What she doesn’t realize is that it may be due to a drug interaction between ciprofloxacin and zolpidem.
Zolpidem is broken down by multiple pathways. Of note in relation to the ciprofloxacin, zolpidem is broken down by CYP1A2 and CYP3A4. CYP3A4 is the most significant pathway of zolpidem metabolism as noted in our Z-drug comparison table. Where does ciprofloxacin come in? Ciprofloxacin inhibits CYP1A2 and to a lesser extent CYP3A4. Inhibiting these enzymes reduces the rate of metabolism of zolpidem and can ultimately increase concentrations of the drug. As concentrations of zolpidem rise, the patient is more likely to experience adverse effects like sedation and confusion which could carry over into the morning.
Ciprofloxacin and Zolpidem Interaction – Clinical Management
The ciprofloxacin and zolpidem interaction should go away when ciprofloxacin is discontinued. The length of therapy was not given in the case above but typically, ciprofloxacin will only be given for 3-10 days depending upon the severity of the infection.
The easiest intervention is to reduce the dose of zolpidem. Recall in females that it is recommended to use a maximum of 5 mg anyway. In addition, it is generally not recommended to use zolpidem long-term for insomnia. I’d be interested to further investigate this and identify how long she has been taking this medication.
The other alternative would be to look at other antibiotic options. While effective at treating UTIs, fluoroquinolones do carry some boxed warnings and are generally reserved for more severe infections or situations where alternatives like Bactrim, nitrofurantoin, or fosfomycin cannot be utilized.
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