Study identifies fracture risk with insomnia treatments for patients on dialysis
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A study comparing the impact of zolpidem and trazodone on patients receiving hemodialysis found zolpidem conferred a higher risk of hospitalization for fall-related fractures.
“Patients receiving hemodialysis may be particularly susceptible to the untoward effects of insomnia medications due to their frequent use of other sedating and/or disorienting drugs, recurrent exposure to dialysis-induced BP shifts, and high prevalence of autonomic dysfunction, peripheral neuropathy, cognitive impairment, and disease-related osteodystrophy,” Magdalene M. Assimon, PharmD, PhD, and Jennifer E. Flythe, MD, MPH, of the University of North Carolina Kidney Center at the University of North Carolina School of Medicine, wrote. “However, we lack population-specific comparative safety data to guide clinicians as they consider prescribing an insomnia medication to individuals receiving hemodialysis.”
To address this knowledge gap, Assimon and Flythe utilized data from the United States Renal Data System and identified patients on hemodialysis with Medicare coverage who initiated zolpidem (n = 18,941) or trazodone (n = 12,114) therapy between 2013 and 2016.
“Before [inverse probability of treatment] IPT weighting, baseline covariates were generally well balanced between treatment groups, with some exceptions (eg, Hispanic ethnicity, history of depression and anxiety, skilled nursing facility admissions),” the researchers wrote. “After IPT weighting, all baseline covariates were well balanced between treatment groups.”
Patients were followed for 30 days, during which 101 fall-related fractures occurred.
Results showed zolpidem initiation was associated with a higher risk of hospitalized fall-related fracture compared with trazodone (weighted hazard ratio = 1.71), with the association being more pronounced for those prescribed higher doses and for men.
Assimon and Flythe proposed this may be due to men being prescribed higher doses, but they recommend further study.
Sensitivity analyses were also conducted to examine the effects of the medications during a longer term. These yielded similar results, according to the researchers.
“Our study begins to fill [the] evidence gap by providing initial comparative safety data, showing that treatment with zolpidem (especially at higher doses) may elevate the already high underlying fall-related fracture risk in patients receiving hemodialysis more than trazodone,” they wrote. “These findings plausibly stem from differences in the degree of drug-induced cognitive and motor impairment between the two medications. Zolpidem may be a stronger sedative than trazodone, potentially raising the risk of sedative-related falls and fractures to a greater extent. However, data comparing the sedative potency of zolpidem and trazodone and the incidence and severity of relevant side effects are needed to confirm this hypothesis.”
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