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Pharmacokinetic and Pharmacodynamic Interactions Between Zolpidem and

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Article  in  Clinical Pharmacology & Therapeutics · August 2007

DOI: 10.1038/sj.clpt.6100211 · Source: PubMed

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Pharmacokinetic and Pharmacodynamic

Interactions Between Zolpidem and Caffeine
RM Cysneiros1, D Farkas1, JS Harmatz1, LL von Moltke1 and DJ Greenblatt1

The kinetic and dynamic interaction of caffeine and zolpidem was evaluated in a double-blind, single-dose, six-way
crossover study of 7.5 mg zolpidem (Z) or placebo (P) combined with low-dose caffeine (250 mg), high-dose caffeine
(500 mg), or placebo. Caffeine coadministration modestly increased maximum plasma concentration (Cmax) and area
under the plasma concentration-time curve of zolpidem by 30–40%, whereas zolpidem did not significantly affect the
pharmacokinetics of caffeine or its metabolites. Compared to P þ P, Z þ P significantly increased sedation, impaired
digit-symbol substitution test performance, slowed tapping speed and reaction time, increased EEG relative beta
amplitude, and impaired delayed recall. Caffeine partially, but not completely, reversed most pharmacodynamic effects
of zolpidem. Thus, caffeine only incompletely reverses zolpidem’s sedative and performance-impairing effects, and
cannot be considered as an antidote to benzodiazepine agonists.

Zolpidem is the most frequently prescribed hypnotic
throughout the world. It has a short elimination half-life
and is unlikely to cause drowsiness or sedation persisting into
the daytime hours.1–6 Zolpidem is also unlikely to cause
rebound or withdrawal symptoms after discontinuation of
treatment.7–9 Although zolpidem is not a benzodiazepine in
structure, it is a GABAA–benzodiazepine receptor agonist
with relative selectivity for the type 1 receptor subtype.10 The
pharmacodynamic properties of zolpidem resemble those of
the benzodiazepine agonist triazolam, in terms of clinical
efficacy as well as the profile of typical benzodiazepine
agonist effects.6,11–14
With such extensive use of zolpidem, there is concern
regarding the possibility of interactions with drugs, foods,
and beverages. Caffeine is a psychoactive compound that is
widely used throughout the world.15,16 The stimulant effects
of caffeine, presumably mediated through central adenosine
receptor antagonism,16–22 can counteract fatigue associated
with sleep deprivation,23–26 and may also partly reverse
sedation produced by benzodiazepine receptor ligands such
as diazepam, lorazepam, triazolam, and flurazepam.27–31 A
recent survey estimated that 88% of benzodiazepine users
also consume caffeine, and 26% of them consume more than
250 mg in 24 h.32
Although coffee consumption is estimated to have
decreased twofold in the past 5 years, soft drink consumption
has increased almost fivefold, and other caffeinated bev-
erages, such as energy drinks and caffeinated water, have been
added to the market. Overall, a growing percentage of the
population is consuming caffeine, and caffeine consumption
tends to increase with age, particularly in men.33 Since
zolpidem is likely to be prescribed to the elderly as a sleeping
aid, this population could be exposed to possible caffeine–-
zolpidem interactions.
The metabolism of zolpidem is mediated approximately
61% via CYP3A4, 22% via CYP2C9, 14% via CYP1A2, and
about 3% via CYP2D6. Caffeine, on the other hand, is
metabolized mainly by CYP1A2, with an additional small
contribution by CYP2E1. A pharmacokinetic interaction
between zolpidem and caffeine, if it occurs, is likely to involve
CYP1A2. A study examining sedation and memory impair-
ment suggested that 10 mg zolpidem is incompletely
antagonized by 300 mg caffeine.34 However, the pharmaco-
kinetics of this interaction have not been investigated. In
addition, the effects of higher doses of caffeine on the
pharmacokinetics and pharmacodynamics of zolpidem need
to be examined.
In this study, we investigated the pharmacokinetic and
pharmacodynamic interactions between 7.5 mg of zolpidem
and 250 or 500 mg caffeine. A cup of brewed coffee is
assumed to have 80–170 mg of caffeine,35 with an average of
approximately 120 mg per 8 oz. Thus, these doses of caffeine

1
Department of Pharmacology and Experimental Therapeutics, Tufts University School of Medicine and Tufts-New England Medical Center, Boston, MA, USA.
Correspondence: DJ Greenblatt (dj.greenblatt@tufts.edu)
Received 21 December 2006; accepted 28 March 2007; published online 18 April 2007. doi:10.1038/sj.clpt.6100211

54 VOLUME 82 NUMBER 1 | JULY 2007 | www.nature.com/cpt

 ARTICLES

approximately correspond to two and four cups of coffee,
respectively. The pharmacokinetic effects were quantitated by
measuring the plasma levels of zolpidem, caffeine, and
caffeine metabolites from 0 to 24 h after exposure. Pharma-
codynamic interactions were determined with both subjective
and objective tests. The goal of the pharmacodynamic tests
was to determine whether either dose of caffeine can
counteract the sedation, drowsiness, and impairment in
cognitive ability and memory function brought on by
zolpidem.
RESULTS
Pharmacokinetics
Zolpidem. When coadministered with placebo, mean zolpi-
dem Cmax was 174 ng/ml, with a Tmax of 1.9 h (Table 1).
Mean elimination half-life was 2.04 h, total AUC was 675 ng/
ml h, and apparent oral clearance was 168 ml/min (Table 1).
Zolpidem Cmax and AUC increased, and oral clearance
decreased, with increasing doses of coadministered caffeine
(Table 1, Figure 1). Between Z þ P and Z þ HC conditions,
zolpidem AUC increased by 41% and oral clearance
decreased by 29%.
rated sedation, self-ratings of feeling ‘‘spacey’’, and EEG beta
amplitude, significant decreases in DSST performance and
tapping speed, and slowing of reaction time (Figures 3 to 5;
Tables 3 and 4). There were also increases in self-ratings of
fatigue and reductions in perceived thinking speed (‘‘thinking
slowed down’’), which did not reach significance using
Dunnett’s test following the six-way ANOVA. The increase in
self-rated fatigue was significant (Po0.001) in a paired
comparison of P þ P versus P þ Z without regard to the
multiple comparisons.
Coadministration of caffeine with zolpidem (Z þ LC and
Z þ HC trials) caused a partial reversal of effects attributed to
zolpidem plus placebo for the following measures: self- and
observer-rated sedation; self-ratings of fatigue, feeling spacey,
and thinking slowed down; and DSST scores, tapping speed,
and reaction time. The reversal effect of caffeine was
significant for self- and observer-rated sedation, tapping
speed, and reaction time using Dunnett’s test. Using a three-
trial comparison only (Z þ P versus Z þ LC versus Z þ HC),
reversal by caffeine of DSST impairment also was significant.
However, there was no evidence of caffeine-induced reversal
of zolpidem effects on the EEG.

Caffeine. When administered with placebo, caffeine Cmax

averaged 5.2 and 11.6 mg/ml, and AUC values were 60 and
225 Zolpidem + placebo
128 mg/ml h following LC and HC, respectively (Table 2, Zolpidem + low-dose caffeine
Figure 2). Apparent oral clearance and elimination half-life 200 Zolpidem + high-dose caffeine
Plasma zolpidem (ng/ml)

were independent of dosage. Coadministration of zolpidem 175

with caffeine yielded no significant change in caffeine
150
elimination half-life, AUC, or clearance. Cmax also was not
different between P þ LC and Z þ LC trials. Cmax for P þ HC 125
was slightly, although significantly higher, than for the 100
Z þ HC trial (Table 2, Figure 2).
75
Three caffeine metabolites were detected: paraxanthine,
theobromine, and theophylline. Coadministration of zolpi- 50
dem did not significantly influence 8 h AUC values for any of 25
the metabolites.
0 1 2 3 4 5 6 7 8
Pharmacodynamics Hours after dose
Compared to the placebo-only trial (P þ P), administration Figure 1 Mean (7SE) plasma zolpidem concentrations when
of zolpidem as the only active medication (Z þ P) caused coadministered with placebo, low-dose caffeine, and high-dose caffeine.
significant increases in 4 h effect area for self- and observer- See Table 1 for pharmacokinetic analysis.

Table 1 Effect of caffeine coadministration on zolpidem pharmacokinetics

Mean (7SE) value

Zolpidem Z+P Z+LC Z+HC Value of F from ANOVA

Cmax (ng/mL) 174 (716) 200 (720) 245 (729)* 6.62 (Po0.01)
Tmax (h) 1.92 (70.17) 1.79 (70.21) 2.00 (70.20) 0.55 (NS)
t12 (h) 2.04 (70.11) 2.21 (70.16) 2.31 (70.18) 0.32 (NS)
AUC (ng/ml h) 676 (771) 865 (7111)* 968 (7106)* 7.40 (Po0.005)
Oral clearance (ml/min) 168 (717) 135 (714)* 118 (713)* 10.29 (Po0.001)
t1 , elimination half-life; AUC, area under the concentration-time curve; ANOVA, analysis of variance; Cmax, maximum plasma concentration; NS, not significant; Tmax, time to
2
reach maximum plasma concentration. Z+P, zolpidem plus placebo; Z+LC, zolpidem plus low-dose caffeine (250 mg); Z+HC, zolpidem plus high-dose caffeine (500 mg).
Asterisk (*) indicates a significant difference (Po0.05) compared to the Z+P trial based on Dunnett’s test.

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Table 2 Effect of zolpidem coadministration on the pharmacokinetics of caffeine and its metabolites
Mean (7SE) value

P+LC Z+LC P+HC Z+HC

Caffeine
Cmax (ng/mL) 5.2 (70.5) 5.6 (70.8) 11.5 (70.8) 9.8 (70.6)
Tmax (h) 1.46 (70.21) 1.96 (70.11) 2.22 (70.26) 2.25 (7 .27)
t12 (h) 7.7 (70.9) 7.3 (71.0) 7.0 (70.9) 8.8 (72.0)
AUC (mg/ml h) 59.6 (76.9) 58.7 (76.8) 127.8 (715.7) 134.3 (731.3)
Clearance (ml/min) 82 (712) 81 (79) 76 (79) 82 (711)

Paraxanthine
8-h AUC (mg/ml h) 8.46 (70.85) 9.98 (71.78) 12.89 (71.89) 12.47 (71.5)

Theobromine
8-h AUC (mg/ml h) 3.90 (70.94) 4.52 (71.28) 6.71 (72.0) 4.35 (70.87)

Theophylline
8-h AUC (mg/ml h) 0.83 (70.14) 0.79 (70.12) 1.21 (70.22) 1.07 (70.17)
t1, elimination half-life; AUC, area under the concentration-time curve; Cmax, maximum plasma concentration; Tmax, time to reach maximum plasma concentration. Values
2
of Cmax, AUC, and clearance were corrected for nonzero baseline plasma caffeine concentrations. Abbreviations: P, placebo; Z, zolpidem; LC, low-dose caffeine (250 mg); HC,
high-dose caffeine (500 mg). There were no statistically significant (Po0.05) differences between P+LC versus Z+LC, and between P+HC versus Z+HC, based on Student’s
paired t-test. Exception: Cmax for P+HC versus Z+HC: t=3.01, Po0.02.

12 12 High-dose caffeine+placebo
High-dose caffeine+zolpidem
10 Low-dose caffeine+placebo 10
Plasma caffeine (
g/ml)

Low-dose caffeine+zolpidem
8 8

6 6

4 4

2 2

0 2 4 6 8 24 0 2 4 6 8 24
Hours after dose Hours after dose

Figure 2 Mean (7SE) plasma caffeine concentrations when coadministed with placebo or with zolpidem. See Table 2 for pharmacokinetic analysis.

Placebo + placebo
25 Placebo + low-dose caffeine
14
Placebo + high-dose caffeine
20 12 Zolpidem + placebo
(change over baseline)

Observer-rated sedation
(change over baseline)

Zolpidem + low-dose caffeine

Self-rated sedation

10 Zolpidem + high-dose caffeine

15
8
10 6
4
5
2
0
0
−5 −2
0 1 2 3 4 5 6 7 8 0 1 2 3 4 5 6 7 8
Hours after dose Hours after dose

Figure 3 Mean changes over pre-dose baseline in self-rated sedation (left) and observer-rated sedation (right). See Table 3 for statistical analysis.

Compared to the P þ P trial, the two trials involving tense, and thinking faster. These differences did not reach
caffeine alone (P þ LC, P þ HC) produced improved DSST significance using Dunnett’s test.
performance, faster tapping speed, faster reaction time, and The word-list test of information acquisition and recall
increased self-ratings of feeling anxious, energetic, excited, (Table 5) showed small but significant changes in immediate

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10
9

Percent beta EEG amplitude

6

(change over baseline)

8

(change over baseline)

3
6 0

DSST score
−3
4 −6
Placebo + placebo
−9 Placebo + low-dose caffeine
2
− 12 Placebo + high-dose caffeine
Zolpidem + placebo
− 15
0 Zolpidem + low-dose caffeine
− 18 Zolpidem + high-dose caffeine
−2 − 21
0 1 2 3 4 5 6 7 8 0 1 2 3 4 5 6 7 8
Hours after dose Hours after dose

Figure 4 Mean changes over pre-dose baseline in EEG beta amplitude (left) and DSST scores (right). See Table 3 for statistical analysis.

Tapping speed
30
Tapping speed (responses in 60 s)

100
20 F=5.98,
75
(change over baseline)

P<0.001
10 50

4-h AUC for change

over baseline
0 25
P+P Z+P Z+LC Z+HC
0 P+LC P+HC
−10
Placebo + placebo −25
−20 Placebo + low-dose caffeine
Placebo + high-dose caffeine −50
−30 Zolpidem + placebo −75
Zolpidem + low-dose caffeine
−100 *
−40 Zolpidem + high-dose caffeine
−125
0 1 2 3 4 5 6 7 8
Hours after dose

Figure 5 Left: mean changes over baseline in the tapping speed test. Right: mean (7SE) area under the 4-h plot of effect change score versus time for the
tapping speed test in the six treatment conditions. Asterisk (*) indicates a significant difference (Po0.05) compared to the double-placebo (P þ P) trial using
Dunnett’s test.

Table 3 Area under the curve of pharmacodynamic effect change score versus time (0–4 h after dosage)
Mean (7SD) value
Values of F from rank-
P+P P+LC P+HC Z+P Z+LC Z+HC transformed ANOVA
Self-rated sedation 3.84 (720.56) 7.19 (734.09) 3.58 (722.54) 47.40 (743.37)* 21.09 (726.95) 19.36 (738.94) 5.21 (Po0.001)
Observer-rated 3.97 (77.59) 0.23 (716.30) 0.45 (76.68) 29.70 (740.32)* 19.05 (723.17)* 11.09 (715.37) 6.84 (Po0.001)
sedation
EEG beta 1.98 (76.68) 5.21 (77.51) 7.00 (79.89) 19.09 (718.28)* 22.35 (79.73)* 19.27 (79.66)* 14.16 (Po0.001)
amplitude (frontal)
DSST 0.05 (718.58) 14.08 (732.53) 7.82 (714.43)42.43 (731.31)*30.74 (716.19)*23.00 (722.51)* 20.57 (Po0.001)
Tapping speed 3 (778) 27 (738) 65 (764) 84 (776)* 31 (796) 31 (775) 7.25 (Po0.001)

Rating scale items

Calm/anxious 3.66 (712.57) 1.38 (746.38) 16.57 (732.59) 3.39 (719.19) 4.92 (725.88) 24.65 (747.75) 1.75 (NS)
Energetic/ 1.59 (743.31)36.68 (757.10)20.55 (750.41) 44.88 (755.08) 14.38 (743.47) 4.31 (748.42) 3.39 (Po0.01)
fatigued
Thinking 3.45 (727.46) 17.45 (725.41) 41.56 (773.80)20.42 (734.74) 5.70 (737.03) 7.64 (732.51) 2.71 (Po0.03)
slower/faster
Normal/spacey 0.67 (717.09) 12.67 (734.99) 6.41 (712.41) 37.58 (739.47)* 31.88 (733.88)* 34.93 (754.57) 4.30 (Po0.005)
At ease/nervous 0.84 (715.61) 8.45 (723.42) 10.66 (743.21) 15.19 (721.70) 3.56 (729.34) 27.68 (754.73) 1.76 (NS)
Relaxed/excited 3.73 (78.52) 13.39 (723.97) 30.29 (743.69) 9.20 (733.44) 15.07 (723.56) 24.40 (755.07) 0.98 (NS)
Peaceful/tense 1.07 (710.78) 5.72 (730.91) 14.70 (730.37) 6.42 (738.92) 1.63 (717.38) 8.69 (712.99) 0.59 (NS)
Normal/irritable 7.5 (711.29) 1.45 (78.49) 1.85 (733.77) 24.06 (718.93) 15.23 (715.93) 22.13 (732.00) 4.93 (Po0.001)
Autonomic 1.14 (78.42) 5.31 (76.25) 5.25 (79.18) 6.18 (715.75) 4.03 (75.05) 10.58 (723.39) 1.84 (NS)
scale
ANOVA, analysis of variance; DSST, digit-symbol substitution test; NS, not significant. For sedation, DSST, tapping speed and the EEG, higher numbers indicate an increase in
the respective parameters. For the rating scale items, the extreme measures (separated by a slash) appear on the left and right sides of the scale respectively. Negative
numbers indicate ratings in the leftward direction, whereas positive numbers indicate ratings in the rightward direction. *Indicates a significant difference (Po0.05) compared
to the P+P trial based on Dunnett’s test.

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Table 4 Results of reaction time test in the six treatment conditions

Mean (7SD) value (ms)

P+P P+LC P+HC Z+P Z+LC Z+HC Value of F from ANOVA

Pre-dose baseline value 42 (79) 41 (78) 41 (78) 42 (78.5) 40 (79) 40 (76) 0.83 (NS)

Change over pre-dose baseline at post-dosage times

0.5 h 1.8 (73.3) 1.0 (72.2) 1.2 (74.7) 2.4 (74.9)* 0.9 (72.2) 0.7 (74.7) 2.15 (P=0.074)
1.5 h 1.0 (74.2) 1.3 (72.3) 0.5 (74.4) 3.4 (74.0)* 0.9 (74.6) 0.2 (735) 2.27 (P=0.061)
ANOVA, analysis of variance; NS, not significant. *Indicates a significant difference (Po0.05) compared to the P+P trial based on Dunnett’s test.

Table 5 Number of words recalled (out of 16) in word-list test of information acquisition and recall
Mean (7SD) value

Number of words recalled P+P P+LC P+HC Z+P Z+LC Z+HC Values of F from ANOVA
Immediate recall (1.5 h) 14.00 (72.70) 14.47 (71.44) 13.92 (73.06) 11.33 (74.14)* 12.58 (73.82) 13.25 (72.60) 3.63 (Po0.01)
Delayed recall (24 h) 12.92 (73.29) 11.5 (74.06) 11.58 (74.50) 5.5 (75.78)* 4.67 (74.40)* 6.08 (74.44)* 14.92 (Po0.001)
*Indicates a significant difference (Po0.05) compared to the P+P trial based on Dunnett’s test.

recall of words learned at 1.5 h after dosage. The decrease in
words acquired in the Z þ P trial was significant compared to
P þ P. This effect was partially reversed in the caffeine
coadministration trials (Z þ LC, Z þ HC). At 24 h after
dosage, delayed recall (free recall) of the word list indicated
large decreases in delayed recall of words in all the trials in
which zolpidem was administered. There was no evidence of
reversal by caffeine.
DISCUSSION
Zolpidem is a substrate for multiple hepatic cytochrome
P450s,36 including CYP3A4, CYP2C9, CYP1A2, and CYP2D6,
in order of decreasing importance, whereas caffeine is
metabolized mainly by CYP1A2, with a small contribution of
CYP2E1.37–41 Pharmacokinetic data showed a modest but
statistically significant increase in zolpidem AUC and a
reduction in clearance with increasing doses of caffeine. The
interaction might be attributable to competitive inhibition of
CYP1A2 by caffeine, but CYP1A2 accounts for a relatively small
fraction of zolpidem clearance. Furthermore, the impairment
of zolpidem clearance by caffeine in vivo was similar to that
produced by the CYP3A inhibitor itraconazole.42,43 Therefore,
the caffeine–zolpidem pharmacokinetic interaction probably
involves other mechanisms in addition to CYP1A2.
Plasma levels of caffeine decreased slightly after coadmi-
nistration of zolpidem, but this change was not statistically
significant. Plasma levels of caffeine metabolites para-
xanthine, theobromine, and theophylline were unaffected
by zolpidem administration. It is notable that pre-dose levels
of caffeine and metabolites were nonzero (Figure 2) despite
subjects being instructed to abstain from caffeine-containing
beverages overnight. This has been observed in previous
studies,44,45 and could represent noncompliance with the
abstinence instruction, and/or persistence of levels from
caffeine ingestion during the previous day or earlier.
Compared to the double-placebo trial (P þ P), zolpidem
alone (Z þ P) significantly increased self- and observer-rated
sedation and feelings of spaciness, increased EEG beta
activity, impaired DSST performance, and slowed tapping
speed and reaction time. These effects were most notable
during the first 4 h after drug administration. Zolpidem also
greatly impaired storage and subsequent delayed recall
(at 24 h) of information from the word list acquired at
1.5 h after dosage. All of these effects are consistent with
established benzodiazepine agonist effects of zolpidem
reported previously.1–5,12–14,43,46
Compared to the double-placebo trial (P þ P), caffeine
combined with placebo (P þ LC, P þ HC) produced rating
scale changes consistent with an energizing or altering effect.
There were also improvements in DSST performance and
tapping speed. However, these changes did not reach
statistical significance. The combination of caffeine and
zolpidem had the general effect of partially reversing the
sedative and performance-impairing effects of zolpidem. The
reversal effects of caffeine reached significance for self- and
observer-rated sedation, self-ratings of feeling ‘‘spacey’’,
tapping speed, and reaction time. It is of interest that
caffeine did not reverse the effects of zolpidem on the EEG,
nor the impairment of delayed recall associated with
zolpidem.
The doses of caffeine in this study were chosen based on
consumption patterns in the US. An 8 oz cup of brewed
coffee is estimated to contain 80–170 mg of caffeine, with the
average being around 120 mg.35 Thus, a 500 mg dose of
caffeine is approximately equivalent to four cups of coffee.
However, caffeine is also found in over-the-counter medica-
tions (up to 200 mg caffeine/dose), soft drinks (approxi-
mately 50 mg per 12 oz), tea (15–50 mg per 8 oz), caffeinated
water, and coffee-flavored ice creams.35 Thus, the caffeine
intake of moderate coffee drinkers (two cups a day) can be

58 VOLUME 82 NUMBER 1 | JULY 2007 | www.nature.com/cpt


close to 500 mg of caffeine a day if they also consume other
caffeinated products.
There are several other reports of interactions
between caffeine and benzodiazepine agonists. A 12 mg dose
of midazolam was incompletely counteracted by a 250 mg
dose of caffeine. Midazolam alone reduced scores on
cognitive and psychomotor tests, and there was a slight
increase in learning ability when coadministered with 250 mg
of caffeine but not with 125 mg of caffeine.47 In another
study, caffeine (125–500 mg) reversed some of the impair-
ment in cognitive and psychomotor tests caused by
lorazepam. In addition, caffeine also reduced the anxiolytic
effects of lorazepam.28 A 300 mg dose of caffeine also
moderately antagonized the pharmacodynamic effects (seda-
tion and digit-symbol substitution) of 0.25 mg of triazolam
and 7.5 mg of zopiclone, another benzodiazepine agonist.29
The drowsiness and learning impairment produced by
diazepam also are partially counteracted by caffeine48
and theophylline49 in a dose-dependent manner. While
zolpidem is not a benzodiazepine in structure, it is a
benzodiazepine receptor agonist, and it is likely that caffeine
can reverse some of zolpidem’s pharmacodynamic effects
through the same mechanism by which it antagonizes
benzodiazepines.
In conclusion, this study found that caffeine can partially
reverse some of the typical pharmacodynamic effects
associated with zolpidem. The mechanism for the interaction
is not likely to be pharmacokinetic because coadminstration
of caffeine with zolpidem if anything increased systemic
exposure to zolpidem. Rather, the interaction probably
represents the combination of activation of the GABAA–-
benzodiazepine receptor system by zolpidem and inhibition
of the adenosine receptor by caffeine. The important public
health message is that caffeine reversal of zolpidem effects is
only partial—despite a dose of caffeine (500 mg) approx-
imating four cups of coffee, sedative and performance-
impairing effects of zolpidem, although diminished, still
persisted. Furthermore, the effects of zolpidem on delayed
recall of information (‘‘antergrade amnesia’’) were not
affected by caffeine.
This study involved concurrent administration of caffeine
and zolpidem, and is not necessarily applicable to a situation
in which zolpidem dosage precedes caffeine administration
by a significant interval,50 such that zolpidem plasma
concentrations had fallen to low or undetectable levels. An
example would be the use of caffeine in the morning to
enhance alertness following bedtime dosage of zolpidem.
Nonetheless, patients and consumers cannot assume that
caffeine represents a fully effective ‘‘antidote’’ to zolpidem
and other benzodiazepine agonists.
METHODS
Design. The protocol was reviewed and approved by the Human
Investigation Review Committee serving Tufts University School of
Medicine and Tufts-New England Medical Center. Twelve healthy
male and female volunteers, aged 18–35 years, initiated participation
after giving written informed consent. All were active, ambulatory,
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ARTICLES
nonsmoking adults, with no evidence of medical disease and taking
no other medication. Female subjects were not taking oral
contraceptives and did not have contraceptive implants.
Subjects participated in a double-blind, randomized, six-way
crossover study, with at least 1 week elapsing between trials.
Medications were: zolpidem tartrate (Ambien), 7.5 mg (Z); low-dose
caffeine (LC; 250 mg); high-dose caffeine (HC; 500 mg); and placebo
(P). The six trials were as follows: a, placebos only (P þ P); b, Z þ P; c,
Z þ LC; d, Z þ HC; e, P þ LC; and f, P þ HC. Zolpidem dosage
(7.5 mg) was chosen as the midpoint of the usual clinical dosage range
(5–10 mg). Caffeine doses were based on typical consumption in the
US, where an 8 oz cup of coffee is assumed to have about 120 mg of
caffeine,35 and moderate caffeine consumption is considered to be
two cups a day. Medications consisted of commercially available
dosage forms encapsulated in opaque blue capsules verified to have
immediate disintegration at 371C in 0.1 N hydrochloric acid. Placebos
were the same capsules containing only sucrose.
Procedures. At 0700 on the study day, subjects were admitted to
the Clinical Psychopharmacology Research Unit at Tufts University
School of Medicine. They ingested a light breakfast with no caffeine-
containing beverages or food, and no grapefruit juice. A single 250
or 500 mg dose of caffeine, or matching placebo, was coadministered
with a single 7.5 mg dose of zolpidem or placebo. The medications
were administered at 0900 with 200 ml tap water. Volunteers
resumed a normal diet at noon (without caffeine).
Venous blood samples were drawn into heparinized tubes prior
to dosing and at post-dosage times of .5, 1, 1.5, 2, 2.5, 3, 4, 5, 6, 8,
12, and 24 h. Samples were centrifuged, and the plasma separated
and frozen until the time of the assay.
An eight-electrode EEG montage was affixed as follows: left and
right frontal (F3, F4), left and right central (C3, C4), as well as
midline frontal (Fz), central (Cz), parietal (Pz), and occipital (Oz),
with a nose electrode as reference. The EEG was recorded in 4 s
epochs, for as long as necessary to ensure at least 2 min of artifact-
free information, prior to medication and the times corresponding
to blood samples. Data were digitized over the power spectrum from
4 to 30 cycles per second (Hz), and analyzed by fast Fourier
transform to determine amplitude in the total spectrum (4–30 Hz)
and in the beta (13–30 Hz) frequency range.11,51,52
Subjects’ self-ratings of sedative effects and mood state were
obtained on a series of 100-mm visual analog scales.11,51–53 Ratings
of sedation were also performed by a trained observer, who used the
same rating instrument without knowledge of the treatment
condition. Self- and observer-ratings were obtained twice prior to
dosing, and at post-dosage times of .5, 1, 1.5, 2, 2.5, 3, 4, 5, 6, 8, 12,
and 24 h. The rating scale items also included a list referred to as the
autonomic scale, which included items such as heart pounding,
headache, restlessness, and sweatiness. All of the items within the
autonomic scale were averaged to give one value per time point.
A number of tests of psychomotor performance and reaction
time were performed. The digit-symbol substitution test (DSST) was
administered twice prior to dosing and at times corresponding to
blood sampling. Subjects make as many symbol-for-digit substitu-
tions as possible in a 2 min period.11,51–53 A 60 s test of tapping speed
was done twice prior to dosing and at times corresponding to blood
sampling.53,54 A single-choice reaction time test55,56 was adminis-
tered twice prior to medication administration and at .5 and 1.5 h
after dosage. This test involves a visual stimulus in which a green
light changes to red. The subject is asked to move his/her foot as
quickly as possible from an accelerator pedal to a ‘‘brake’’ pedal, the
configuration of which is similar to that found in an automobile.
The time between the presentation of the visual stimulus and the
depression of the brake pedal is automatically determined and used
as a measure of reaction time. On each trial, the subject performs the
test 12 times. The highest and lowest scores are discarded, and the
score is taken as the mean of the remaining 10.
59
ARTICLES
Acquisition and recall of information were evaluated using a
word-list free-recall procedure that was administered at 1.5 and 24 h
after medication.57 Sixteen words, taken from four different
categories, were read in random order in shopping-list fashion.
Recall was tested immediately after presentation of the list as
subjects wrote list items in any order. The list was then presented in
a different random order, with subjects again writing down the items
immediately. This was repeated a total of six times. At 24 h after
dosing, subjects were asked to remember as many words as possible
from the list (free recall); thereafter, the same list was read in the
same six different random sequences.
Analysis of data. Plasma concentration of zolpidem was deter-
mined by high-performance liquid chromatography with fluores-
cence detection.58 After the internal standard (propyl-zolpidem) was
added to unknown plasma samples (0.5 ml) and to calibration curve
plasma standards containing known amounts of zolpidem, samples
were extracted by vortex-mixing with toluene/isoamyl alcohol
(98:2). Samples were centrifuged, and the organic layer was
evaporated. The residue was reconstituted with mobile phase and
transferred to high-performance liquid chromatography sample
vials. The analytical column was a 30 cm  3.9 mm reversed-phase
C-18 mBondapack column (Waters) eluted with a mixture of
acetonitrile/50 mM KH2PO4 (50:50, v/v) at a flow of 1.5 ml/min.
Column effluent was monitored by fluorescence detection (254 nm
excitation, 390 nm emission). The sensitivity limit was 1 ng/ml.
Within- and between-day coefficients of variation (CVs) were 13%
or less at 1 ng/ml, and 8% or less at concentrations of 2.5 ng/ml and
higher.
For analysis of caffeine and its principal metabolites, the internal
standard b-hydroxy theophylline was added to unknown plasma
samples (0.5 ml) and to calibration standards containing known
amount of caffeine, theophylline, theobromine, and para-
xanthine.59,60,44 Samples were acidified with 0.2 ml of 0.1 M HCl
and extracted with a mixture of ethyl acetate/isoamyl alcohol (98:2).
Samples were centrifuged, and the organic phase was evaporated
under vacuum. The residue was reconstituted with mobile phase
and transferred to high-performance liquid chromatography vials.
The analytical column was a 15 cm  0.46 cm reversed-phase C-18
mBondapack column (Waters) eluted with a mixture of 1.75 mM
orthophosphoric acid-acetonitrile-tetrahydrofuran (97:02:01, v/v) at
1.5 ml/min. Column effluent was monitored by UV detection at
273 nm. The sensitivity limit for caffeine and metabolites was 0.1 mg/
ml and the within- and between-day CVs did not exceed 9%.
Model-independent methods were used to determine the kinetic
parameters for zolpidem and caffeine and its metabolites. The slope
(beta) of the terminal log-linear phase of each plasma concentration
curve was determined by linear regression analysis and used to
calculate the apparent elimination half-life. Area under the plasma
concentration-time curve (AUC) from time 0 until the last
detectable concentration was determined by linear trapezoidal
method. To this was added the residual area (final concentration
divided by beta), yielding the total AUC. The 8-h AUC was also
calculated for caffeine metabolites. Due to prior caffeine
consumption, the pre-dose plasma levels of caffeine and its
metabolites were nonzero in 11 of the subjects, and the maximum
plasma concentrations (Cmax) and AUC values were adjusted
accordingly. The apparent oral clearance was calculated as
administered dose divided by the corrected total AUC. For the
statistical analysis, F values were calculated using analysis of variance
(ANOVA) for repeated measures.
For self- and observer-ratings, the two pre-dose baseline values
were averaged, and all post-dose scores were expressed as the
increment or decrement relative to the mean pre-dose baseline.
Scores for the DSST, tapping speed, and reaction time tests were
similarly analyzed. For each EEG recording session, the relative beta
amplitude (beta divided by total, expressed as a percentage) in the
60
pre-dose recordings were used as baseline. All post-dose values were
expressed as the increment or decrement relative to the mean pre-
dose baseline value.
For rating scale items, the DSST, the tapping speed test, and the
EEG, area under the effect change versus time curve for 0–4 h after
dosage was calculated by the trapezoidal method. The effect areas,
following rank transformation, were evaluated by six-way ANOVA
for repeated measures. The significance of individual trial values
versus the double-placebo condition (Trial a) was evaluated by
Dunnett’s test. Pharmacodynamic effect areas for 0–8 h after dosage
were similarly calculated and analyzed. However, since the
pharmacodynamic effects distinguishing active drugs from placebo
were largely complete by 4 h after dosage, analysis of 8 h effect area
data did not provide additional information.
For the reaction-time test data, change scores at 0.5 and 1.5 h
after dosage were analyzed by ANOVA for repeated measures. For
the word-list memory test, the absolute number of words
remembered at 1.5 h after dosage (immediate recall) and at 24 h
after dosage (delayed recall) were evaluated by ANOVA for repeated
measures.
ACKNOWLEDGMENTS
This study was supported by grants AG-017880, AT-003540, DA-005258,
AI-058784, AT-001381, DA-013834, DK-058496, MH-058435, and
RR-000054 from the Department of Health and Human Services.
Dr Cysneiros was supported by grant 200473/01-8 from Conselho
Nacional de Desenvolvimento Cientı́fico e Tecnológico (CNPq), Brazil.
CONFLICT OF INTEREST
The authors declared no conflict of interest.
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