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Nimodipine

Class: Dihydropyridines
- Calcium-Channel Blocking Agents, Dihydropyridine
- Calcium Antagonists
VA Class: CV200
Chemical Name: 1,4-Dihydro-2,6-dimethyl-4-(3-nitrophenyl)-3,5-pyridinedicarboxylic acid 2-methoxyethyl 1-methylethyl ester
Molecular Formula: C21H26N2O7
CAS Number: 66085-59-4
Brands: Nimotop

Medically reviewed by Drugs.com. Last updated on Jan 22, 2021.

Warning

  • Do not administer contents of nimodipine oral capsules by IV or other parenteral routes.

  • Death and serious, life-threatening adverse effects reported following parenteral injection of the contents of nimodipine capsules. (See Parenteral Administration under Cautions and see Hypotension and Other Cardiovascular Effects under Cautions and see Oral Administration under Dosage and Administration.)

Introduction

A dihydropyridine-derivative calcium-channel blocking agent that affects the CNS preferentially.

Uses for Nimodipine

Subarachnoid Hemorrhage

Used to improve neurologic outcome by reducing the incidence and severity of ischemic deficits in patients with subarachnoid hemorrhage resulting from ruptured intracranial berry aneurysms regardless of the patient’s postictal neurologic condition (e.g., Hunt and Hess grades I–V).

Decreases severity and incidence of delayed ischemic neurologic deficits associated with subarachnoid hemorrhage.

Efficacy in reducing mortality from subarachnoid hemorrhage after oral administration not fully established.

Acute Ischemic Stroke

Limited evidence suggests that nimodipine may improve neurologic recovery and reduce mortality compared with plasma volume expansion therapy or placebo in some patients with acute ischemic stroke.

Migraine

Has been used with equivocal results for reduction of frequency and possibly severity and duration of vascular headaches (e.g., migraine attacks) in patients with classic or common migraine.

Also has been used in a few patients with cluster headache.

Additional studies are needed to determine the role of nimodipine relative to that of other therapies used in the management of migraine headaches and to determine whether tolerance to the prophylactic effects of the drug develops during chronic therapy.

Nimodipine Dosage and Administration

Administration

Oral Administration

Nimodipine capsules are for oral administration only. (See Boxed Warning.)

Administer orally every 4 hours, preferably at least 1 hour before or 2 hours after meals.

Nasogastric Tube

If the oral capsule cannot be swallowed (e.g., when administered at the time of surgery or to an unconscious patient), puncture the capsule at both ends with an 18-gauge needle and empty the contents into a syringe, preferably using a syringe designed for nasogastric or percutaneous endoscopic gastrostomy administration (e.g., Toomey syringe). To help minimize administration errors, label the syringe for oral use only; not for IV use. The contents of the capsule should then be emptied into the patient’s nasogastric tube. Following administration, flush with 30 mL of 0.9% sodium chloride solution.

Reinforce awareness among health-care professionals of potential medical errors that may result in inadvertent injection of syringe contents into an IV line or via other parenteral routes. (See Parenteral Administration under Cautions, see Hypotension and Other Cardiovascular Effects under Cautions, and see Boxed Warning.)

If inadvertent IV administration of contents of nimodipine capsules occurs, administer vasopressor agents for cardiovascular support if required for clinically important hypotension and promptly administer specific treatment for overdosage associated with calcium-channel blocking agents.

The contents of the capsule should not be admixed with any solution prior to oral administration because of the possibility of drug decomposition.

IV Administration

The contents of nimodipine capsules must not be administered by IV injection or any other parenteral route; serious adverse effects such as hypotension, cardiovascular collapse, and cardiac arrest have occurred with such administration. Report adverse events or medication errors involving nimodipine capsules to the FDA MedWatch program.

Has been administered by IV infusion (IV dosage form currently is not commercially available in the US) in patients with subarachnoid hemorrhage, often in conjunction with intracisternal application during surgery and usually followed by oral therapy.

Dosage

Adults

Subarachnoid Hemorrhage
Oral

60 mg every 4 hours for 21 consecutive days. Initiate therapy as soon as possible after the occurrence of subarachnoid hemorrhage, preferably within 96 hours.

It has been suggested that the drug may be discontinued after 14 consecutive days (but not earlier) in some uncomplicated cases in which early aneurysm surgery is performed.

In patients in whom surgical repair of the aneurysm is performed relatively late (e.g., day 20), some clinicians suggest continuation of therapy for ≥5 days after surgery to minimize the possibility of postoperative vasospasm.

It has been suggested that patients with unstable BP receive a lower dosage (e.g., 30 mg every 4 hours); however, the manufacturer states that the usual adult dosage should be used in such patients. (See Hypotension and Other Cardiovascular Effects under Cautions.)

Acute Ischemic Stroke†
Oral

120 mg daily given in divided doses for 21 or 28 days has been used.

Migraine†
Prophylaxis of Classic or Common Migraine†
Oral

120 mg daily given in divided doses has been used.

Special Populations

Hepatic Impairment

Subarachnoid Hemorrhage
Oral

Initially, 30 mg every 4 hours.

Monitor BP and heart rate closely. May use pharmacologic support of BP (e.g., vasopressors such as norepinephrine or dopamine), if necessary.

Renal Impairment

No specific dosage recommendations.

Geriatric Patients

Select dosage with caution because of age-related decreases in hepatic, renal, and/or cardiac function and concomitant disease and drug therapy.

Cautions for Nimodipine

Contraindications

  • No known contraindications in patients with subarachnoid hemorrhage.

Warnings/Precautions

Warnings

Parenteral Administration

Do not administer contents of nimodipine oral capsules by IV or other parenteral routes. Death and serious life-threatening adverse effects (e.g., cardiac arrest, cardiovascular collapse, hypotension, bradycardia) reported following parenteral injection of nimodipine capsule contents. (See Hypotension and Other Cardiovascular Effects under Cautions and see Boxed Warning.)

IV use of nimodipine, with serious and sometimes fatal outcomes, continues to be reported despite revisions to the drug’s labeling (including addition of a boxed warning) that warn against such use.

Factors identified by FDA as contributing to this error include use of IV syringes to administer the drug by NG tube (IV syringes sometimes are used to remove the liquid contents from the capsules) and the fact that most patients receiving the drug are in critical care settings and are receiving other IV therapy.

Report adverse events or medication errors involving nimodipine capsules to the FDA MedWatch program.

General Precautions

Hypotension and Other Cardiovascular Effects

IV administration of the contents of nimodipine capsules has resulted in serious cardiovascular effects. (See Parenteral Administration under Cautions and see Boxed Warning.)

Possible decreased systemic BP; decreases generally are not marked with usual oral dosages.

Monitor BP closely during therapy. In patients with unstable BP, frequently monitor BP and heart rate; a lower dosage has been suggested. (See Subarachnoid Hemorrhage under Dosage and Administration.)

Shares the toxic potentials of other calcium-channel blocking agents; consider possible occurrence of other adverse effects associated with these drugs (e.g., AV-conduction disturbances).

GI Effects

Intestinal pseudo-obstruction and ileus responsive to conservative management has been reported rarely.

Specific Populations

Pregnancy

Category C.

Lactation

Distributed into milk in rats; not known whether distributed into human milk. Discontinue nursing because of potential risk to nursing infants.

Pediatric Use

Safety and efficacy not established in children <18 years of age.

Geriatric Use

Insufficient experience in patients ≥65 years of age to determine whether geriatric patients respond differently than younger adults; select dosage with caution.

Hepatic Impairment

Possible decreased metabolism, substantially reduced clearance, and increased peak plasma concentrations. (See Absorption: Special Populations and see also Elimination: Special Populations, under Pharmacokinetics.)

Possible hypotension. Use with caution; monitor BP and pulse rate closely; dosage adjustment recommended. (See Hepatic Impairment under Dosage and Administration.)

Renal Impairment

Clearance may be decreased. (See Elimination: Special Populations, under Pharmacokinetics.)

Common Adverse Effects

Decreased BP, headache.

Interactions for Nimodipine

Specific Drugs

Drug

Interaction

Comments

Anesthetic agents

Does not appear to potentiate hemodynamic effects of anesthetic agents during surgery

Antineoplastic agents

Risk of enhanced cytotoxic effects of certain antineoplastic agents

Clinical importance not known

Antihypertensive agents

Possible additive antihypertensive effects

Monitor BP carefully if used concomitantly; when possible use short-acting antihypertensive agents

Reduced dosage or cautious discontinuance of the antihypertensive agent and/or initiation of pharmacologic support of BP may be required

Calcium-channel blockers (e.g., diltiazem)

Possible potentiation of cardiovascular effects of nimodipine (e.g., negative inotropic effect)

Clinical importance not known; avoid combined therapy if possible

Cimetidine

Decreased clearance and increased plasma nimodipine concentrations

Clinical importance not known

Digoxin

Low doses (i.e., 30 mg twice daily) of nimodipine do not alter the pharmacokinetics or hemodynamic effects of digoxin

Fentanyl

Possible potentiation of analgesia in patients undergoing heart surgery

Phenytoin

Possible decreased phenytoin metabolism

Monitor plasma phenytoin concentrations when nimodipine is initiated or discontinued

No drug interactions reported in patients with subarachnoid hemorrhage receiving concomitant therapy

Nimodipine Pharmacokinetics

Absorption

Bioavailability

Rapidly and almost completely absorbed following oral administration, with peak concentrations attained within 1 hour.

Bioavailability is about 13% and variable due to extensive first-pass metabolism in the liver.

Food

Food substantially decreases the extent of absorption; peak plasma concentrations reduced by 68% and bioavailability by 38%.

Special Populations

In patients with hepatic cirrhosis, systemic availability, peak serum drug concentrations, and AUCs may be increased substantially.

Distribution

Extent

Widely distributed into body tissues after oral or IV administration in animals.

Distributes to a limited extent into CSF.

May distribute more extensively into CSF in patients with subarachnoid hemorrhage.

In animals, nimodipine crosses the placenta and is distributed into milk.

Plasma Protein Binding

>95%.

Elimination

Metabolism

Extensively metabolized in the liver to either inactive or substantially less active metabolites principally via demethylation followed by dehydrogenation.

Elimination Route

Following oral administration, approximately 50% excreted in urine as metabolites and to a lesser extent in feces (possibly secondary to biliary excretion).

In animals, nimodipine and/or its metabolites appear to undergo extensive enterohepatic circulation; possible enterohepatic circulation in humans.

Half-life

Following oral administration: 1.7–9 hours.

Following IV (IV dosage form currently is not commercially available in the US) administration: 0.9–1.5 hours.

Special Populations

Substantially decreased clearance in patients with hepatic dysfunction. Mean clearance rates in patients with hepatic cirrhosis were decreased by >50% in one study.

Increased half-life and reduced plasma clearance reported in patients with renal impairment; findings may have been related in part to age-related reductions in liver function.

Hemodialysis or peritoneal dialysis not likely to affect elimination.

Stability

Storage

Oral

Capsules

25°C (may be exposed to 15–30°C) in the original container. Do not freeze; protect from light.

Actions

  • Inhibits transmembrane influx of extracellular calcium ions across the membranes of myocardial, vascular smooth muscle, and neuronal cells.

  • Appears to affect the CNS preferentially.

  • Mechanism of selectivity for cerebral tissue is complex and has not been fully elucidated; tissue selectivity of 1,4-dihydropyridine calcium-channel blockers may be related to differences in chemical structure, binding site characteristics, and/or calcium-channel gating behavior.

  • Mechanism(s) of clinical benefit in patients with subarachnoid hemorrhage has not been fully elucidated; current evidence suggests that dilation of small cerebral resistance vessels, with a resultant increase in collateral circulation, and/or a direct effect involving prevention of calcium overload in neurons may be responsible.

Advice to Patients

  • Importance of informing clinicians of existing or contemplated concomitant therapy, including prescription and OTC drugs, as well as any concomitant illnesses.

  • Importance of women informing clinicians if they are or plan to become pregnant or plan to breast-feed.

  • Importance of advising patients of other important precautionary information. (See Cautions.)

Preparations

Excipients in commercially available drug preparations may have clinically important effects in some individuals; consult specific product labeling for details.

Please refer to the ASHP Drug Shortages Resource Center for information on shortages of one or more of these preparations.

niMODipine

Routes

Dosage Forms

Strengths

Brand Names

Manufacturer

Oral

Capsules, liquid-filled

30 mg

Nimotop

Bayer

AHFS DI Essentials™. © Copyright 2021, Selected Revisions February 1, 2011. American Society of Health-System Pharmacists, Inc., 4500 East-West Highway, Suite 900, Bethesda, Maryland 20814.

† Use is not currently included in the labeling approved by the US Food and Drug Administration.

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