Nimodipine (Monograph)

Brand name: Nimotop
Drug 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

Medically reviewed by Drugs.com on Jan 22, 2025. Written by ASHP.

Warning

Do not administer contents of nimodipine oral capsules by IV or other parenteral routes.¹ ²⁴⁵ ²⁴⁶ ²⁴⁸ ²⁴⁹ ²⁵⁰
Death and serious, life-threatening adverse effects reported following parenteral injection of the contents of nimodipine capsules.¹ ²⁴⁵ ²⁴⁶ ²⁴⁸ ²⁴⁹ ²⁵⁰ (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.¹ ⁴ ⁵ ¹³ ²² ⁹⁶ ^d

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).¹ ² ⁴ ⁵ ⁸ ²⁰ ²¹ ²² ²³ ⁶⁹ ⁹⁵ ¹⁰⁹ ²³⁰ ²³¹

Decreases severity and incidence of delayed ischemic neurologic deficits associated with subarachnoid hemorrhage.¹ ² ⁵ ²⁰ ²¹ ²² ²³ ⁴⁰ ⁸² ⁹⁵ ²³¹

Efficacy in reducing mortality from subarachnoid hemorrhage after oral administration not fully established.¹ ²⁰ ⁶⁹ ⁹⁵

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^{† [off-label]}.⁴ ¹⁰ ⁷⁶ ⁷⁷ ²²⁰ ²⁴⁰ ²⁴¹ ²⁴⁷

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^{† [off-label]}.⁴ ⁸ ¹¹ ¹² ⁷⁸ ⁷⁹ ⁸⁰ ⁹⁰ ¹⁰¹ ¹¹⁴ ²⁰⁶ ²³³ ²⁴⁴

Also has been used in a few patients with cluster headache^{† [off-label]}.⁹⁰ ¹⁰⁰ ¹¹⁴

Additional studies are needed to determine the role of nimodipine relative to that of other therapies used in the management of migraine headaches⁷⁸ ⁷⁹ ⁸⁰ ²⁰⁶ ²³⁰ ²³¹ and to determine whether tolerance to the prophylactic effects of the drug develops during chronic therapy.²⁰⁶

Nimodipine Dosage and Administration

Administration

Oral Administration

Nimodipine capsules are for oral administration only.¹ ²⁴⁵ ²⁴⁶ ²⁴⁸ ²⁴⁹ ²⁵⁰ (See Boxed Warning.)

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

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,¹ ²⁴⁹ ²⁵⁰ preferably using a syringe designed for nasogastric or percutaneous endoscopic gastrostomy administration (e.g., Toomey syringe).²⁴⁶ ²⁵⁰ To help minimize administration errors, label the syringe for oral use only; not for IV use.¹ ²⁴⁵ ²⁴⁸ ²⁴⁹ ²⁵⁰ The contents of the capsule should then be emptied into the patient’s nasogastric tube.¹ ²⁴⁹ ²⁵⁰ Following administration, flush with 30 mL of 0.9% sodium chloride solution.¹ ²⁴⁵ ²⁴⁶ ²⁴⁹

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.²⁴⁶ ²⁴⁸ ²⁴⁹ ²⁵⁰ (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.¹ ²⁴⁶

The contents of the capsule should not be admixed with any solution prior to oral administration because of the possibility of drug decomposition.²³⁰

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.¹ ²⁴⁸ ²⁴⁹ ²⁵⁰ Report adverse events or medication errors involving nimodipine capsules to the FDA MedWatch program.²⁴⁸ ²⁵⁰

Has been administered by IV infusion^{† [off-label]} (IV dosage form currently is not commercially available in the US)^d in patients with subarachnoid hemorrhage, often in conjunction with intracisternal^{† [off-label]} application during surgery⁶⁷ ¹¹⁷ ¹¹⁹ ¹²⁰ ²¹⁴ and usually followed by oral therapy.⁵ ⁶⁷ ⁹³ ¹¹⁶ ¹¹⁷ ¹¹⁸ ¹¹⁹ ¹²⁰ ²¹⁴

Dosage

Adults

Subarachnoid Hemorrhage

Oral

60 mg every 4 hours for 21 consecutive days.¹ ⁵ Initiate therapy as soon as possible after the occurrence of subarachnoid hemorrhage, preferably within 96 hours.¹ ⁴ ⁵ ²⁰ ²³⁰ ²³¹

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.²³¹

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.⁴ ²³¹

It has been suggested that patients with unstable BP receive a lower dosage (e.g., 30 mg every 4 hours);⁴ ²³¹ however, the manufacturer states that the usual adult dosage should be used in such patients.²³⁰ (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.⁷⁶ ⁷⁷ ²⁴² ²⁴⁷

Migraine†

Prophylaxis of Classic or Common Migraine†

Oral

120 mg daily given in divided doses has been used.⁴ ⁸ ¹¹ ¹² ⁷⁸ ⁷⁹ ⁸⁰ ¹⁰¹ ¹¹⁴ ²⁰⁶

Special Populations

Hepatic Impairment

Subarachnoid Hemorrhage

Oral

Initially, 30 mg every 4 hours.¹ ⁵ ⁸⁹

Monitor BP and heart rate closely.¹ ⁵ ⁸⁹ May use pharmacologic support of BP (e.g., vasopressors such as norepinephrine or dopamine), if necessary.²³⁰ ²³¹

Renal Impairment

No specific dosage recommendations.¹

Geriatric Patients

Select dosage with caution because of age-related decreases in hepatic, renal, and/or cardiac function and concomitant disease and drug therapy.¹

Cautions for Nimodipine

Contraindications

No known contraindications in patients with subarachnoid hemorrhage.¹

Warnings/Precautions

Warnings

Parenteral Administration

Do not administer contents of nimodipine oral capsules by IV or other parenteral routes.¹ ²⁴⁵ ²⁴⁶ ²⁴⁸ ²⁴⁹ ²⁵⁰ Death and serious life-threatening adverse effects (e.g., cardiac arrest, cardiovascular collapse, hypotension, bradycardia) reported following parenteral injection of nimodipine capsule contents.¹ ²⁴⁵ ²⁴⁶ ²⁴⁸ ²⁴⁹ ²⁵⁰ (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.²⁴⁸ ²⁴⁹ ²⁵⁰

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.²⁴⁹ ²⁵⁰

Report adverse events or medication errors involving nimodipine capsules to the FDA MedWatch program.²⁴⁸ ²⁵⁰

General Precautions

Hypotension and Other Cardiovascular Effects

IV administration of the contents of nimodipine capsules^† has resulted in serious cardiovascular effects.¹ ²⁴⁸ ²⁴⁹ ²⁵⁰ (See Parenteral Administration under Cautions and see Boxed Warning.)

Possible decreased systemic BP;¹ decreases generally are not marked with usual oral dosages.¹ ² ⁶ ⁷ ²⁰ ²¹ ²² ²³ ⁵⁴ ⁶⁹ ¹³²

Monitor BP closely during therapy.¹ In patients with unstable BP, frequently monitor BP and heart rate; a lower dosage has been suggested.²³¹ (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).¹ ⁷ ¹²⁸ ²³⁰ ²³¹

GI Effects

Intestinal pseudo-obstruction and ileus responsive to conservative management has been reported rarely.¹ ¹²⁷

Specific Populations

Pregnancy

Category C.¹

Lactation

Distributed into milk in rats;¹ ⁹¹ not known whether distributed into human milk.¹ Discontinue nursing because of potential risk to nursing infants.¹

Pediatric Use

Safety and efficacy not established in children <18 years of age.¹ ²³⁰

Geriatric Use

Insufficient experience in patients ≥65 years of age to determine whether geriatric patients respond differently than younger adults; select dosage with caution.¹

Hepatic Impairment

Possible decreased metabolism, substantially reduced clearance, and increased peak plasma concentrations.¹ ⁸⁹ (See Absorption: Special Populations and see also Elimination: Special Populations, under Pharmacokinetics.)

Possible hypotension.¹ ⁴ ⁹⁰ ²³⁰ ²³¹ Use with caution; monitor BP and pulse rate closely; dosage adjustment recommended.¹ (See Hepatic Impairment under Dosage and Administration.)

Renal Impairment

Clearance may be decreased.⁸⁸ (See Elimination: Special Populations, under Pharmacokinetics.)

Common Adverse Effects

Decreased BP, headache.¹ ⁴ ⁵ ²³ ¹¹² ¹²² ¹⁵⁴ ²³⁰ ²³¹

Drug Interactions

Specific Drugs

Drug	Interaction	Comments
Anesthetic agents	Does not appear to potentiate hemodynamic effects of anesthetic agents during surgery⁵⁴ ²³⁰ ²³¹
Antineoplastic agents	Risk of enhanced cytotoxic effects of certain antineoplastic agents¹⁴⁰ ¹⁴¹ ¹⁹⁰ ¹⁹¹ ¹⁹² ¹⁹³ ¹⁹⁵ ²¹⁵ ²¹⁶ ²¹⁷ ²¹⁸ ²¹⁹	Clinical importance not known²³⁰ ²³¹
Antihypertensive agents	Possible additive antihypertensive effects¹ ⁹³	Monitor BP carefully if used concomitantly; when possible use short-acting antihypertensive agents²³¹ Reduced dosage or cautious discontinuance of the antihypertensive agent and/or initiation of pharmacologic support of BP may be required²³⁰ ²³¹
Calcium-channel blockers (e.g., diltiazem)	Possible potentiation of cardiovascular effects of nimodipine (e.g., negative inotropic effect)¹⁵⁵	Clinical importance not known;¹ ²³⁰ ²³¹ avoid combined therapy if possible²³¹
Cimetidine	Decreased clearance and increased plasma nimodipine concentrations¹ ²⁴³	Clinical importance not known²⁴³
Digoxin	Low doses (i.e., 30 mg twice daily) of nimodipine do not alter the pharmacokinetics or hemodynamic effects of digoxin¹³⁷
Fentanyl	Possible potentiation of analgesia in patients undergoing heart surgery¹⁵⁴
Phenytoin	Possible decreased phenytoin metabolism¹ ¹⁷⁹	Monitor plasma phenytoin concentrations when nimodipine is initiated or discontinued¹⁷⁹ No drug interactions reported in patients with subarachnoid hemorrhage receiving concomitant therapy ²³⁰

Nimodipine Pharmacokinetics

Absorption

Bioavailability

Rapidly¹ ⁴⁶ ⁸⁵ ⁸⁹ ²¹³ and almost completely⁴ ⁵ ²¹³ absorbed following oral administration, with peak concentrations attained within 1 hour.¹ ⁴⁶ ⁸⁹ ²¹³

Bioavailability is about 13% and variable due to extensive first-pass metabolism in the liver.¹ ⁴⁶ ⁸⁵ ²¹³ ²³⁰

Food

Food substantially decreases the extent of absorption; peak plasma concentrations reduced by 68% and bioavailability by 38%.¹

Special Populations

In patients with hepatic cirrhosis, systemic availability, peak serum drug concentrations, and AUCs may be increased substantially.¹ ⁸⁹ ²³⁰

Distribution

Extent

Widely distributed into body tissues after oral or IV administration in animals.⁸⁷

Distributes to a limited extent into CSF.⁴ ²² ⁸⁶ ²³¹

May distribute more extensively into CSF in patients with subarachnoid hemorrhage.¹ ²³⁰

In animals, nimodipine crosses the placenta⁴ ⁸⁷ and is distributed into milk.¹ ⁹¹

Plasma Protein Binding

>95%.¹ ⁴ ²¹³

Elimination

Metabolism

Extensively metabolized in the liver¹ ⁵ ⁴ ⁸⁸ ⁸⁹ ²¹³ to either inactive or substantially less active metabolites¹ ¹²⁴ ¹²⁵ ²¹³ principally via demethylation followed by dehydrogenation.⁴ ⁸⁵ ⁸⁶

Elimination Route

Following oral administration, approximately 50% excreted in urine as metabolites and to a lesser extent in feces (possibly secondary to biliary excretion).⁴

In animals, nimodipine and/or its metabolites appear to undergo extensive enterohepatic circulation;¹²³ possible enterohepatic circulation in humans.⁸⁹

Half-life

Following oral administration: 1.7–9 hours.¹ ⁴ ⁵ ⁴⁶ ⁸⁵ ⁸⁶ ⁸⁸ ⁸⁹ ²¹³

Following IV (IV dosage form currently is not commercially available in the US)^d administration: 0.9–1.5 hours.⁴ ⁴⁶ ⁸⁵ ⁸⁶ ²¹³

Special Populations

Substantially decreased clearance in patients with hepatic dysfunction.⁴ ⁸⁹ ²³¹ Mean clearance rates in patients with hepatic cirrhosis were decreased by >50% in one study.⁸⁹

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.⁸⁸

Hemodialysis or peritoneal dialysis not likely to affect elimination.¹ ²³⁰ ²³¹

Stability

Storage

Oral

Capsules

25°C (may be exposed to 15–30°C) in the original container.¹ Do not freeze; protect from light.¹ ¹²⁹

Actions

Inhibits transmembrane influx of extracellular calcium ions across the membranes of myocardial, vascular smooth muscle, and neuronal cells.¹ ⁴ ⁷ ¹⁰ ¹⁴ ⁴¹ ⁴⁸ ⁴⁹ ⁵³ ¹²⁶ ¹²⁸ ¹³² ¹³³ ²³⁶
Appears to affect the CNS preferentially.¹ ⁴ ⁷ ⁸ ¹³ ¹⁷ ³⁵ ⁴² ⁴⁵ ⁵⁵ ⁸² ¹⁵⁵ ¹⁸⁵ ²⁰⁶ ²²⁹ ²³⁰
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.⁴⁷ ⁴⁸ ²¹⁰
Mechanism(s) of clinical benefit in patients with subarachnoid hemorrhage has not been fully elucidated;¹ ⁴ ²⁰ ⁶⁹ ¹⁰² current evidence suggests that dilation of small cerebral resistance vessels,² ²³ ³⁶ ¹⁰² ¹³¹ with a resultant increase in collateral circulation,⁴ ⁵ ²³ ⁵² ⁶⁷ ⁸³ ⁹⁸ ¹³¹ and/or a direct effect involving prevention of calcium overload in neurons² ⁴ ⁵ ¹³ ²³ ⁶⁸ ⁶⁹ ⁸² ⁸³ ⁹⁶ ¹⁰² ¹⁰⁴ ¹³² ²⁰⁶ may be responsible.

Importance of informing clinicians of existing or contemplated concomitant therapy, including prescription and OTC drugs, as well as any concomitant illnesses.¹
Importance of women informing clinicians if they are or plan to become pregnant or plan to breast-feed.¹
Importance of advising patients of other important precautionary information.¹ (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

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

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