Nimotop: Targeted Cerebral Vasospasm Management Post-SAH
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Synonyms
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Nimotop (nimodipine) is a calcium channel blocker specifically formulated for the improvement of neurological outcomes by reducing the incidence and severity of ischemic deficits in patients with subarachnoid hemorrhage (SAH) from ruptured congenital intracranial aneurysms. Its cerebroselective mechanism targets cerebral arteries, offering a critical therapeutic intervention during a high-risk clinical window. Administered orally, it represents a cornerstone of post-hemorrhagic neurologic care, supported by extensive clinical evidence and neurocritical guidelines.
Features
- Active pharmaceutical ingredient: Nimodipine 30 mg
- Pharmaceutical form: Soft gelatin capsule for oral administration
- Mechanism: Calcium channel blocker with high cerebroselectivity
- Bioavailability: High first-pass metabolism; administration timing relative to food is critical
- Excipients: Glycerol, purified water, polyethylene glycol 400 in capsule shell
- Packaging: Blister packs of 100 capsules, requiring protection from light
Benefits
- Reduces the incidence of cerebral vasospasm, a leading cause of morbidity and mortality following aneurysmal SAH.
- Improves overall neurological outcome by mitigating delayed cerebral ischemia.
- Demonstrates a favorable benefit-risk profile within the established treatment window.
- Oral administration facilitates continued treatment in step-down units or outpatient settings.
- Supported by robust clinical trial data and inclusion in major international stroke management guidelines.
Common use
Nimotop is indicated specifically for the improvement of neurological outcome by reducing the incidence and severity of ischemic deficits in patients with subarachnoid hemorrhage from ruptured congenital intracranial aneurysms who are in good neurological condition post-ictus (e.g., Hunt and Hess Grades I-III). Its use is prophylactic and therapeutic, aimed at preventing the secondary brain injury caused by vasospasm, which typically occurs 4 to 14 days after the initial bleed. It is not indicated for hypertension or other cardiovascular conditions.
Dosage and direction
The standard dosage is 60 mg (two 30 mg capsules) every four hours for 21 consecutive days, commencing within 96 hours of the subarachnoid hemorrhage.
- Administration: Should be administered orally, or via nasogastric tube if the patient is unable to swallow. For nasogastric administration, aspirate the capsule contents into a syringe and wash through the tube with 30 mL of normal saline.
- Timing: Administer at least one hour before or two hours after meals. Food, particularly lipid-rich meals, significantly increases bioavailability and the risk of adverse effects.
- Duration: Complete the full 21-day course as prescribed, even if the patient’s condition improves.
- Dosage Adjustment: Required in patients with hepatic impairment. A reduction to 30 mg every 4 hours is typically recommended, with close monitoring of blood pressure.
Precautions
- Hypotension: Nimotop can cause systemic hypotension. Blood pressure must be monitored regularly, especially during the initiation of therapy and in volume-depleted patients.
- Hepatic Impairment: Patients with liver disease require dose reduction and careful monitoring due to decreased metabolism and increased plasma levels of nimodipine.
- Grapefruit Juice: Contraindicated. Grapefruit juice inhibits cytochrome P450 3A4, potentially increasing nimodipine plasma concentrations and the risk of adverse effects.
- CYP3A4 Inhibitors: Concomitant use with strong inhibitors (e.g., ketoconazole, macrolide antibiotics) should be avoided due to the risk of significant interaction.
- Monitoring: Neurological status and signs of cerebral perfusion deficits should be continuously assessed alongside hemodynamic parameters.
Contraindications
- Known hypersensitivity to nimodipine, any other calcium channel blocker, or any component of the formulation.
- Concomitant administration with strong inhibitors of CYP3A4 (e.g., ketoconazole, clarithromycin, ritonavir).
- Patients with cardiogenic shock or significant hypotension (systolic BP < 90 mm Hg).
- Coadministration with grapefruit juice.
Possible side effects
The most common side effects are directly related to its vasodilatory mechanism. Incidence is often dose-related.
- Very Common (>1/10): Decreased blood pressure.
- Common (1/10 to 1/100): Headache, nausea, gastrointestinal upset, bradycardia.
- Uncommon (1/100 to 1/1000): Rash, itching, diarrhea, peripheral edema.
- Rare (<1/1000): Tachycardia, palpitations, thrombocytopenia, increased liver enzymes.
- Isolated cases of non-specific neurological symptoms like light-headedness have been reported.
Drug interaction
Nimotop is primarily metabolized by the CYP3A4 system, making it highly susceptible to interactions.
- Strong CYP3A4 Inhibitors (e.g., ketoconazole, itraconazole, clarithromycin, ritonavir): Contraindicated. Markedly increase nimodipine plasma levels, potentiating hypotension and other adverse effects.
- CYP3A4 Inducers (e.g., rifampicin, carbamazepine, phenytoin, St. John’s Wort): May significantly decrease nimodipine plasma levels, potentially reducing its efficacy.
- Other Antihypertensives (e.g., beta-blockers, ACE inhibitors, other calcium antagonists): Additive hypotensive effect. Requires careful hemodynamic monitoring.
- Alpha-blockers (e.g., prazosin): Potentiates the blood-pressure-lowering effect.
- Dantrolene: Concomitant use may lead to hyperkalemia and cardiovascular collapse in susceptible patients (animal data).
Missed dose
If a dose is missed, it should be taken as soon as remembered. However, if it is almost time for the next scheduled dose, the missed dose should be skipped. The regular dosing schedule should be resumed. Do not double the dose to make up for a missed one. Maintaining the every-4-hour schedule is important for stable plasma levels.
Overdose
Symptoms of overdose are primarily extensions of its pharmacological activity and can be severe.
- Symptoms: Profound hypotension, bradycardia, palpitations, nausea, gastrointestinal distress, and neurological drowsiness or confusion.
- Management: There is no specific antidote. Treatment is supportive and symptomatic.
- Cardiovascular Support: Place patient in Trendelenburg position. Administer intravenous fluids for volume expansion. For refractory hypotension, vasopressors such as dopamine or norepinephrine may be required. Calcium gluconate administration (10%) IV can be considered to counteract calcium channel blockade.
- Bradycardia: May require atropine or cardiac pacing.
- Gastric Lavage: May be considered if ingestion was recent.
- Monitoring: Continuous cardiac and hemodynamic monitoring in an intensive care setting is essential.
Storage
- Store in the original blister package at controlled room temperature (20°-25°C or 68°-77°F).
- Excursions are permitted between 15°-30°C (59°-86°F).
- Protect from light and moisture.
- Keep out of reach of children and pets.
- Do not use after the expiration date printed on the packaging.
Disclaimer
This information is for educational and professional reference purposes only and does not constitute medical advice. It is not exhaustive. The prescribing physician is responsible for determining the appropriate treatment based on the individual patient’s clinical condition, contraindications, and a thorough review of the official prescribing information. Dosage and administration must be performed under the supervision of a qualified healthcare professional. Always refer to the full local approved product monograph for complete details on warnings, precautions, and adverse reactions before initiating therapy.
Reviews
- “A landmark 1989 NEJM study by Pickard et al. demonstrated a significant reduction in cerebral infarction and poor outcomes. Nimotop remains a guideline-backed standard of care in neurocritical units worldwide.”
- “From a clinical neurologist’s perspective: Its cerebroselectivity is its greatest asset. While systemic hypotension is a management consideration, the neurological benefit in compliant SAH patients is unequivocal.”
- “Meta-analyses of randomized controlled trials consistently show a relative risk reduction for poor outcome and secondary ischemia. It is one of the few neuroprotective agents with a robust evidence base.”
- “Logistically, the 4-hour dosing schedule is demanding for nursing staff and patients, but the 21-day proven benefit window makes adherence a critical priority for positive outcomes.”