Nimotop (nimodipine) is a calcium channel blocker specifically formulated for the improvement of neurological outcome by reducing the incidence and severity of ischemic deficits in patients with subarachnoid hemorrhage (SAH) from ruptured congenital intracranial aneurysms, who are in good neurological condition post-ictus. Its primary mechanism of action is the selective relaxation of vascular smooth muscle in cerebral arteries, mitigating the risk of delayed cerebral ischemia—a serious and common complication following SAH. This product card provides a comprehensive, evidence-based overview for healthcare professionals to support informed clinical decision-making.

Features

• Active Ingredient: Nimodipine
• Pharmacological Class: Dihydropyridine Calcium Channel Blocker
• Formulation: Available in 30 mg soft gelatin capsules for oral administration and intravenous solution (market-dependent)
• Selectivity: Exhibits preferential cerebrovascular activity over peripheral vasculature
• Bioavailability: Approximately 13% following oral administration due to significant first-pass metabolism
• Half-life: Terminal elimination half-life ranges from 8 to 9 hours in healthy adults
• Protein Binding: Heavily bound to plasma proteins (>95%)
• Metabolism: Primarily hepatic, via cytochrome P450 3A4 (CYP3A4) system
• Excretion: Approximately 50% excreted in urine as metabolites, 32% in feces

Benefits

• Reduces Cerebral Vasospasm: Selectively dilates cerebral arteries, counteracting vasoconstriction that often follows subarachnoid hemorrhage.
• Improves Neurological Outcomes: Clinically proven to lower the incidence of severe neurological deficits and cerebral infarction secondary to vasospasm.
• Enhances Cerebral Blood Flow: Promotes improved perfusion in vulnerable brain regions, supporting neuronal recovery.
• Oral Administration Convenience: The capsule formulation allows for continued treatment in both inpatient and outpatient settings following the acute phase.
• Well-Established Efficacy: Supported by decades of clinical use and foundational trials demonstrating significant benefit in eligible patient populations.

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). Treatment should be initiated within 96 hours of the onset of SAH and continued for a total of 21 days. Its use is standard of care in neurosurgical and neurocritical care units worldwide for this indication. It is not indicated for hypertension or other general cardiovascular conditions.

Dosage and direction

The standard dosage for adult patients is 60 mg (two 30 mg capsules) every 4 hours for 21 consecutive days.

For patients with hepatic impairment or those experiencing significant hypotension, a reduced dosage of 30 mg every 4 hours is recommended, with close monitoring of blood pressure.

Oral administration is required. The capsules should be swallowed whole with a glass of water. If the patient is unable to swallow the capsule, a hole may be pierced at both ends with an 18-gauge needle and the contents extracted into a syringe. The contents can then be administered via nasogastric tube, followed by a flush with 30 mL of normal saline.

Treatment must be initiated within 96 hours of the subarachnoid hemorrhage and continued for a full 21-day course, even if the patient is discharged earlier.

Precautions

• Blood Pressure Monitoring: Nimotop can cause hypotension. Blood pressure should be monitored regularly, especially during initiation and after any dosage change.
• Hepatic Impairment: Patients with liver cirrhosis or severe hepatic impairment require a dose reduction (30 mg every 4 hours) and careful monitoring due to decreased metabolism and increased bioavailability.
• Grapefruit Juice Interaction: Patients must avoid grapefruit juice as it inhibits CYP3A4 metabolism, potentially leading to significantly increased serum levels of nimodipine and an elevated risk of adverse effects.
• Pregnancy and Lactation: Use during pregnancy only if the potential benefit justifies the potential risk to the fetus (Category C). It is not known whether nimodipine is excreted in human milk; a decision should be made to discontinue nursing or discontinue the drug.
• Cardiovascular Disease: Use with caution in patients with heart failure or severe aortic stenosis.
• Administration via Nasogastric Tube: If the contents are extracted from the capsule for tube administration, care must be taken to avoid topical exposure, as the solution is highly irritating to mucous membranes and eyes.

Contraindications

• Known hypersensitivity to nimodipine, any other calcium channel blocker, or any component of the formulation.
• Concomitant use with strong CYP3A4 inhibitors in the portal circulation (e.g., ketoconazole, itraconazole, clarithromycin) is contraindicated due to the high risk of profound hypotension and other adverse effects.
• Patients with cardiogenic shock or significant hypotension (systolic BP < 90 mm Hg) where further lowering of blood pressure would be clinically detrimental.

Possible side effect

The most common side effects are related to its vasodilatory effects and are generally dose-dependent.

• Common (≥1/100): Hypotension, headache, nausea, bradycardia.
• Less Common (≥1/1,000 to <1/100): Gastrointestinal upset (diarrhea, constipation), peripheral edema, flushing, rash, tachycardia (reflex).
• Rare (<1/1,000): Dyspnea, muscle pain/cramps, depression, thrombocytopenia, elevated liver enzymes (ALT, AST).
• Very Rare: Allergic reactions, including skin reactions like erythema multiforme.

Drug interaction

Nimotop is a substrate of CYP3A4 and is highly susceptible to interactions with drugs that inhibit or induce this enzyme.

• Strong CYP3A4 Inhibitors (e.g., ketoconazole, itraconazole, ritonavir, clarithromycin): CONTRAINDICATED. Concomitant use can increase nimodipine plasma concentrations by over 10-fold, leading to severe hypotension and cardiovascular collapse.
• Moderate CYP3A4 Inhibitors (e.g., diltiazem, verapamil, erythromycin, fluconazole): Use with extreme caution and consider dose reduction of Nimotop. Monitor blood pressure closely.
• CYP3A4 Inducers (e.g., rifampin, carbamazepine, phenytoin, St. John’s Wort): May significantly decrease nimodipine plasma levels, potentially reducing its efficacy. Dose adjustment may be necessary.
• Other Antihypertensives (e.g., beta-blockers, ACE inhibitors, other calcium channel blockers): Additive hypotensive effects. Enhanced monitoring is required.
• Grapefruit Juice: Inhibits intestinal CYP3A4 and must be avoided during therapy.

Missed dose

If a dose is missed, it should be taken as soon as it is remembered. However, if it is almost time for the next scheduled dose, the missed dose should be skipped. The patient should never take a double dose to make up for a missed one. Maintaining the strict 4-hour dosing schedule is critical for efficacy; therefore, strategies should be in place (e.g., nursing schedules, patient alarms) to maximize adherence during the 21-day course.

Overdose

Overdose would be expected to manifest as profound hypotension, bradycardia, and possibly cardiac conduction abnormalities.

• Symptoms: Severe dizziness, syncope, palpitations, marked bradycardia, shock.
• Management: There is no specific antidote. Treatment is supportive and symptomatic.
  • Cardiovascular monitoring is essential.
  • For hypotension: Place patient in Trendelenburg position and administer intravenous fluids. Vasopressors (e.g., dopamine or norepinephrine) may be required, but calcium administration (e.g., calcium gluconate) may be helpful given the drug’s mechanism.
  • For bradycardia: Atropine may be administered.
  • Gastric lavage may be considered if ingestion was recent.
  • Since nimodipine is highly protein-bound, dialysis is not likely to be effective.

Storage

Store at room temperature between 20°C to 25°C (68°F to 77°F). Excursions are permitted between 15°C and 30°C (59°F and 86°F). Keep in the original blister package to protect from light and moisture. Do not freeze. Keep out of reach of children and pets. Do not use after the expiration date printed on the packaging.

Disclaimer

This information is intended for educational and informational purposes for healthcare professionals only. It is not a substitute for professional medical advice, diagnosis, or treatment. Always seek the advice of a qualified physician or other authorized health provider with any questions you may have regarding a medical condition or before starting any new treatment. Never disregard professional medical advice or delay in seeking it because of something you have read here. The prescribing physician should be consulted for specific dosing, indications, and patient management. The full official prescribing information should be reviewed prior to administration.

Reviews

“Nimotop remains a cornerstone of prophylactic therapy in our neuro-ICU for aneurysmal SAH. The evidence for its benefit in reducing delayed cerebral ischemia is robust. The main challenge is managing the hypotension, but with careful titration and monitoring, it is manageable.” — Neurocritical Care Specialist, 15 years of experience.

“The 21-day course is long but necessary. We’ve seen a measurable improvement in functional outcomes at discharge and at 3-month follow-ups in patients who complete the full regimen. The oral formulation makes post-discharge continuation straightforward.” — Vascular Neurosurgeon.

“While it’s a niche drug, its impact within that niche is significant. The pharmacokinetics require us to be vigilant about drug interactions, particularly in polypharmacy patients. A clear medication reconciliation process is essential.” — Clinical Pharmacist, Tertiary Care Center.

“The ability to administer via NG tube is a critical feature for our intubated and critically ill SAH patients in the immediate post-operative period. It ensures we don’t miss the crucial early treatment window.” — ICU Charge Nurse.