Can nimodipine be given to a patient with subarachnoid hemorrhage and what is the recommended dose?

Nimodipine in Subarachnoid Hemorrhage: Dosing and Administration

Nimodipine should be administered at a dose of 60 mg orally every 4 hours for 21 consecutive days, starting within 96 hours of subarachnoid hemorrhage onset. 1, 2, 3

Indication and Evidence

Nimodipine is the only FDA-approved medication for neuroprotection in subarachnoid hemorrhage (SAH) patients. It works primarily through neuroprotective effects rather than vasodilation, reducing the risk of delayed cerebral ischemia (DCI) and improving functional outcomes after SAH.

• Strong recommendation (Class I, Level A evidence) from the American Heart Association/American Stroke Association 1, 2
• Reduces severity of neurological deficits resulting from vasospasm 3
• Significantly improves long-term clinical outcomes 2, 3

Administration Protocol

• Dose: 60 mg (two 30 mg capsules) every 4 hours
• Duration: 21 consecutive days
• Timing: Start as soon as possible within 96 hours of SAH onset
• Administration: Capsules should be swallowed whole with liquid, preferably not less than one hour before or two hours after meals 3

Alternative Administration Methods

For patients who cannot swallow capsules:

1. Make a hole in both ends of the capsule using an 18-gauge needle
2. Extract contents into an oral syringe (label as "Not for IV Use")
3. Administer via nasogastric tube or PEG
4. Flush with 30 mL normal saline 3

Important Warnings

• NEVER administer nimodipine intravenously - severe hypotension may occur 2, 3
• Avoid grapefruit juice during treatment (affects metabolism) 2, 3
• Consistent administration is crucial - disruption is associated with increased DCI incidence 1

Dose Adjustments

• Liver dysfunction/cirrhosis: Reduce to 30 mg every 4 hours and monitor closely for hypotension 2, 3
• Elderly patients: May require dose reduction due to approximately 2× higher plasma concentrations 3
• Hypotension: Consider dose reduction if significant hypotension occurs, but maintain therapy if possible 1, 2

Management of Side Effects

• Hypotension is common (up to 78% of patients)
• If mild hypotension occurs, continue nimodipine if possible
• If severe hypotension occurs, temporarily reduce or stop nimodipine 1, 2

Additional Management Considerations

• Maintain euvolemia rather than hypervolemia or hypovolemia 1, 2
• Prophylactic hemodynamic augmentation should not be performed 1
• Nimodipine should be part of a comprehensive management strategy including early securing of the aneurysm 2

Common Pitfalls to Avoid

1. Using other calcium channel blockers instead of nimodipine
2. Administering nimodipine intravenously
3. Discontinuing nimodipine due to mild hypotension
4. Failing to start nimodipine within the 96-hour window
5. Inducing hypervolemia (potentially harmful) 1, 2

Nimodipine remains a cornerstone in SAH management, with consistent evidence showing improved neurological outcomes when properly administered.