Mechanism Of Action
Nimodipine is a dihydropyridine calcium channel blocker. The contractile processes of smooth muscle cells are dependent upon calcium ions, which enter these cells during depolarization as slow ionic transmembrane currents. Nimodipine inhibits calcium ion transfer into these cells and thus inhibits contractions of vascular smooth muscle. In animal experiments, nimodipine had a greater effect on cerebral arteries than on arteries elsewhere in the body perhaps because it is highly lipophilic, allowing it to cross the blood-brain barrier; concentrations of nimodipine as high as 12.5 ng/mL have been detected in the cerebrospinal fluid of nimodipine-treated SAH patients.
The precise mechanism of action of nimodipine in reducing the incidence and severity of ischemic deficits in adult patients with SAH from ruptured intracranial berry aneurysms is unknown. Although the clinical studies demonstrate a favorable effect of nimodipine on the severity of neurological deficits caused by cerebral vasospasm following SAH, there is no arteriographic evidence that nimodipine either prevents or relieves the spasm of these arteries. However, whether or not the arteriographic methodology utilized was adequate to detect a clinically meaningful effect, if any, on vasospasm is unknown.
In humans, nimodipine is rapidly absorbed after oral administration, and peak concentrations are generally attained within one hour. The terminal elimination half-life is approximately 8 to 9 hours but earlier elimination rates are much more rapid, equivalent to a half-life of 1-2 hours; a consequence is the need for frequent (every 4 hours) dosing. There were no signs of accumulation when nimodipine was given three times a day for seven days. Nimodipine is over 95% bound to plasma proteins. The binding was concentration independent over the range of 10 ng/mL to 10 mcg/mL. Nimodipine is eliminated almost exclusively in the form of metabolites and less than 1% is recovered in the urine as unchanged drug. Numerous metabolites, all of which are either inactive or considerably less active than the parent compound, have been identified. The metabolism of nimodipine is mediated by CYP3A4. Because of a high first-pass metabolism, the bioavailability of nimodipine averages 13% after oral administration.
In a study of 24 healthy male volunteers, administration of nimodipine capsules following a standard breakfast resulted in a 68% lower peak plasma concentration and 38% lower bioavailability relative to dosing under fasted conditions [see DOSAGE AND ADMINISTRATION].
Patients With Cirrhosis
The bioavailability of nimodipine is significantly increased in patients with cirrhosis, with Cmax approximately double that in normals which necessitates lowering the dose in this group of patients [see DOSAGE AND ADMINISTRATION, WARNINGS AND PRECAUTIONS].
In a single parallel-group study involving 24 elderly subjects (aged 59-79) and 24 younger subjects (aged 22-40), the observed AUC and Cmax of nimodipine was approximately 2-fold higher in the elderly population compared to the younger study subjects following oral administration (given as a single dose of 30 mg and dosed to steady-state with 30 mg three times daily for 6 days). The clinical response to these age-related pharmacokinetic differences, however, was not considered significant. [see Use In Specific Populations, Geriatric Use].
The safety and efficacy of NYMALIZE (nimodipine oral solution) in the treatment of patients with SAH is based on adequate and well-controlled studies of nimodipine oral capsules in patients with SAH. NYMALIZE (nimodipine oral solution) has comparable bioavailability to nimodipine oral capsules.
Nimodipine has been shown in 4 randomized, double-blind, placebo-controlled trials to reduce the severity of neurological deficits resulting from vasospasm in patients who have had a recent SAH (Studies 1, 2, 3, and 4).
The trials used doses ranging from 20-30 mg to 90 mg every 4 hours, with drug given for 21 days in 3 studies, and for at least 18 days in the other. Three of the four trials followed patients for 3-6 months. Three of the trials studied relatively well patients, with all or most patients in Hunt and Hess Grades I - III (essentially free of focal deficits after the initial bleed). Study 4 studied much sicker patients with Hunt and Hess Grades III - V. Studies 1 and 2 were similar in design, with relatively unimpaired SAH patients randomized to nimodipine or placebo. In each, a judgment was made as to whether any latedeveloping deficit was due to spasm or other causes, and the deficits were graded. Both studies showed significantly fewer severe deficits due to spasm in the nimodipine group; Study 2 showed fewer spasm-related deficits of all severities. No effect was seen on deficits not related to spasm. See Table 2.
Table 2: Deficits in Patients with Hunt and Hess Grades I to III in Study 1 and Study 2
|Number Analyzed||Number of Patients with Any Deficit Due to Spasm||Numbers with Severe Deficit|
|Study 1||I-III||Nimodipine 20-30 mg every 4 hours||56||13||1|
|Study 2||I-III||Nimodipine 60 mg every 4 hours||31||4||2|
|*Hunt and Hess Grade|
Study 3 was a 554-patient trial that included SAH patients with all grades of severity (89% were in Hunt and Hess Grades I-III). In Study 3, patients were treated with placebo or 60 mg of nimodipine every 4 hours. Outcomes were not defined as spasm related or not but there was a significant reduction in the overall rate of brain infarction and severely disabling neurological outcome at 3 months (Table 3):
Table 3: Degree of Recovery or Disability in Study 3 (89% Hunt and Hess Grades I-III)
|*p = 0.0444 â€“ good and moderate vs severe and dead|
†p = 0.001 â€“ severe disability
‡p = 0.056 â€“ death
Study 4 enrolled much sicker patients, (Hunt and Hess Grades III-V), who had a high rate of death and disability, and used a dose of 90 mg every 4 hours, but was otherwise similar to Study 1 and Study 2. Analysis of delayed ischemic deficits, many of which result from spasm, showed a significant reduction in spasm-related deficits. Among analyzed patients (72 nimodipine, 82 placebo), there were the following outcomes (Table 4).
Table 4: Neurological Ischemic Deficits in Study 4 [Hunt and Hess Grades III-V]
|Delayed Ischemic Deficits (DID)||Permanent Deficits|
|Nimodipine 90 mg every 4 hours|
|Nimodipine 90 mg every 4 hours|
|DID Spasm Alone||8 (11)*||25 (31)||5 (7)*||22 (27)|
|DID Spasm Contributing||18 (25)||21 (26)||16 (22)||17 (21)|
|DID Without Spasm||7 (10)||8 (10)||6 (8)||7 (9)|
|No DID||39 (54)||28 (34)||45 (63)||36 (44)|
|*p= 0.001, Nimodipine vs placebo|
When data were combined for Study 3 and Study 4, the treatment difference on success rate (i.e., good recovery) on the Glasgow Outcome Scale was 25.3% (nimodipine) versus 10.9% (placebo) for Hunt and Hess Grades IV or V. Table 5 demonstrates that nimodipine tends to improve good recovery of SAH patients with poor neurological status post-ictus, while decreasing the numbers with severe disability and vegetative survival.
Table 5: Glasgow Outcome Scale in Combined Studies 3 and 4
|Good Recovery||22 (25.3%)||11 (10.9%)|
|Moderate Disability||8 (9.2%)||12 (11.9%)|
|Severe Disability||6 (6.9%)||15 (14.9%)|
|Vegetative Survival||4 (4.6%)||9 (8.9%)|
|Death||47 (54.0%)||54 (53.5%)|
|*p = 0.04 5, nimodipine vs. placebo|
A dose-ranging study comparing 30 mg, 60 mg, and 90 mg doses found a generally low rate of spasmrelated neurological deficits but no dose response relationship.