Journal of Vascular Medicine & Surgery

Abstract

Controversies on Dosing of Prophylactic Nimodipine in Subarachnoid Haemorrhage, a Narrative Review

Judith Bellapart*, María Patricia Hernández-Mitre, Charles Yates, Jennifer Paratz, Jason A Roberts

The use of nimodipine for the prophylaxis of neurological complications related to angiographic vasospasm has been a common practice for more than four decades. However, only few trials demonstrated an outcome benefit, defined as a reduction in mortality and vegetative states. By contemporary standards, these benefits may be considered marginal. The controversies regarding the use of nimodipine relate to its mechanism of action, the idiosyncratic factors involved in its effects and the current use of a standardised dose. Furthermore, the multifactorial nature of Delayed Cerebral Ischemia (DCI) adds ambiguity on its clinical endpoints. Consequently, the absence of a specific clinical target limits the capacity to describe a therapeutic plasma level of nimodipine, thus restricting the attainment of individualised dosing. This review aims to consolidate evidence regarding nimodipine dosing and its pharmacokinetic profile, identifying knowledge gaps to guide the design of future studies focused on optimising nimodipine dosing. We conducted a search using Medline, Embase, Cochrane, Web of Science, and PubMed search engines. We narrowed the search to experimental and clinical studies focusing on dose-regimens of nimodipine. A total of 16 experimental studies, 23 clinical studies, and 8 dose-response experimental and clinical trials were reviewed. Limitations related to route of administration, dose, bioavailability, drug clearance, and clinical endpoints were identified. We concluded that the considerable variability in nimodipine’s pharmacokinetics may result in suboptimal dosing for SAH patients. Re-evaluation of the current standardised dosing regimen of nimodipine and the consideration of the potential benefits of personalised dosing are warranted.

Published Date: 2026-02-17; Received Date: 2024-12-20