Enteral Nimodipine in Aneurysmal Subarachnoid Hemorrhage: Real-World Application and Challenges.

Abstract

Background: Guidelines recommend nimodipine as the standard of care for patients with aneurysmal subarachnoid hemorrhage (aSAH). Compared with placebo, this agent has been shown to reduce death and dependency on others for activities of daily living. However, retrospective data suggest that patients may not receive full treatment with nimodipine.

Objectives: The primary objective was to determine the proportion of patients with aSAH admitted to an intensive care unit (ICU) or high-acuity unit (HAU) at a tertiary referral hospital who received the guideline-recommended dose and duration of nimodipine. A secondary objective was to describe barriers to receiving full treatment.

Methods: This retrospective chart review involved a convenience sample of 100 patients with aSAH who were admitted to the ICU or HAU of a tertiary referral hospital between January 1, 2012, and August 31, 2022. The analysis was based on descriptive statistics.

Results: Of the 100 patients with aSAH admitted to the ICU or HAU, 1 (1%) received the guideline-recommended dose and duration of nimodipine. Ninety-five (95%) of the patients experienced a delay to initiation, mainly due to transfer from another hospital (n = 45, 47%) and/or lack of a safe enteral route (n = 62, 65%). Sixty-six (66%) of the patients received alternative dosing, most because their blood pressure was below target (n = 16, 24%) or because of vasospasm requiring a higher blood pressure target (n = 22, 33%). A total of 99 patients (99%) had early discontinuation and/or treatment interruption of nimodipine; reasons included vasospasm requiring a higher blood pressure target (n = 12, 12%) and nimodipine not being continued on transfer or discharge (n = 14, 14%).

Conclusions: Most of the patients in this study did not receive the full course of nimodipine therapy due to multiple barriers. Pharmacists can play a role in optimizing treatment by educating staff at transferring sites about timely initiation of therapy, reconciling medications on transfer or discharge, and mitigating interactions with concomitant medications.