PBM-MAP-Vpeabbreviated NME Review: Nimodipine Oral Solution

PBM-MAP-VPEAbbreviated NME Review: Nimodipine Oral Solution

Nimodipine Oral Solution(NYMALIZE™)

National Drug Monograph

Abbreviated Review

November2013

VA Pharmacy Benefits ManagementServices, Medical Advisory Panel, and VISN Pharmacist Executives

The PBM prepares abbreviated reviews to compile information relevant to making formulary decisions. VA clinical experts may provide input on the content. Wider field review is not sought. Documents no longer current will be placed in the Archive section of the PBM INTRAnet (

Introduction1-12

Nimodipine oral solution (NYMALIZE™) was approved by the U.S. Food and Drug Administration(FDA) May 10, 2013for the improvement of neurological outcome by reducing the incidence and severity of ischemic deficits in adult patients with subarachnoid hemorrhage (SAH) from ruptured intracranial berry aneurysms regardless of their post-ictus neurological condition (i.e., Hunt and Hess Grades I-V).1 Nimodipine is a dihydropyridine calcium channel blocker that is also available as an oral capsule with the same indication.2 Nimodipine capsules are available nonformulary in VA.

In August 2010, the FDA published a safety announcement stating that nimodipine capsules should only be given by mouth or through a feeding tube and should never be given by the intravenous (IV) route.3 At that time, FDA reported atotal of 31 case reports of medication errors that were identified between 1989, when nimodipine was originally approved, and 2009. Reports included four patient deaths, five near-death events, and one permanent injury.3,4 There are now 5 deaths that have been reported due to a medication error with nimodipine being accidentally administered IV.5 In 2006, a Boxed Warning was added to the product information for nimodipine alerting providers to these safety concerns, and instructions were added to the prescribing information on how to avoid the risk for mistaken IV administration of the capsule’s liquid contents.3,4 The oral solution of nimodipine received fast track designation and priority review since it provided an alternate formulation with the potential to decrease medication errors that have been seen with the inappropriate IV administration of the contents of the nimodipine oral capsules when drawn up by syringe.6

According to clinical practice guidelines on the management of patients withaneurysmal SAH, oral nimodipine should be administered to all patients (Class I; Level of Evidence A), due to an improvement in patient outcomes.7,8 According to a meta-analyses of seven clinical trials including 1202 patients, treatment with nimodipine in patients with SAH resulted in an improvement in the odds of a good outcome (1.86; P<0.005), a reduction in the odds of deficit and/or mortality due to vasospasm by 0.46 (P<0.008) and reduced infarction rate as assessed by computed tomography (CT) scan by 0.58 (P<0.008).9 Similar findings were reported in another meta-analyses of ten clinical trials reporting a relative risk reduction with nimodipine of 24% (95% CI 12 to 38) of a poor outcome (death or dependency); with a number needed to treat (NNT) of 13 (8 to 30) patients to prevent one poor outcome.10 A more recent Cochrane review of outcomes in patients with aneurysmal SAH receiving treatment with calcium channel blockers evaluated sixteen trials with 3361 patients and found that oral nimodipine alone reduced the risk of poor outcomes (RR 0.67; 95% CI 0.55 to 0.81) compared to controls. Overall, calcium channel blockers reduced the risk of a poor outcome (RR 0.81; 95% CI 0.72 to 0.92); however, the results for calcium channel blockers other than nimodipine, or withintravenous nimodipine, were not statistically significant.11,12

Summary of Clinical Trial Data1,2,13-17

The manufacturer’s product information states that based on in vitro comparisons, nimodipine oral solution is comparable in bioavailability to nimodipine oral capsules, where separate pharmacokinetic comparisons were not required by the FDA.1,13 The FDA approval of nimodipine oral solution in patients with aneurysmal SAH is based on clinical trial data from 4 randomized, double-blind, placebo-controlled trials evaluating the use of oral nimodipine in capsule or tablet formulation in reducing the severity of neurologic deficits in patients with recent SAH.Patients enrolled in the trials received oral nimodipine (20 to 90 mg every 4 hours), for 21 days in three of the studies and for at least 18 days in one of the studies, or placebo.1,2,14-17

Allen14 / Philippon15 / Pickard16 / Petruk17
Gradea / I-III / I-III / I-IV / III-IV
NimodipineDose / 20 to 30 mg every 4 hrs / 60 mg every 4 hrs / 60 mg every 4 hrs / 90 mg every 4 hrs
Nimodipine (N) / 56 / 31 / 278 / 72
Placebo (N) / 60 / 39 / 276 / 82

aGrade=Hunt and Hess Grades [I. asymptomatic or mild headache, slight nuchal rigidity; II. moderate to severe headache, nuchal rigidity, no neurologic deficit except cranial nervepalsy; III. drowsy, minimal neurologic deficit; IV. stupor, moderate-severe hemiparesis; V. coma, decerebrate rigidity; moribund]

In the following two studies, treatment with oral nimodipine significantly reduced the number of severe events (including death) related to spasm compared to placebo.14,15

Resultsa / Allen14 / Philippon15
Nimodipine / Placebo / Nimodipine / Placebo
Study N / 56 / 60 / 31 / 39
Normal/good / 8 / 6 / 2 / 1
Mild or moderate / 4 / 2
Severe or [death]b / 1 [1] / 8 [3] / 2 [2] / 10 [4]

aPatients with deficits from spasm

bNimodipine vs. Placebo: Allen (P=0.03); Philippon (P<0.05)

In another study, treatment with oral nimodipine demonstrated a significant reduction in rates of cerebral infarction and in poor outcomes (death and severe disability) compared to placebo in patients with SAH.16

Results / Pickard16
Nimodipine / Placebo / RR (%) / 95% CI / P value
Study N / 278 / 276
Cerebral infarct / 61 (22%) / 92 (33%) / 34 / 13 to 50 / 0.003
Poor outcome / 55 (20%) / 91 (33%) / 40 / 20 to 55 / <0.001
Death / 43 / 60 / 29 / -1 to 50 / 0.06

CI=Confidence Interval; RR=Relative Reduction

In a study of patients with SAH with a higher degree of disability (Hunt and Hess Grades III-IV), treatment with oral nimodipine demonstrated a significant increase in good outcomes and a reduction in delayed ischemic deficits due to spasm compared to placebo.17

Results / Petruk17
Nimodipine / Placebo / P value
Study N / 72 / 82
Good outcome / 21 (29.2%) / 8 (0.8%) / <0.001
DIDa / 8 (11%) / 25 (31%) / 0.001
Permanent deficitsa / 5 (7%) / 22 (27%) / 0.001

DID=Delayed Ischemic Deficits

aDID from vasospasm alone

Safety1-6

Refer to the manufacturer’s prescribing information for complete safety information.1

Contraindications:None.1

Warnings and Precautions:Hypotension, with careful monitoring of blood pressure recommended during treatment. As nimodipine concentrations may be significantly increased when administered with strong CYP3A4 inhibitors, there is an increased risk for hypotension; therefore, concomitant use should generally be avoided. Concomitant use of nimodipine with strong CYP3A4 inducers should also be avoided, in general, as these agents may decrease the plasma concentration of nimodipine and reduce its efficacy. Patients with cirrhosis are at an increased risk for adverse effects with nimodipine; monitor pulse and blood pressure and use lower doses.1

Deaths and Other Serious Adverse Events (Sentinel Events):Deaths and serious life threatening adverse events (cardiac arrest, cardiovascular collapse, hypotension, bradycardia) have occurred when the contents of the nimodipine capsules have inadvertently been administered IV.2-6

Adverse Reactions: In clinical trials of patients with SAH, 11% of patients receiving nimodipine capsules reported an adverse event compared to 6% of patients on placebo. The most common adverse event in patients treated with nimodipine capsules was decreased blood pressure.1 The following is a comparison of adverse events reported in > 1% of patients in 4 clinical trials with nimodipine capsules.1

Adverse Reaction / Placebo N (%)
(N=479) / Nimodipine dose every 4 hours N (%)
0.35 mg/kg
(N=82) / 30 mg
(N=71) / 60 mg
(N=494) / 90 mg
(N=172) / 120 mg
(N=4)
Decreased BP / 6 (1.2) / 1 (1.2) / 0 / 19 (3.8) / 14 (8.1) / 2 (50.0)
Edema / 3 (0.6) / 0 / 0 / 2 (0.4) / 2 (1.2) / 0
Diarrhea / 3 (0.6) / 0 / 3 (4.2) / 0 / 3 (1.7) / 0
Rash / 3 (0.6) / 2 (2.4) / 0 / 3 (0.6) / 2 (1.2) / 0
Headache / 1 (0.2) / 0 / 1 (1.4) / 6 (1.2) / 0 / 0
GI symptoms / 0 / 2 (2.4) / 0 / 0 / 2 (1.2) / 0
Nausea / 0 / 1 (1.2) / 1 (1.4) / 6 (1.2) / 1 (0.6) / 0
Dyspnea / 0 / 1 (1.2) / 0 / 0 / 0 / 0
ECG abnormalities / 0 / 0 / 1 (1.4) / 0 / 1 (0.6) / 0
Tachycardia / 0 / 0 / 1 (1.4) / 0 / 0 / 0
Bradycardia / 0 / 0 / 0 / 5 (1.0) / 1 (0.6) / 0
Muscle pain/cramp / 0 / 0 / 1 (1.4) / 1 (0.2) / 1 (0.6) / 0
Acne / 0 / 0 / 1 (1.4) / 0 / 0 / 0
Depression / 0 / 0 / 1 (1.4) / 0 / 0 / 0

BP=blood pressure; ECG=electrocardiogram; GI=gastrointestinal

Drug Interactions: Concomitant use of other antihypertensive medications; CYP3A4 inhibitors; CYP3A4 inducers. Refer to prescribing information for further details.1

Pregnancy and Nursing Mothers:Nimodipine is pregnancy category C and should only be used in pregnant women if the benefit of treatment outweighs the potential risk to the fetus. It is unknown if nimodipineis excreted in human milk; therefore, the risk to the nursing infant vs. the benefit of treatment to the mother needs to be taken into consideration.1

Look-alike/Sound-alike (LA/SA) Error Risk Potential

As part of a Joint Commission standard, LA/SA names are assessed during the formulary selection of drugs. Based on clinical judgment and an evaluation of LA/SA information from four data sources (Lexi-Comp, First Databank, and ISMP Confused Drug Name List), the following drug names may cause LASA confusion:

NME Drug Name / Lexi-Comp / First DataBank / ISMP / Clinical Judgment
Nimodipine oral solution
NYMALIZE™ / Nicardipine
Nifedipine
Nisoldipine
None / Nicardipine
Nifedipine
None / Nifedipine
*Nimodipine caps / Nevirapine oral susp
Nyamyc
Nylidrin
Nydrazid

* ISMP recommends that hospitals must have a system in place (e.g., included in order sets) to alert providers that the patient has a nasogastric or gastric tube so that nimodipine liquid can be ordered and dispensed rather than nimodipine capsules.

Dosage and Administration1

Nimodipine oral solution is available as 60 mg per 20 ml (3 mg/ml) in a 16 oz. (473 ml) bottle.1 The recommended dose of nimodipine oral solution is 20 ml (60 mg) every 4 hours orally or via a nasogastric (NG) or gastric tube, for 21 consecutive days. When administered by NG or gastric tube, after each dose, the oral syringe should be refilled with 20 ml 0.9% saline solution to then flush any remaining contents from the NG or gastric tube into the stomach. The dose should be reduced to 10 ml (30 mg) every 4 hours in patients with cirrhosis.1

Nimodipine oral solution should be administered within 96 hours of the onset of SAH. It is recommended that the dose be administered one hour before or two hours after a meal.1

Nimodipine oral solution should NOT be administered IV or by any other parenteral route.1

Acquisition Cost

Refer to VA pricing sources for updated information.

Conclusions

Nimodipine oral solution is a new formulation to prevent medication errors seen with the inadvertent intravenous administration of the oral nimodipine capsule contents. Approval of nimodipine oral solution in patients with aneurysmal SAH is based on clinical trial data with oral nimodipine in capsule or tablet formulation, that has been shown to reduce poor outcomes, including death and severe disability, and rates of cerebral infarction, in patients with recent aneurysmal SAH. Clinical practice guidelines on the management of patients withaneurysmal SAH recommend that oral nimodipine should be administered to all patients withrecent aneurysmal SAH, to improve patient outcomes.

References

1. NYMALIZE™ (nimodipine) oral solution. Atlanta, GA: Arbor Pharmaceuticals, Inc.; May2013.
2. Nimodipine capsule. Detroit, MI: Caraco Pharmaceutical Laboratories, Ltd.; Jan2012.
3. FDA Drug Safety Communication: Serious medication errors from intravenous administration of nimodipine oral capsules. August 2, 2010. Available at:
4. FDA Drug Safety Communication: Serious medication errors from IV administration of nimodipine oral capsules.

Pharmacy Benefits Management, Medical Advisory Panel, VISN Pharmacist Executives Ez minutes Newsletter. Aug-Oct 2010; 8(4):1.

1. Institute for Safe Medication Practices (ISMP). Safety briefs: Liquid nimodipine approval. ISMP Medication Safety Alert 2013:18(11):2-3. Available at:
2. FDA News Release: FDA approves NYMALIZE – first nimodipine oral solution for use in certain brain hemorrhage patients: new oral formulation may help reduce potentially fatal medication errors. May 14, 2013.Available at:
3. Connolly ES Jr, Rabinstein AA, Carhuapoma JR, et al. Guidelines for the management of aneurysmal subarachnoid hemorrhage: a guideline for healthcare professionals from the American Heart Association/American Stroke Association. Stroke 2012;43:1711–37.
4. Velat GJ, Kimball MM, Mocco JD, Hoh BL. Vasospasm after aneurysmal subarachnoid hemorrhage: review of randomized controlled trials and meta-analyses in the literature. World Neurosurg 2011;76:446-54.
5. Barker FG 2nd, Ogilvy CS. Efficacy of prophylactic nimodipine for delayed ischemic deficit after subarachnoid hemorrhage: a metaanalysis. J Neurosurg 1996;84:405-14.
6. Feigin VL, Rinkel GJ, Algra A, Vermeulen M, van Gijn J. Calcium antagonists in patients with aneurysmal subarachnoid hemorrhage: a systematic review. Neurology. 1998;50:876-83.
7. Dorhout Mees SM, Rinkel GJ, Feigin VL, et al. Calcium antagonists for aneurysmal subarachnoid haemorrhage. Cochrane Database Syst Rev 2007;(3) CD000277.
8. Adamczyk P, He S, Amar AP, Mack WJ. Medical management of cerebral vasospasm following aneurysmal subarachnoid hemorrhage: a review of current and emerging therapeutic interventions. Neurol Res Int 2013;2013:462491. doi: 10.1155/2013/462491. Epub 2013 Apr 15.
9. NYMALIZE™ (nimodipine) oral solution 60 mg/ 20 ml formulary information. Arbor Pharmaceuticals, Inc.; 2013.
10. Allen GS, Ahn HS, Preziosi TJ, et al. Cerebral arterial spasm--a controlled trial of nimodipine in patients with subarachnoid hemorrhage.N Engl J Med 1983;308:619-24.
11. Philippon J, Grob R, Dagreou F, Guggiari M, Rivierez M, Viars P. Prevention of vasospasm in subarachnoid haemorrhage. A controlled study with nimodipine. Acta Neurochir (Wien) 1986;82:110-4.
12. Pickard JD, Murray GD, Illingworth R, et al.Effect of oral nimodipine on cerebral infarction and outcome after subarachnoid haemorrhage: British aneurysm nimodipine trial.BMJ 1989;298:636-42.
13. Petruk KC, West M, Mohr G, et al.Nimodipine treatment in poor-grade aneurysm patients. Results of a multicenter double-blind placebo-controlled trial.J Neurosurg 1988;68:505-17.

Prepared (July 2013)/Contact Person: Elaine M. Furmaga, PharmD, National PBM Clinical Pharmacy Program Manager, VA National Pharmacy Benefits Management Services

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November 2013

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