Comparison of nimodipine formulations and administration techniques via enteral feeding tubes in patients with aneurysmal subarachnoid hemorrhage: A multicenter retrospective cohort study

BACKGROUND

Nimodipine improves outcomes following aneurysmal subarachnoid hemorrhage (aSAH) and current guidelines suggest that patients with aSAH receive nimodipine for 21 days. Patients with no difficulty swallowing will swallow the whole capsules or tablets; otherwise, nimodipine liquid must be drawn from capsules, tablets need to be crushed, or the commercially available liquid product be used to facilitate administration through an enteral feeding tube (FT). It is not clear whether these techniques are equivalent. The goal of the study was to determine if different nimodipine formulations and administration techniques were associated with the safety and effectiveness of nimodipine in aSAH.

METHODS

This was a retrospective multicenter observational cohort study conducted in 21 hospitals across North America. Patients admitted with aSAH and received nimodipine by FT for ≥3 days were included. Patient demographics, disease severity, nimodipine administration, and study outcomes were collected. Safety end points included the prevalence of diarrhea and nimodipine dose reduction or discontinuation secondary to blood pressure reduction. Predictors of the study outcomes were analyzed using regression modeling.

RESULTS

A total of 727 patients were included. Administration of nimodipine liquid product was independently associated with higher prevalence of diarrhea compared to other administration techniques/formulations (Odds ratio [OR] 2.28, 95% confidence interval [CI] 1.41-3.67, p-value = 0.001, OR 2.76, 95% CI 1.37-5.55, p-value = 0.005, for old and new commercially available formulations, respectively). Bedside withdrawal of liquid from nimodipine capsules prior to administration was significantly associated with higher prevalence of nimodipine dose reduction or discontinuation secondary to hypotension (OR 2.82, 95% CI 1.57-5.06, p-value = 0.001). Tablet crushing and bedside withdrawal of liquid from capsules prior to administration were associated with increased odds of delayed cerebral ischemia (OR 6.66, 95% CI 3.48-12.74, p-value <0.0001 and OR 3.92, 95% CI 2.05-7.52, p-value <0.0001, respectively).

CONCLUSIONS

Our findings suggest that enteral nimodipine formulations and administration techniques might not be equivalent. This could be attributed to excipient differences, inconsistency and inaccuracy in medication administration, and altered nimodipine bioavailability. Further studies are needed.

Fludrocortisone evaluation in aneurysmal subarachnoid hemorrhage patients with cerebral salt wasting (Flush Salt)

OBJECTIVE

Cerebral salt wasting is a condition that can occur in patients with aneurysmal subarachnoid hemorrhage and is characterized by excessive natriuresis, resulting in hyponatremia and hypovolemia. Fludrocortisone is a mineralocorticoid that facilitates retention of sodium and water. Guideline recommendations are weak regarding fludrocortisone use in this patient population due to mixed clinical effectiveness in prior studies. The purpose of this study was to evaluate the clinical effectiveness of fludrocortisone for cerebral salt wasting in patients with aneurysmal subarachnoid hemorrhage.

METHODS

This single-site, retrospective study evaluated data from March 29th, 2014 through August 31st, 2021. Patients were included if they were admitted for aneurysmal subarachnoid hemorrhage and received fludrocortisone. Patients were excluded if they were less than 18 years old, pregnant, or received fludrocortisone for less than 48 h. Patients served as their own control and endpoints compared baseline data (24 h prior to fludrocortisone) to a run-in period (0-24-hour post fludrocortisone) and a steady-state period (24-48-hour post fludrocortisone). The primary endpoint was fluid balance, determined by urine output and net daily intake. Secondary endpoints included 3 % hypertonic saline (or equivalent) intake and median serum sodium.

RESULTS

There were 110 patients included in this study. Daily doses of fludrocortisone over the 48-hour period varied from 100 mcg to 500 mcg, with 48 % of patients receiving between 200 mcg and 300 mcg daily. Median 24-hour urine output was reduced over the course of the study period (8232 mL at baseline, 8464 mL during 24-hour run-in, and 7080 mL during steady-state timeframe); p = 0.014. There was a 18 % reduction in net volume intake (p = 0.001), including a 38 % reduction in 3 % hypertonic saline (or equivalent) required during the study period; p = 0.025).

CONCLUSION

Fludrocortisone was associated with decreased urine output and subsequently, decreased volume intake, to maintain euvolemia in patients with aneurysmal subarachnoid hemorrhage and cerebral salt wasting.

Therapeutic augmentation of ketogenic diet with a sodium-glucose cotransporter 2 inhibitor in a super-refractory status epilepticus patient

Background

A ketogenic diet (KD) may have a role in treating patients in super-refractory status epilepticus (SRSE). Sodium-glucose cotransporter 2 (SGLT2) inhibitors have a risk of ketoacidosis that could facilitate induction of KD.

Case summary

A 42-year-old with a history of drug resistant epilepsy developed SRSE requiring several pharmacological interventions during her hospital course including the initiation of KD that failed. SGLT2 inhibitor therapy was initiated in a successful attempt to augment ketone production.

Conclusion

SGLT2 inhibitors may have a therapeutic value in SRSE patients who cannot achieve ketosis with KD alone.

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Super-refractory status epilepticus (SRSE) carries a high risk of morbidity and mortality despite both pharmacologic and non-pharmacologic interventions.

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The ketogenic diet can play an important role as an adjunct treatment for these patients, but delaying ketosis could negate those benefits.

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Sodium-glucose cotransporter 2 inhibitors can carry an increased risk of ketoacidosis that may benefit patients in SRSE who do not achieve ketosis on the ketogenic diet alone.