Pronunciation: (NYE-troe-GLIS-er-in)Class: Vasodilator, Nitrate
Trade Names:Minitran- Transdermal patch 9 mg- Transdermal patch 18 mg- Transdermal patch 36 mg- Transdermal patch 54 mg
Trade Names:Nitrek- Transdermal patch 22.4 mg- Transdermal patch 44.8 mg- Transdermal patch 67.2 mg
Trade Names:Nitro-Bid- Ointment, topical 2% in a lanolin-petrolatum base
Trade Names:Nitro-Dur- Transdermal patch 20 mg- Transdermal patch 40 mg- Transdermal patch 60 mg- Transdermal patch 80 mg- Transdermal patch 100 mg- Transdermal patch 120 mg- Transdermal patch 160 mg
Trade Names:Nitro-Time- Capsules, sustained-release 2.5 mg- Capsules, sustained-release 9 mg
Trade Names:Nitroglycerin- Injection, solution, concentrate 5 mg/mL- Capsules, sustained-release 6.5 mg
Trade Names:Nitroglycerin in 5% Dextrose- Injection 100 mcg/mL- Injection 200 mcg/mL- Injection 400 mcg/mL
Trade Names:Nitrolingual- Aerosol spray, sublingual 0.4 mg/metered dose
Trade Names:Nitrostat- Tablets, sublingual 0.3 mg- Tablets, sublingual 0.4 mg- Tablets, sublingual 0.6 mgGen-Nitro
Relaxation of vascular smooth muscle and dilation of peripheral arteries and veins.
Vd is 3 L/kg (ER buccal tablets). Protein binding is approximately 60% (parent) (sublingual tablets); 1,2 dinitroglycerin is 60%; 1,3 dinitroglycerin is 30%.
Primarily metabolized in the liver by nitrate reductase; known sites of extrahepatic metabolism include red blood cells and vascular walls. Metabolized to inorganic nitrate and the active 1,2 and 1,3 dinitroglycerols.
Serum half-life is 3 min ( Minitran ) and 1 to 8 min (sublingual). Cl is 1 L/kg/min ( Minitran ).
1 to 2 min (IV), 1 to 3 min (sublingual), 1 h (ER).
1 to 4 h (immediate-release tablet), 6 to 7 min (sublingual), 2 h (transdermal).
3 to 5 min (IV), 30 to 60 min (sublingual), 5 h (ER), up to 12 h (topical ointment).
Indications and Usage
ER capsules, ointment, transdermal patch Prevention of angina pectoris caused by coronary artery disease (CAD). IV Treatment of perioperative hypertension; control of CHF in the setting of acute MI; treatment of angina pectoris in patients not responding to sublingual nitroglycerin and beta-blockers; induction of intraoperative hypotension. Aerosol spray, sublingual tablets Acute relief of an attack or prophylaxis of angina pectoris caused by CAD.
IV Management of acute MI; treatment of hypertensive emergencies; in combination with vasopressin to treat variceal bleeding, cocaine-induced acute coronary syndrome; management of Prinzmetal angina occurring in patients without coronary heart disease; management of sympathomimetic-induced cardiopulmonary toxicities. Sublingual Management of acute MI; management of Prinzmetal angina occurring in patients without coronary heart disease. Topical Management of acute MI; treatment of Prinzmetal angina occurring in patients without coronary heart disease; treatment of chronic anal fissure pain; erectile dysfunction; Raynaud disease.
IV, aerosol spray, sublingual tablets, transdermal patch Allergy to organic nitrates; patient using phosphodiesterase type 5 inhibitors (eg, sildenafil, tadalafil, vardenafil). IV Pericardial tamponade; restrictive cardiomyopathy; constrictive pericarditis; solutions containing dextrose in patients with known allergy to corn or corn products. Ointment, ER Allergy to organic nitrates. Sublingual tablets Early MI; severe anemia; increased intracranial pressure. Transdermal patch Allergy to adhesives used in transdermal patches.
Dosage and AdministrationAnginaAdults
ER capsules 2.5 to 6.5 mg 3 to 4 times daily initially, titrate to response. Sublingual tablets 0.3 to 0.6 mg dissolved under the tongue or in buccal pouch at first sign of acute angina attack; repeat every 5 min (do not exceed 3 tablets in 15 min). Also may be used as a single dose 5 to 10 min before activity that might precipitate an anginal attack. Topical Initially, ½-inch dose applied twice daily (upon arising in the morning and 6 h later). May double dose in patients tolerating this dose but failing to respond to it. Transdermal Initially, 0.2 to 0.4 mg/h patch applied once daily; titrate dose to response. Remove patch after 12 to 14 h to provide nitroglycein-free interval. Aerosol spray 1 or 2 sprays onto or under tongue at first sign of acute angina attack; repeat every 5 min (do not exceed 3 sprays in 15 min). Also may be used 5 to 10 min before activity that might precipitate an anginal attack.Perioperative Hypertension, Induction of Intraoperative Hypotension, Refractory Angina, CHF Secondary to Acute MIAdults
IV 5 mcg/min initially using nonabsorbing infusion set or 25 mcg/min using a polyvinyl chloride (PVC) administration set; titrate to response. Initial dose (non-PVC set) titration should be in 5 mcg/min increments every 3 to 5 min until some response is observed. If no response occurs at 20 mcg/min, increments of 10 to 20 mcg/min can be used. Once a partial BP response is observed, reduce dose and lengthen interval between dose increases.
- To minimize development of tolerance, ensure daily nitroglycerin-free interval of 10 to 12 h is provided.
- Caution patient not to chew, crush, or open ER capsules.
- Sublingual tablets
- Caution patient not to crush, chew, or swallow sublingual tablets.
- During administration of sublingual tablets and sublingual spray, patient should rest, preferably in the sitting position.
- Transdermal patch
- Remove patch from foil pouch immediately prior to application.
- Remove protective liner from patch and apply to any area of the body except the extremities below the knee or elbow; the chest is preferred site. Press the patch on the skin and smooth down.
- Apply only to area that is clean, dry, and hairless. If hair is likely to interfere with patch adherence, clip, do not shave, the area before application.
- Do not apply patch to skin areas with cuts or irritation or immediately after showering or bathing.
- If the patch becomes dislodged, discard it and put a new one on at a different skin site.
- Do not discharge cardioverter/defribrillator through paddle electrode that overlies a transdermal patch. May damage the paddles and burn the patient.
- Topical ointment
- Measure prescribed dose of ointment using measuring applicator supplied with tube. Squeeze necessary amount of ointment onto applicator and place applicator (ointment side down) on desired area of skin. Spread ointment using dose-measuring applicator, then tape applicator into place. Do not rub ointment into skin.
- Keep ointment tube tightly wrapped; cover dose-measuring applicator with plastic kitchen wrap to prevent staining of clothing by ointment.
- For IV infusion only. Not for intradermal, subcutaneous, IM, IV bolus, intra-arterial, or intracoronary administration.
- Several preparations of nitroglycerin injection are available. They differ in concentration and/or volume per container. When switching from one product to another, pay attention to the dilution and dosage and administration instructions.
- Nitroglycerin solution for injection is concentrated and must be diluted prior to administration. Transfer contents of 1 vial (25 or 50 mg) into 500 mL glass bottle of dextrose 5% or sodium chloride 0.9% to provide final concentration of 50 mcg/mL or 100 mg/mL. After initial titration, concentration of solution may be increased, if necessary, to a max concentration of 400 mcg/mL to limit fluids given to patient.
- Nitroglycerin in dextrose 5% is premixed and requires no further dilution.
- Use only with glass bottles and non-PVC infusions sets provided by manufacturer, or use non-PVC infusion sets.
- Administer only via infusion pump that can maintain constant infusion rate.
- Do not administer if container has lost vacuum or if solution is discolored or cloudy, or contains particulate matter.
- Avoid use of in-line filters that absorb nitroglycerin.
- When changing concentrations, disconnect tubing from patient and flush with new solution before continuing therapy.
- Do not mix nitroglycerin infusions through the same infusion set as blood to avoid pseudoagglutination and hemodialysis.
- Do not mix nitroglycerin solutions with any other medication.
- Aerosol spray
- Do not shake container before administering dose.
- Prime aerosol unit initially with 1 spray. Reprime with 1 spray if unit has not been used for 6 or more weeks.
- Hold container upright as close to open mouth as possible; press button firmly to release spray onto or under the tongue; caution patient not to inhale spray. Have patient avoid swallowing immediately after administering spray. Do not expectorate medicine or rinse mouth for 5 to 10 min following administration.
- Contains alcohol. Do not spray toward flames.
Store solution for injection at controlled room temperature (59° to 86°F). Protect from freezing and light. Discard any unused solution. Store premixed nitroglycerin with dextrose at room temperature of 77°F (brief exposure up to 104°F does not affect product). Protect from freezing. Avoid excessive heat. Store ER capsules, aerosol spray, topical ointment, and transdermal patch at controlled room temperature (59° to 86°F). Store sublingual tablets at controlled room temperature (68° to 77°F). Protect sublingual tablets from moisture.
Severe hypotension and CV collapse may occur.Alteplase
Coadministration decreases thrombolytic effects of alteplase.Aspirin
Vasodilatory and hemodynamic effects of nitroglycerin may be enhanced.Calcium channel blockers
Symptomatic orthostatic hypotension may occur.Dihydroergotamine
May increase systolic BP and decrease antianginal effects.Heparin
May decrease anticoagulation effect when used in conjunction with IV nitroglycerin.Phosphodiesterase type 5 inhibitors (eg, sildenafil, tadalafil, vardenafil)
Because the hypotensive effects of nitrates may be potentiated, concomitant use of any form of organic nitrates is contraindicated in patients receiving phosphodiesterase type 5 inhibitors.
Laboratory Test Interactions
May cause false report of reduced serum cholesterol with Zlatkis-Zak color reaction. May cause falsely elevated results of serum triglyceride assays (IV).
Crescendo angina, hypotension, palpitations, rebound hypertension, syncope, vasodilation.
Asthenia, dizziness, headache, light-headedness, paresthesia, restlessness, vertigo, weakness.
Allergic reactions including contact dermatitis or fixed drug eruptions (ointment or patches), drug rash, exfoliative dermatitis, flushing, perspiration.
Abdominal pain, burning or tingling in the oral cavity (sublingual), nausea, vomiting.
Application-site irritation (transdermal).
Collapse, pallor, peripheral edema.
Continuously monitor BP and heart rate while administering IV nitroglycerin; monitor pulmonary capillary wedge pressure when indicated.
Category C .
Safety and efficacy not established.
Make dose selection with caution, usually starting at the lower end of the dosing range, reflecting the greater frequency of decreased hepatic, renal, or cardiac function, and comorbidity.
Acute MI/Heart failure
Benefits of oral and topical nitroglycerin not established; use with caution and with close clinical and hemodynamic monitoring in these settings to avoid hypotension and tachycardia. Use of ER nitroglycerin in these settings is not recommended because effects of nitroglycerin are difficult to terminate rapidly.
May aggravate angina caused by hypertrophic cardiomyopathy.
Use nitroglycerin solutions containing dextrose with caution.
High doses may produce methemoglobinemia, especially in patients with methemoglobin reductase deficiency.
Severe hypotension and shock may occur even with small doses, particularly with an upright posture. Use with caution in patients who are hypotensive or volume depleted; alcohol accentuates this reaction.
May develop with repeated use for prolonged periods of time; minimize tolerance by ensuring daily nitroglycerin-free intervals of 10 to 12 h are provided.
Air hunger, bloody diarrhea, coma, confusion, death, diaphoresis with flushed or cold and clammy skin, dyspnea followed later by reduced ventilatory effort, heart block and bradycardia, increased intracranial pressure, methemoglobinemia, moderate fever, nausea, palpitations, paralysis, seizures, syncope, throbbing headache, vertigo, visual disturbances, vomiting.
- Advise patient to carefully review the patient information leaflets and booklets supplied with each product before starting therapy, and to read and check for new information each time the medication is refilled.
- Review with patient and family the signs and symptoms of angina (eg, acute onset of pressure-like chest pain that may radiate down the left arm and/or into the neck or jaw, often associated with sweating and shortness of breath or difficulty breathing).
- Ensure patient using ER capsules, topical ointment, or transdermal patch to prevent angina attacks has sublingual nitroglycerin tablets or aerosol spray available at all times. Ensure patient knows when and how to use sublingual nitroglycerin or aerosol spray and what to do if angina pain worsens or fails to respond to sublingual nitroglycerin.
- Caution patient that antianginal effectiveness of nitroglycerin is strongly related to the dosing regimen and not to stop taking or change the dose or frequency of administration unless advised by health care provider.
- Advise patient that headaches are a common adverse reaction of therapy and are also a marker of antianginal effectiveness. Advise patient that acetaminophen can be used to relieve headache without reducing the medication's antianginal effectiveness. Caution patient not to reduce the dose or change the frequency of administration of isosorbide to avoid medication-induced headache.
- Advise patient to notify health care provider if angina symptoms increase in frequency or severity, or if there is a sudden increase in the frequency of use of sublingual nitroglycerin or aerosol spray.
- Caution patient that medication may cause dizziness, light-headedness, or fainting, especially while standing or following consumption of alcohol.
- Caution patient to avoid sudden position changes to prevent orthostatic hypotension.
- Instruct patient to notify health care provider if any of the following occur: frequent episodes of dizziness or light-headedness; fainting; intolerable headache; episodes of sweating; nausea and/or vomiting; any unusual or unexplained feeling or sensation.
- Transdermal patch
- Ensure patient knows how to use transdermal patch: remove patch from foil pouch immediately prior to application and remove protective liner from patch and apply to any area of the body except the extremities below the knee or elbow. Advise patient that the chest is preferred site. Press the patch on the skin and smooth down.
- Advise patient to apply only to area that is clean, dry, and hairless. If hair is likely to interfere with patch adherence, instruct patient to clip, not shave, the area before application.
- Caution patient not to apply patch to skin areas with cuts or irritation, or immediately after showering or bathing.
- Advise patient that if the patch becomes dislodged, discard it and put a new one on at a different skin site.
- Caution patient to remove and discard patch after 12 to 14 h, as instructed by health care provider, to provide nitroglycerin-free interval.
- Topical ointment
- Ensure patient knows how to use topical ointment: measure prescribed dose of ointment using measuring applicator supplied with tube by squeezing necessary amount of ointment onto applicator and placing applicator (ointment side down) on desired area of skin. Spread ointment using dose-measuring applicator, then tape applicator into place. Caution patient not to rub ointment into skin.
- Advise patient to cover dose-measuring applicator with plastic kitchen wrap to prevent staining of clothing by ointment.
- Instruct patient to remove first applicator 6 h after application and apply a second applicator. Instruct patient to remove second applicator after 6 h to provide nitrate-free dosing interval.
- ER capsules
- Instruct patient using ER capsules to swallow whole and not to crush, chew, or open capsules.
- Advise patient, family, or caregiver that medication will be prepared and administered by a health care provider in the intensive care center with close monitoring.
- Aerosol spray
- Ensure patient knows when and how to use aerosol spray: Sit down before using spray. Do not shake container before administering dose. Prime aerosol unit initially with 1 spray. Reprime with 1 spray if unit has not been used for 6 or more weeks. Hold container upright as close to open mouth as possible; press button firmly to release spray onto or under the tongue. Caution patient not to inhale spray. Have patient avoid swallowing immediately after administering spray or expectorating or rinsing the mouth for 5 to 10 min following administration. If pain remains, dose may be repeated every 5 min until 3 sprays are taken. Instruct patient to call 911 if pain becomes more intense or persists after a total of 3 sprays.
- Caution patient that aerosol spray contains alcohol and not to spray toward flames or forcefully open or burn container after use.
- Advise patient to discard aerosol and replace with new unit when end of pump is no longer covered by fluid.
- Sublingual tablets
- Instruct patient to carry the tablets with them at all times and to keep the tablets in the original glass container and tightly capped.
- Instruct patient to sit down and dissolve 1 tablet under the tongue or between the cheek and gum at the first sign of an anginal attack. If pain remains, dose may be repeated every 5 min until 3 tablets are taken. Instruct patient to call 911 if pain becomes more intense or persists after a total of 3 tablets.
- Caution patient not to crush, chew, or swallow sublingual tablets.
- Instruct patient to lie down if dizziness or light-headedness occurs.
- Advise patient that tablets may produce a burning or tingling sensation but that the ability to cause burning or tingling is not considered a reliable method for determining potency of the tablets.
- Advise patient to discontinue nitroglycerin and notify health care provider if vision blurring or dry mouth occurs.
Copyright © 2009 Wolters Kluwer Health.
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