(nye troe gli' ser in)
Nitro-Bid IV, Tridil
nitroglycerin, sustained release
Nitroglyn, Nitrong, Nitro-Time
Nitrobid, Nitrol, Nitrong, Nitrostat
Deponit, Minitran, Nitro-Dur, Nitrodisc, Transderm-Nitro, Nitro-Derm
Pregnancy Category C
- Antianginal agent
Relaxes vascular smooth muscle with a resultant decrease in venous return and decrease in arterial BP, which reduces left ventricular workload and decreases myocardial oxygen consumption.
- Acute angina: sublingual, translingual preparations
- Prophylaxis of angina: oral sustained release, sublingual, topical, transdermal, translingual, transmucosal preparations
- Angina unresponsive to recommended doses of organic nitrates or β -blockers (IV preparations)
- Perioperative hypertension (IV preparations)
- CHF associated with acute MI (IV preparations)
- To produce controlled hypertension during surgery (IV preparations)
- Unlabeled uses: reduction of cardiac workload in acute MI and in CHF (sublingual, topical); adjunctive treatment of Raynaud's disease (topical)
- Contraindications: allergy to nitrates, severe anemia, early MI, head trauma, cerebral hemorrhage, hypertrophic cardiomyopathy, pregnancy, lactation.
- Use cautiously with hepatic or renal disease, hypotension or hypovolemia, increased intracranial pressure, constrictive pericarditis, pericardial tamponade, low ventricular filling pressure or low PCWP.
Available Forms: Injection--0.5, 5 mg/mL; injection solution--25, 50, 100, 200 mg; sublingual tablets--0.15, 0.3, 0.4, 0.6 mg; translingual spray--0.4 mg/spray; transmucosal tablets--1, 2, 3 mg; transmucosal SR tablets--2.6, 6.5, 9 mg; transmucosal SR capsules--2.5, 6.5, 9, 13 mg; transdermal--.1, 0.2, 0.3, 0.4, 0.6, 0.8 mg/h; topical ointment--2%
Initial: 5 µg/min delivered through an infusion pump. Increase by 5-µg increments every 3---5 min as needed. If no response at 20 µg, increase increments to 10---20 µg. Once a partial BP response is obtained, reduce dose and lengthen dosage intervals; continually monitor response and titrate carefully.
Dissolve 1 tablet under tongue or in buccal pouch at first sign of anginal attack; repeat every 5 min until relief is obtained. Do not take more than 3 tablets/15 min. If pain continues or increases, patient should call physician or go to hospital.
Use 5---10 min before activities that might precipitate an attack.
Sustained release (oral):
Initial:2.5---2.6 mg tid or qid. Titrate upward by 2.5- or 2.6-mg increments until side effects limit the dose. Doses as high as 26 mg given 4 × daily have been used.
Initial dose: 1/2 in q8h. Increase by 1/2 inch to achieve desired results. Usual dose is 1---2 inches q8h; up to 4---5 inches q4h have been used. 1 inch = 15 mg nitroglycerin.
Apply one pad each day. Titrate to higher doses by using pads that deliver more drug or by applying more than one pad.
Spray preparation delivers 0.4 mg/metered dose. At onset of attack, spray 1---2 metered doses into oral mucosa; no more than 3 doses/15 min should be used. If pain persists, seek medical attention. May be used prophylactically 5---10 min prior to activity that might precipitate an attack.
1 mg q3---5h during waking hours. Place tablet between lip and gum above incisors, or between cheek and gum.
Safety and efficacy not established.
|IV||1---2 min||3---5 min
|Sublingual||1---3 min||30---60 min
|TL spray||2 min||30---60 min
|Trans/tablet||1---2 min||3---5 min
|Oral, SR||20---45 min||3---8 h
|Topical ointment||30---60 min||2---12 h
|Transdermal||30---60 min||24 h|
Metabolism: Hepatic, T1/2: 47---100 h
Distribution: Crosses placenta; enters breast milk
- Preparations: Dilute in 5% Dextrose Injection or 0.9% Sodium Chloride Injection. Do not mix with other drugs; check the manufacturer's instructions carefully because products vary considerably in concentration and volume per vial. Use only with glass IV bottles and the administration sets provided. Protect from light and extremes of temperature.
- Infusion: Do not give by IV push; regulate rate based on patient response.
- Incompatibilities: Do not mix in solution with other drugs.
- CNS: Headache, apprehension, restlessness, weakness, vertigo, dizziness, faintness
- GI: Nausea, vomiting, incontinence of urine and feces, abdominal pain
- CV: Tachycardia, retrosternal discomfort, palpitations, hypotension, syncope, collapse, postural hypotension, angina
- Dermatologic: Rash, exfoliative dermatitis, cutaneous vasodilation with flushing, pallor, perspiration, cold sweat, contactdermatitis--transdermal preparations, topical allergic reactions--topical nitroglycerin ointment
- Local: Local burning sensation at the point of dissolution (sublingual)
- Other: Ethanol intoxication with high- dose IV use (alcohol in diluent)
Clinically important interactions
- Increased risk of hypertension and decreased antianginal effect with ergot alkaloids
- Decreased pharmacologic effects of heparin
- Drug-lab test
- False report of decreased serum cholesterol if done by the Zlatkis-Zak color reaction
History: Allergy to nitrates, severe anemia, early MI, head trauma, cerebral hemorrhage, hypertrophic cardiomyopathy, hepatic or renal disease, hypotension or hypovolemia, increased intracranial pressure, constrictive pericarditis, pericardial tamponade, low ventricular filling pressure or low PCWP, pregnancy, lactation
Physical: Skin color, temperature, lesions; orientation, reflexes, affect; P, BP, orthostatic BP, baseline ECG, peripheral perfusion; R, adventitious sounds; liver evaluation, normal output; liver and renal function tests (IV); CBC, Hgb
- Give sublingual preparations under the tongue or in the buccal pouch. Encourage patient not to swallow. Ask patient if the tablet "fizzles" or burns. Always check the expiration date on the bottle; store at room temperature, protected from light. Discard unused drug 6 mo after bottle is opened (conventional tablets); stabilized tablets (Nitrostat) are less subject to loss of potency.
- Give sustained-release preparations with water; warn the patient not to chew the tablets or capsules; do not crush these preparations.
- Administer topical ointment by applying the ointment over a 6 × 6 inch area in a thin, uniform layer using the applicator. Cover area with plastic wrap held in place by adhesive tape. Rotate sites of application to decrease the chance of inflammation and sensitization; close tube tightly when finished.
- Administer transdermal systems to skin site free of hair and not subject to much movement. Shave areas that have a lot of hair. Do not apply to distal extremities. Change sites slightly to decrease the chance of local irritation and sensitization. Remove transdermal system before attempting defibrillation or cardioversion.
- Administer transmucosal tablets by placing them between the lip and gum above the incisors or between the cheek and gum. Encourage patient not to swallow and not to chew the tablet.
- Administer the translingual spray directly onto the oral mucosa; preparation is not to be inhaled.
- Arrange to withdraw drug gradually. 4---6 wk is the recommended withdrawal period for the transdermal preparations.
Drug-specific teaching points
- Place sublingual tablets under your tongue or in your cheek; do not chew or swallow the tablet; the tablet should burn or "fizzle" under the tongue. Take the nitroglycerin before chest pain begins, when you anticipate that your activities or situation may precipitate an attack. Do not buy large quantities; this drug does not store well. Keep the drug in a dark, dry place, in a dark-colored glass bottle with a tight lid; do not combine with other drugs. You may repeat your dose every 5 min for a total of ____ tablets. If the pain is still not relieved, go to an emergency room.
- Do not chew or crush the timed-release preparations; take on an empty stomach.
- Spread a thin layer of topical ointment on the skin using the applicator. Do not rub or massage the area. Cover with plastic wrap held in place with adhesive tape. Wash your hands after application. Keep the tube tightly closed. Rotate the sites frequently to prevent local irritation.
- To use transdermal systems, you may need to shave an area for application. Apply to a slightly different area each day. Use care if changing brands; each system has a different concentration.
- Place transmucosal tablets between the lip and gum or between the gum and cheek. Do not chew; try not to swallow.
- Spray translingual spray directly onto oral mucous membranes; do not inhale. Use 5---10 min before activities that you anticipate will precipitate an attack.
- The following side effects may occur: dizziness, light-headedness (may be transient; change positions slowly); headache (lie down in a cool environment and rest; OTC preparations may not help); flushing of the neck or face (transient).
- Report blurred vision, persistent or severe headache, skin rash, more frequent or more severe angina attacks, fainting.
Adverse effects in Italic are most common; those in Bold are life-threatening.