Drug Information Table Nitrates – nitroglycerin, isosorbide (Isordil) Therapeutic Use Administration • Treatment and prophylaxis of • Nitroglycerin available as angina pectoris sublingual tablets, sustained- ◦◦Rapid-acting forms (only release capsules or tablets, transmucosal tablets, a translingual spray or translingual spray and transmucosal tablets, sublingual tablets treat an transdermal ointment or patch, angina attack) and IV form ◦◦Longer acting forms such as • Two types of isosorbide are regular tablets, immediate available release or sustained release ◦◦isosorbide dinitrate (Isordil) tablets/capsules are used to available in regular, chewable, prevent attacks from occurring sublingual or sustained • IV nitroglycerin is used for release tablets. severe unstable angina attacks ◦◦isosorbide mononitrate ((Ismo, and to control blood pressure Imdur) available in sustained perioperatively and to treat release and immediate heart failure after acute MI release tablets or capsules • Place sublingual tablets under tongue to dissolve when chest pain starts; if not relieved in 5 minutes, call 911, take a second tablet; take a third tablet 5 minutes later if no relief • Sublingual sprays: Dose equals 1 or 2 sprays; as for sublingual tablets, no more than 3 doses in a 15 minute period • Patient should not swallow transdermal or transmucosal tablets; may need to moisten mouth to help tablet dissolve • Store tablets in a dark tightly closed container for no more than 24 months after opening. • Transdermal patches are for prevention only; apply to a hairless area and rotate sites. • Remove patches for 10-12 hours daily to prevent tolerance; apply patch in morning, remove at night. • Topical ointment: dosage measured as amount squeezed from tube (e.g. 2 inches = 30 mg); apply to dry skin and cover area with plastic wrap • When discontinuing long- acting forms, taper doses to prevent increased chest pain (vasospasm) • IV form is infused continuously in a glass bottle with special tubing only Side/Adverse Effects Interventions Patient Instructions • Headache (severe at first, • Caregivers should avoid • Take over-the-counter analgesic reduced with treatment) touching ointment when for unrelieved headaches (most applying subside spontaneously within • Monitor length and severity of 20 minutes) patient headache • Orthostatic hypotension • Monitor baseline orthostatic BP • Report dizziness, syncope to and pulse; check again when provider nitrate form reaches its peak • Move slowly from lying down effect (e.g. 1 hr for transdermal to sitting or standing to prevent forms) injury • Do not perform hazardous activity, such as driving, if dizziness occurs • Tachycardia • Monitor heart rate in patients • Take pulse and report taking nitrates tachycardia above prescribed • Give beta blocker or calcium parameters channel blocker, if prescribed, to suppress tachycardia • Tolerance develops quickly • Monitor for drug tolerance • Remove transdermal forms for to all forms (decreased • Give any nitroglycerin form part of each day effectiveness) in smallest needed amount; • Take only as many sublingual use intermittent scheduling for tablets as needed transdermal and long-acting forms Contraindications Precautions Interactions • Allergy or tolerance to • Hypotension • Increased hypotension may nitroglycerin or isosorbide • Hypovolemia result when used with other • Head injury, increased • Hyperthyroidism antihypertensive drugs or with intracranial pressure • Liver disease alcohol • Severe anemia • Conditions that cause dry • PDE5 inhibitors, such as • Glaucoma (sustained release mouth (sublingual and sildenafil (Viagra) may cause forms) transmucosal forms) severe hypotension • GI disease including • Early MI • Beta blockers and calcium hypermotility (sustained release • Older adults channel blockers decrease isosorbide) tachycardia caused by • IV nitroglycerin: nitroglycerin ◦◦hypotension ◦◦hypovolemia (correct before administering) ◦◦Constrictive pericarditis