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Nitroglycerin Nitroglycerin Brand names Generic Medication error Look-alike, sound-alike drug names potential USP reports that nitroglycerin has been confused with Neo-Synephrine, nicotine, nitro- furantoin, nitroprusside, and nystatin. Nitro-Bid has been confused with Macrobid and Nitro-Dur. Tridil has been confused with Toradol.(1) Contraindications Contraindications: Patients allergic to nitrates, and in patients with pericardial tam- and warnings ponade, restrictive cardiomyopathy, or constrictive pericarditis. Do not use in patients taking phosphodiesterase inhibitors due to the risk of severe hypotension, syncope, or myocardial ischemia.(3,4,14) Do not use in patients taking riociguat due to risk of hypoten- sion.(3,14) Solutions containing dextrose may be contraindicated in patients with known allergy to corn or corn products.(3) Warnings: The amount of nitroglycerin delivered is highly dependent on the type of container and administration set used.(3,4,14) (See the Preparation and Delivery section.)(4) Infusion-related Severe hypotension and shock can occur with small doses. Monitor blood pressure and cautions heart rate closely.(3,4,14) Dosage Early published studies may have used PVC administration sets, and, therefore, required doses may be reduced (as much as fivefold) when low-adsorbing infusion sets are used.(3,4,14) Heart failure/angina/coronary artery disease/hypertensive emergencies Neonates, infants, and children: 0.1–1 mcg/kg/min, increase by 0.5–1 mcg/kg/min q 3–5 min until desired clinical response,(5-7) usually ≤20 mcg/kg/min.(8) The PALS recommendation is to begin with 0.25–0.5 mcg/kg/min and increase by 1 mcg/kg/min q 15–20 min PRN up to 1–5 mcg/kg/min (maximum 10 mcg/kg/min).(9) Adolescents and adults: 5 mcg/min, increase by 5 mcg/min q 3–5 min. When initial partial response is observed, use more cautious dose titration. If the desired response is not achieved at 20 mcg/min, increase by 10–20 mcg/min until desired clinical response.(3,4,14) Responses are usually noted with infusion rates from 5–100 mcg/min.(10) The PALS recommendation is to begin with 5–10 mcg/min and increase to a maximum of 200 mcg/min.(9) In hypertensive emergencies, blood pressure should be frequently monitored to ensure that it does not decrease too quickly.(10) One group recommended that the blood pres- sure decrease by one-third of the desired total blood pressure reduction within 6 hours, a further one-third decrease within the next 24–36 hours, with the final one-third decrease achieved over the next 48–72 hours.(11) A blood pressure decrease of <25% within minutes to 1 hour followed by further decreases over the next 2–6 hours if the patient is stable has been suggested.(10) (See the Infusion-Related Cautions section.) Dosage adjustment No dosage adjustment is required for renal dysfunction.(12) in organ dysfunction Maximum dosage 60 mcg/kg/min was infused for ≤30 minutes to infants and children with congenital heart defects who had a low cardiac index postoperatively; however, the type of tubing used for the infusion was not stated.(6) (See the Preparation/Delivery in the Preparation and Delivery section.) In adults with hypertension, doses up to 100 mcg/min have been used.(10) In adults with acute myocardial infarction, despite no absolute maximum dose, the risk of hypotension increases with doses approaching 200 mcg/min.(10) Doses of 400 mcg/min have been reported.(20) PALS recommendations include maximum doses of 10 mcg/kg/min in children and 200 mcg/min in adolescents.(9) 652 Nitroglycerin Additives Nitroglycerin injection contains 30% alcohol and 30% propylene glycol in water.(4) Nitro- glycerin in 5% dextrose injection may contain varying additives by manufacturer including propylene glycol(3,14) and alcohol.(14) See Appendix C for more specific information about potential adverse effects of propylene glycol. Suitable diluents D5W, NS,(3,4,14) D5LR, D5½NS, D5NS, LR, ½NS.(15) Stability as reported in glass or polyolefin containers (see detailed reference for more information).(15) Maximum 400 mcg/mL(3,4,14) concentration Preparation and Parenteral products should be visually inspected for particulate matter and discoloration delivery before use. Refer to appropriate references for more information on compatibility with other drugs and solutions, compatibility following Y-site delivery, and suggested storage and extended stability.(15) Preparation/delivery: Nitroglycerin readily adsorbs to many plastics; therefore, glass infusion bottles and non-PVC administration (i.e., polyolefin)(15) sets are recommended.(4,14) Caution with nonabsorbing administration sets as over-infusion may occur; dose must be reduced from published study recommendations using PVC tubing by as much as five- fold.(3,14) If PVC sets are used, larger doses are required. Some filters absorb nitroglycerin; these filters should be avoided.(3,4,14) IV push Not indicated Intermittent infusion Not indicated Continuous infusion 50–400 mcg/mL(3,4,14) Other routes of IO(9) administration Comments Significant adverse effects: Methemoglobinemia was associated with doses >7 mcg/kg/min in adults.(16,17) However, methemoglobinemia did not occur in 16 pediatric patients (3 days to 23.7 months) who received concomitant IV nitroglycerin (0.5–4 mcg/kg/min) and sodium nitroprusside (0.3–8.4 mcg/kg/min) for 0.5–7.6 days.(18) Monitoring: Blood pressure,(3,4,9,14) heart rate,(3,4,14) and ECG should be continuously monitored.(9) Pharmacodynamic considerations: In adults, tolerance to hemodynamic effects of nitroglycerin is observed within 12–48 hours after beginning continuous infusion. If such tolerance occurs, intermittent therapy or a nitrate-free interval ≥8 hours after 12–48 hours of continuous infusion has been recommended.(19) Drug interactions: IV nitroglycerin may interfere with the anticoagulant effects of heparin; frequent monitoring of heparin is recommended.(3,4,14) Lab interference: The propylene glycol content of nitroglycerin formulations may result in falsely elevated results for serum triglyceride assays that rely on glycerol oxidase.(3,4,14) REFERENCES 1. Hicks RW, Becker SC, Cousins DD, eds. MEDMARX Data Report. A Report on the Relationship of Drug Names and Medication Errors in Response to the Institute of Medicine’s Call for Action. Rockville, MD: USP Center for the Advancement of Patient Safety; 2008. 3. Nitroglycerin in dextrose [prescribing information]. Lake Forest, IL: Hospira Inc; October 2014. 4. Nitroglycerin injection, USP [prescribing information]. Shirley, NY: American Regent Inc; November 2005. 5. Ilbawi MN, Idriss FS, DeLeon SY, et al. Hemodynamic effects of intravenous nitroglycerin in pediatric patients after heart surgery. Circulation. 1985;72(3 pt 2):II101-107. 653.
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