Nitroglycerin (Nitrostat, Nitrogard, Nitrolingual, Nitro-Bid, Nitrol, Nitro-Dur, Transderm-Nitro)

Category:

• Miscellaneous

Description:

• Antianginal (venous (predominantly) and arterial dilator)

Indications:

• Acute angina, angina prophylaxis, perioperative hypertension, CHF associated with MI

• Unresponsive angina pectoris

Contraindications:

• Severe anemia, closed-angle glaucoma, postural hypotension, early MI, head trauma

• Cerebral hemorrhage, hypotension, uncorrected hypovolemia, inadequate cerebral circulation, increased intracrainial pressure, constrictive pericarditis, pericardial tamponade (IV)

Precautions:

• Pregnancy category C; may use SL for angina

• Early days of MI, hypertrophic cardiomyopathy, severe hepatic/renal disease

• Children, glaucoma, abrupt withdrawal, continuous delivery

Adverse Reactions (Side Effects):

• CNS: agitation, anxiety, apprehension, confusion, dizziness, dyscoordination, headache, hypoesthesia, hypokinesia, insomnia, nervousness, nightmares, vertigo, restlessness

• CV: atrial fibrillation, collapse, crescendo angina, dysrhythmias, palpitations, postural hypotension, PVC’s, rebound hypertension, retrosternal discomfort, syncope, tachycardia

• GI: abdominal pain, diarrhea, dyspepsia, fecal incontinence, nausea, tenesmus

• GU: dysuria, impotence, urinary frequency

• HEME: hemolytic anemia, methemoglobinemia

• SKIN: allergic reactions (ointment), contact dermatitis (transdermal), crusty skin lesions, cutaneous vasodilation with flushing, exfloiative dermatitis, rash, sweating

Dosage:

Administered orally (spray, capsule, SL tablet, EC tablet, buccal tablet), topically (transdermal, ointment), and intravenously

• Adult: 

  • BUCCAL 1mg every 3-5 hours while awake initially, titrate dosage upward if angina occurs with tablet in place

  • PO 2.5-9mg 2-4 times daily, up to 26mg 4 times daily;

  • IV 5 mcg/min via continuous infusion, increase by 5 mcg/min every 3-5 minutes to 20 mcg/min; if no response, increase by 10 mcg/min every 3-5 minutes up to 200 mcg min;

  • TOP 1-2 inches every 8 hours, up to 4-5 inches every 4 hours

  • TRANSDERMAL 0.2-0.4 mg/hr initially, titrate to 0.4-0.8 mg/hr; apply new patch daily; tolerance is minimized by removing patch for 10-12 hours daily

  • SL 0.2-0.6mg every 5 minutes for a max of 3 doses in 15 minutes; may also use prophylactically 5-10 minutes prior to activities that provoke angina attack

• Child: 

  • IV 0.25-0.5 mcg/kg/min, titrate by 0.5-1 mcg/kg/min every 3-5 minutes as needed; usual dose 1-3 mcg/kg/min; max 20 mcg/kg/min

Special Considerations:

• 10-12 hour drug-free intervals prevent development of tolerance