NITROGLYCERIN (glyceryl trinitrate)

• Anginine, Deponit, Minitran, Nitradisc, Nitrek, Nitro-Bid, Nitro-Bid lV, Nitrodisc, Nitro-Dur, Nitrogard, Nitroglyn, Nitrolingual, Nitrong, NitroQuick, Nitrostat, NitroTab, Nitro-Time, NTS, Transderm-Nitro, Transiderm-Nitro, Tridil

PHARMACOLOGIC CLASS: NITRATE

PREGNANCY RISK CATEGORY C

 

AVAILABLE FORMS

Aerosol (translingual): 0.4 mg/meterd spray

Capsules (sustained-release): 2.5 mg, 6.5 mg, 9 mg,

Injection: 5 mg/ml; 100 mcg/ml, 200 mcg/ml, 400 mcg/ml

Tablets (S.L): 0.3 mg, 0.4 mg, 0.6 mg

Tablets (sustained-release), 2.6 mg, 6.5 mg, 9 mg, 13 mg

Topical: 2% ointment

Transdermal: 0.1 mg/hour, 0.2 mg/hour, 0.3 mg/hour, 0.4 mg/hour, 0.6 mg/hour, 0.8 mg/hour release rate.

 

INDICATIONS & DOSAGES

> To prevent chronic anginal atracks

Adult: 2.5 or 2.6 mg sustained-release capsule or tablet q 8 to 12 hours. Increase to an effective dose in 2.5 - or 2.6-mg increments b.i.d. to q.i.d. Or, use 2% ointment: Start dosage with 1/2-inch ointment, increasing by 1/2-inch increments until desired results are achieved. Range of dosage with ointment is 1/2 to 5 inches. Usual dose is 1 to 2 inches q 6 to 8 hours. Or, transdermal disc or pad (Nitrodisc, Nitro-Dur, or Transderm-Nitro) 0.2 to 0.4 mg/hour once daily.

> Acute angina pectoris; to prevent or minimize anginal attacks before stressful events

Adult: 1 S.L. tablet (1/400 grain, 1/200 grain, 1/150 grain, 1/100 grain) dissolved under the tonque or in the buccal pouch as soon as angina begins. Repeat q 5 minutes, if needed, for 15 minutes. Or, one or two sprays Nitrolingual into mouth, preferably onto or under the tonque. Repeat q 3 to 5 minutes if needed, to a maximum of three doses within a 15-minutes period. Or, 1 to 3 mg transimucisally q 3 to 5 hours while awake.

>Hypertension from surgery, heart failure after MI, angina pectoris in acute situation, to produce controlled hypotension during surgery (by I.V. infusion)

Adult: Initially, infuse at 5 mcg/minute. Increasing p.r.n. by 5 mcg/minute q 3 to 5 minutes until response occurs. If a 20-mcg/minute rate doesn't produce a responce, increase dosage by as much as 20 mcg/minute q 3 to 5 minutes. Up to 100 mcg/minute may be needed.

I.V. ADMINISTRATION 

• Dilute with D5W or normal saline solution for injection. Concentration shouldn't exceed 400 mcg/ml.
• Always give with an infusion control device and titrate to desired response.
• Regular polyvinyl chloride tubing is available from the manufacturer. Always mix in glass bottles and avoid using a filter.
• Use the same type of infusion set when changing lines

• When changing the concentration of infusion, flush the administration set with 15 to 20 ml of the new concentration before ise. This will clear the line of the old drug solution. 

 INCOMPATIBILITIES

 Alteplase, bretylium, hydralazine, levofloxacin, phenytoin sodium.

 ACTION

  A nitrate that reduces cardiac oxygen demand by decreasing left ventricular end- diastolic pressure (preload) and, to a lesser extent, systemic vascular resistance (afterload). Also increases blood flow through the collateral coronary vessels

_______________________________________

Route         Onset          Peak            Duration
_______________________________________
P.O.          20-45 min     Unknown      3-8 hr
I.V.           Immediate    Unknown      3-5 min
Topical     30 min         Unknown      2-12 hr
Trans-      30 min         Unknown      24 hr 
dermal
S.L           1-3 min       Unknown      30-60 min
Buccal     3 min          Unknown      3-5 hr
Trans-     2-4 min      Unknown      30-60 min
lingual
_______________________________________
 half-life About 1 to 4 minutes




ADVERSE REACTIONS
CNS: headache, dizziness, weakness.
CV: orthostatic, hypotension. tachycardia, flushing, palpitaions, fainting.
EENT: S.L burning.
GI: nausea, vomiting.
Skin: cutaneous vasodilation, cantact dermatitis, rash.
Other:  hypersensitivity reactions.


INTERACTIONS
Drug-drug. Alteplase : May decrease the sue plasminogen activator-antigen level.

Avoid  using together; if unavoidable, use lowest effective dose of nitroglycerin.

Antihypertensive: May increasive hypotensive effect. Monitor BP closely.

Heparin: I.V nitrogycelyn may interfere with anticoagulant effect of heparin. Monitor PTT.

May cause severe hypotension. Use of nitrate in any form with this drugs is contraindicated.

Drug-Lifestyle. alcohol use : may increase hypotension. discourage use together 

EFFECTS ON LAB TEST RESULT

• may falsely decrease values in colesterol determination test using the zlatkisZak color reaction.

CONTRAINDICATION

• contraindicated in patient with early MI ( oral and sublingual ), severe anemia, increased intracranial pressure, angleclosure glaucoma, orthostatic hypotension, allergy adhesives ( transdermal ), or hypersensitivity to nitrate. I.V. nitroglycerin is contraindicated in patient with hypersensitive to I.V. form, with cardiac tamponade, restrictive cardiomyopathy, or constrictive pericarditis. 
• use cautiously in patient with hypotension or volume depletion.

 

NURSING CONSIDERATIONS

•  closely monitor vital signs during infusion particularly BP, specially with a patient with MI. excessive hypotension may worsen the MI.
• to apply ointment, measure the prescribed amount on the application paper; then place the paper on any non hairy area. dont rub in. cover with plastic film to aid absorption and to protect clothing. remove all excess ointment from previous site befora applying the next dose. avoid getting ointment on finger.
• monitor BP and intensity and duration of drug response.
• look alike sound alike; dont confuse nitrobid with nicobid or nitroglycerin with nitroprusside. 

 

PATIENT TEACHING

• caution patient to take nitroglycerin regularly, as prescribed, and to have it accesible at all times.
• alert: advice patient stopping drug abruptly causes spasm of the coronary arteries.
• advice patient to complains of at tingling sensation with S.L. drug to try holding tablet in cheek.
• tell patient to take an additional dose before anticipated stress or at bed time if chest pain occurs at night.

• advice patient that use of sildenafyl, tadalafyl, or verdenafyl with any nitrate may cause severe low BP. the patient should talk to his prescriber before considering use of this drugs together.