nitroglycerin

(nye troe gli' ser in)

Intravenous:

Nitro-Bid IV, Nitroject (CAN), Tridil

Spray:

Nitrolingual Pumpspray
Sublingual:

NitroQuick, Nitrostat
Sustained-release:

Nitroglyn E-R, Nitrong, Nitro-Time, NitroTab

Topical:

Nitro-bid, Nitrong
Transdermal:

Deponit, Minitran, Nitrek, Nitro-Dur, Nitrodisc, Transderm-Nitro

Translingual:

Nitrolingual
Transmucosal:

Nitrogard Pregnancy Category C

Drug classes

Antianginal Nitrate
Therapeutic actions

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.
Indications

Sublingual, translingual preparations: Acute angina Oral sustained release, sublingual, topical, transdermal, translingual, transmucosal preparations: Prophylaxis of angina IV: Angina unresponsive to recommended doses of organic nitrates or betablockers IV: Perioperative hypertension IV: CHF associated with acute MI IV: To produce controlled hypertension during surgery Unlabeled uses: Reduction of cardiac workload in acute MI and in CHF (sublingual, topical); adjunctive treatment of Raynaud's disease (topical) Contraindicated with allergy to nitrates, severe anemia, early MI, head trauma, cerebral hemorrhage, hypertrophic cardiomyopathy, pregnancy, lactation.

Contraindications and cautions

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

Injection0.5, 5 mg/mL; injection solution25, 50, 100, 200 mg; sublingual tablets 0.3, 0.4, 0.6 mg; translingual spray0.4 mg/spray; transmucosal tablets1, 2, 3 mg; transmucosal SR tablets1, 2, 2.5, 3, 5 mg; oral SR capsules2.5, 6.5, 9 mg; transdermal0.1, 0.2, 0.3, 0.4, 0.6, 0.8 mg/hr; topical ointment2%
Dosages ADULTS IV

Initial dose, 5 mcg/min delivered through an infusion pump. Increase by 5-mcg/minincrements every 35 min as needed. If no response at 20 mcg/min, increase increments to 1020 mcg/min. Once a partial BP response is obtained, reduce dose and lengthen dosage intervals; continually monitor response and titrate carefully.
Sublingual

Acute attack: 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. Prophylaxis: Use 510 min before activities that might precipitate an attack.

Sustained-release (oral)

Initial dose, 2.59 mg q 12 hr. Increase to q 8 hr as needed and tolerated. Doses as high as 26 mg given qid have been used.
Topical

Initial dose, one-half inch q 8 hr. Increase by one-half inch to achieve desired results. Usual dose is 12 inches q 8 hr; up to 45 inches q 4 hr have been used. 1 inch = 15 mg nitroglycerin.
Transdermal

Apply one patch each day. Adjust to higher doses by using patches that deliver more drug or by applying more than one patch. Apply patch to arm; remove at bedtime.
Translingual

Spray preparation delivers 0.4 mg/metered dose. At onset of attack, spray 12 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 510 min prior to activity that might precipitate an attack.
Transmucosal

1 mg q 35 hr during waking hours. Place tablet between lip and gum above incisors, or between cheek and gum.
PEDIATRIC PATIENTS

Safety and efficacy not established.

Pharmacokinetics
Route IV Sublingual Onset 12 min 13 min Duration 35 min 3060 min

Translingual spray Transmucosal tablet Oral, sustained-release Topical ointment Transdermal

2 min 12 min 2045 min 3060 min 3060 min

3060 min 35 min 812 hr 48 hr 24 hr

Metabolism: Hepatic; T1/2: 14 min Distribution: Crosses placenta; enters breast milk Excretion: Urine
IV facts

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.
Adverse effects

CNS: Headache, apprehension, restlessness, weakness, vertigo, dizziness, faintness CV: Tachycardia, retrosternal discomfort, palpitations, hypotension, syncope, collapse, orthostatic hypotension, angina Dermatologic: Rash, exfoliative dermatitis, cutaneous vasodilation with flushing, pallor, perspiration, cold sweat, contact dermatitistransdermal preparations, topical allergic reactionstopical nitroglycerin ointment GI: Nausea, vomiting, incontinence of urine and feces, abdominal pain Local: Local burning sensation at the point of dissolution (sublingual) Other: Ethanol intoxication with high-dose IV use (alcohol in diluent)

Interactions

Drug-drug 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
Nursing considerations Assessment

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. 46 wk is the recommended withdrawal period for the transdermal preparations. 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 3 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.

Interventions

Teaching points

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 510 min before activities that you anticipate will precipitate an attack. These side effects may occur: Dizziness, light-headedness (may be transient; change positions slowly); headache (lie down in a cool environment and rest; over-the-counter preparations may not help); flushing of the neck or face (transient). Report blurred vision, persistent or severe headache, rash, more frequent or more severe angina attacks, fainting.

Adverse effects in Italic are most common; those in Bold are life-threatening.