GL/PTC/04.

R4-2014

CHANGI GENERAL HOSPITAL

GUIDELINES ON USE OF
INTRAVENOUS GLYCERYL TRINITRATE (GTN)
These guidelines were approved by the Pharmacy and Therapeutics Committee with effect from 8 JAN 2014
and supersedes the previous version (GL/PTC/04.R3-2009) dated 26 Dec 2009

Drug Class
Vasodilators, organic nitrates

Drug Status
General, unrestricted use in areas where continuous blood and pressure and heart rate monitoring
can be carried out

Mechanism of Action
GTN relaxes smooth muscles, particularly in the vascular system. It balances the myocardial oxygen
demand and delivery by decreasing left ventricular filling pressure and systemic vascular resistance
and increasing cardiac output. The dilation of coronary arteries by GTN improves collateral flow to
ischaemic regions of the myocardium.

Therapeutic Indications
1. Treatment or prevention of angina pectoris, acute decompensated heart failure associated with
acute myocardial infarction and acute left-sided heart failure
2. Hypertensive urgencies/emergencies
3. Control of peri-operative hypertension (especially during cardiovascular surgery)
4. Induction of controlled hypotension for surgery
5. Short-term management of pulmonary hypertension (unlicensed indication)

Contraindications
1. Hypersensitivity to nitrates
2. Hypotensive shock or uncorrected hypovolemia
3. Hypotension (SBP <90mmHg or >30mmHg below baseline), extreme bradycardia (<50bpm),
tachycardia in the absence of heart failure (>100bpm)
4. Right ventricular infarction
5. Constrictive pericarditis
6. Pericardial tamponade
7. Arterial hypoxaemia and angina caused by hypertrophic obstructive cardiomyopathy
8. Angle-closure glaucoma (may increase intra-ocular pressure)
9. Head trauma or cerebral haemorrhage (may increase intracranial pressure)
10. Toxic pulmonary oedema
11. Concurrent use with phosphodiesterase type 5 inhibitors (e.g., sildenafil, tadalafil, vardenafil)

Precautions for use

1. Hepatic insufficiency, renal insufficiency
2. Volume depletion.
3. Moderate hypotension.

Drug Interactions
1. Increased risk of orthostatic hypotension if ethanol (alcohol) is ingested within an hour before
nitrate administration.
2. May antagonise anticoagulant effect of heparin.
3. May reduce effect of recombinant tissue plasminogen activator (rTPA).
4. Ergot alkaloids (e.g., ergotamine) may cause overall increase in blood pressure and reduced anti-
anginal effect.
5. Avoid concomitant use with phosphodiesterase type 5 inhibitors.

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Pregnancy Risk Factor

Category C
Increased foetal mortality has been observed in animal studies; no adequate and well-controlled
studies in pregnant women.

Lactation
Extent of excretion into breast milk unknown, GTN should not be used unless considered essential

Adverse Drug Effects

(All incidences undefined)

Cardiovascular : Hypotension, tachycardia, flushing, peripheral oedema, paradoxical

bradycardia
Central nervous system : Headache (very common), light-headedness, dizziness
Gastrointestinal : Nausea, vomiting, xerostomia
Genitourinary : Urinary incontinence
Haematologic : Methaemoglobinaemia (rare, associated with overdose)
Neuromuscular & skeletal : Weakness, paraesthesia
Ocular : Blurred vision
Respiratory : Dyspnoea, pharyngitis, rhinitis
Miscellaneous : Cold sweat (diaphoresis)

Recommended Dosing
5 mcg/min initially, increasing by 5 mcg/min every 3-5 minutes till angina is resolved or blood
pressure is controlled. Usual maximum dose is 20 mcg/min.
(N.B. When IV glyceryl trinitrate is prescribed, it is advisable that physicians indicate in writing
what the desired clinical outcome(s) are, e.g., target blood pressure readings and/or heart rate, as
well as how they intend the dose of the drug to be titrated based on the response of the patient).
If response is inadequate at 20 mcg/min, dose may be increased cautiously by 5-10 mcg/min
every 3-5 minutes to a maximum of 400 mcg/min with close monitoring of blood pressure and
heart rate.

Dilution and Administration

Each ampoule/vial of glyceryl trinitrate injection is a solution for injection and may come in variable
concentrations (e.g., 10 mg/10 mL, 50 mg/5 mL, 50 mg/10 mL, 50 mg/50 mL).

Dilution guidelines for infusion initiated in all wards

Dilute 20 mg (double-check carefully for required volume needed) of IV GTN to a final volume of
100 mL using sodium chloride 0.9% (use 100mL plastic infusion bottle).
The final concentration of the drug solution is 0.20 mg/mL (i.e., 200 mcg/mL).
The drug should be infused as a continuous IV infusion via an infusion device which permits
maintenance of a constant infusion rate.
Discard unused solution 24 hours after dilution
See Table 1 for infusion rates corresponding to dose ranges.
The infusion rates (in mL/hour) for a given dose of IV GTN (in mcg/min) may be calculated using
the following formula:

Dose (in mcg/min) x 60 (mins)

Infusion rate (mL/hour) = ----------------------------------------------
200 (mcg/mL)

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Table 1. Infusion rates for 200mcg/mL solution

Dose Infusion rate
(mcg/min) (mL/hour)
5 1.5
6 1.8
7 2.1
8 2.4
9 2.7
10 3
11 3.3
12 3.6
13 3.9
14 4.2
15 4.5
16 4.8
17 5.1
18 5.4
19 5.7
20 6

Monitoring
1. Blood pressure.
2. Heart rate.
3. Pulmonary capillary wedge pressure (if necessary)
4. Cardiac output and precordial electrocardiogram (if necessary)

References
st
1. Drug Information Handbook (21 Edition),2012-2013
th
2. Pharmacotherapy. A Pathophysiologic Approach. (5 Edition).
3. Glyceryl trinitrate Summary of Product Characteristics
http://www.medicines.org.uk/emc/medicine/20943/SPC/Glyceryl+Trinitrate+1mg+ml+solution+for+
st
infusion/. Last accessed on 31 Dec 2013.

For any clarification regarding this document, contact the pharmacist at:
In-patient Pharmacy (Ext. 1915/1917)
Drug Information Centre (Ext. 1885)