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(nye-troe-GLIH-suh-rin)
Deponit, Minitran, Nitrek, Nitro-Bid, Nitro-Bid IV, Nitro-Dur, Nitro-Time, Nitrodisc, Nitrogard, Nitroglyn, Nitrol, Nitrolingual, Nitrong, NitroQuick, Nitrostat, Transderm-Nitro, Tridil,  Nitrong SR
Class: Antianginal

 Action Relaxation of smooth muscle of venous and arterial vasculature.

 Indications Treatment of acute angina (SL, translingual, IV, transmucosal); prophylaxis of angina (SL, transmucosal, translingual, sustained release, transdermal, topical); control of blood pressure in perioperative or intraoperative hypertension (IV); CHF associated with MI (IV). unlabeled use(s): Reduce cardiac workload in patients with MI and in refractory CHF (SL, topical, oral, IV); adjunctive treatment of Raynaud’s disease (topical); treatment of hypertensive crisis (IV).

 Contraindications Hypersensitivity to nitrates; severe anemia; closed-angle glaucoma; orthostatic hypotension; early MI; pericarditis or pericardial tamponade; head trauma or cerebral hemorrhage; allergy to adhesives (transdermal); hypotension or uncorrected hypovolemia (IV); increased intracranial pressure or decreased cerebral perfusion (IV).

 Route/Dosage

Perioperative Hypertension

ADULTS IV 5 mcg/min using nonperipheral vein catheter (PVCP) IV administration set initially; titrate to response.

Angina

ADULTS SL 0.15 to 0.6 mg dissolved under tongue or in buccal pouch at first sign of acute angina attack; repeat q 5 min (do not exceed 3 tablets in 15 min). Translingual 1 to 2 sprays onto or under tongue at first onset of attack. Transmucosal 1 mg every 3 to 5 hr during waking hours; tablet placed between lip or cheek and gum. PO 2.5 or 2.6 mg (sustained-release form) tid to qid initially; titrate to response. Transdermal 0.2 to 0.4 mg/hr patch initially applied once daily; titrate dose to response. Topical 1 to 2 inches q 8 hr up to 4 to 5 inches spread over 3 x 4 inch area and cover with plastic wrap to prevent staining of clothes or application q 4 hr prn. Allow a nitrate-free period of 10 to 12 hr/day.

Refractory Angina, CHF Secondary to Acute MI

Adults IV 5 mcg/min initially; titrate according to hemodynamic readings (BP, heart rate, pulmonary capillary wedge pressure).

 Interactions

Alcohol: Severe hypotension and cardiovascular collapse may occur. Calcium channel blockers: Symptomatic orthostatic hypotension may occur. Dihydroergotamine: May increase systolic blood pressure and decrease antianginal effects. Heparin: May decrease anticoagulation effect when used in conjunction with IV nitroglycerin.

 Lab Test Interferences May cause false report of reduced serum cholesterol with Zlatkis-Zak color reaction. May cause false-positive result in urinary catecholamines and VMA determinations.

 Adverse Reactions

CV: Tachycardia; palpitations; hypotension; syncope; arrhythmias. CNS: Headache; apprehension; weakness; vertigo; dizziness; agitation; insomnia. DERM: Cutaneous vasodilation with flushing; contact dermatitis (transdermal); topical allergic reactions (ointment); local burning or tingling sensation in oral cavity (sublingual). EENT: Blurred vision. GI: Nausea; vomiting; diarrhea; dyspepsia. GU: Dysuria; urinary frequency; impotence. HEMA: Methemoglobinemia; hemolytic anemia. RESP: Bronchitis; pneumonia. OTHER: Arthralgia; perspiration; pallor; cold sweat; edema.

 Precautions

Pregnancy: Category C. Lactation: Undetermined. Children: Safety and efficacy not established. Alcohol intoxication: Has occurred in patients receiving high doses of IV nitroglycerin. Angina: May aggravate angina caused by hypertrophic cardiomyopathy Defibrillation: Do not discharge cardioverter/defibrillator through paddle electrode overlying transdermal system. Arcing may occur and burn patient. Glaucoma: May increase intraocular pressure; administer with caution in patients with glaucoma. Hepatic and renal impairment: Use IV product with caution. Hypotension: Avoid excessive, prolonged hypotension with IV product because of possible harmful effects on brain, heart, liver and kidneys. MI: Safety of oral or sublingual products in acute MI not established; use only with close observation and monitoring. However, IV nitroglycerin is drug of choice in acute MI. Orthostatic Hypotension: May occur even with small doses; alcohol accentuates this reaction. Sublingual administration: Absorption is dependant on salivary secretion; dry mouth decreases absorption. Transdermal nitroglycerin: Not for immediate relief of anginal attacks.

PATIENT CARE CONSIDERATIONS

 Administration/Storage

IV

  • Dilute in D5W or 0.9% Sodium Chloride injection prior to infusion. Do not mix with any other infusions. Use glass bottles only and non-PVC tubing provided. Use with infusion pump. Do not use IV filter. Store premixed IV solution in dark. Do not freeze.

Topical

  • Apply uniform layer with applicator or on dose-measuring paper. Apply in thin, uniform layer on nonhairy area on upper arm or upper torso. After spreading measured dose, cover skin with plastic wrap to prevent staining of clothes. Wash hands after application. Store in original tube. Do not freeze.

Sublingual

  • Give while patient is lying or sitting. Place in buccal pouch to decrease stinging. Do not swallow. Store at room temperature in original, brown glass container. If cotton is in bottle, remove and discard after opening. Do not place cotton or other materials within bottle because they may absorb nitroglycerin. Protect from moisture. Discard unused amounts after 6 months.

PO (sustained-release)

  • Tell patients not to chew or dissolve capsule in mouth. Store at room temperature.

Transdermal

  • Apply patch to nonhairy area on upper arm or torso. Do not apply over cuts or abrasions. Remove old patch prior to applying new patch. Stor at room temperature. Do not open until ready to use.

Translingual

  • Do not shake canister prior to using. Patient should release spray under tongue. Do not inhale spray.

 Assessment/Interventions

  • Obtain patient history, including drug history and any known allergies.
  • Assess baseline vital signs, ECG, lung and heart sounds.
  • All other forms: Monitor vital signs, I&O. Assess for tolerance of drug effects.
  • Monitor for nausea, diarrhea, incontinence, abdominal pain, chest pain, bradycardia, flushing, pruritis, rash, or contact dermatitis.
  • Notyfy phys9cian ofPany muscle twitching, diaphoresis, pallor, edema, blurred vision, wheezing, hypotension, or chest pain.

IV

  • Assess lung and heart sounds regularly during IV therapy.
  • Monitor vital signs frequently while patient is receiving infusion and titrate dosage to systolic BP or pain relief as prescribed.
  • Monitor LOC. Notify physician of any significant hypotension, bradycardia, headache, or no reduction of anginal pain. Keep patient on bedrest.
  • Monitor pulmonary capillary wedge pressure and I&O.
OVERDOSAGE: SIGNS & SYMPTOMS
  Hypotension, tachycardia, flushing, excessive sweating, headache, vertigo, palpitations, visual disturbances, nausea, vomiting, confusion and dyspnea may occur as a result of vasodilation and methemoglobinemia

 Patient/Family Education

  • Review with patient and family the following signs of angina: Pressure-like chest pain of acute onset, often associated with physical activity, that may radiate down to left arm or up to neck and jaw.

Sublingual

  • Advise patient to dissolve tablet under tongue and not to swallow. If pain remains, the dose may be repeated every 5 min until 3 tablets are taken. If pain still persists or becomes more intense, patient should be taught to call 911 or appropriate local number to obtain emergency services.
  • Tell patient to place tablet between gum and cheek if stinging sensation occurs.
  • Caution patient to sit or lie down while taking and for 20 minutes after initial dose. If dizziness occurs, instruct patient to lie down.
  • Teach patient storage instructions (per Administration/Storage information).
  • Advise patient to discard 6 mo after opening package.
  • Instruct patient to report these symptoms to physician: Severe headache, blurred vision, dry mouth, dizziness or flushing.

Ointment, Spray, Sustained-Release, Transdermal

  • Advise patient to wear gloves or use dose-determining applicator when applying ointment.
  • Teach patient to leave a 10 to 12 hr nitrate-free period at night to decrease likelihood of developing tolerance.
  • For transdermal form, tell patient to change site of application to avoid skin sensitization.
  • Explain that swimming or bathing does not affect effectiveness of drug.
  • Advise patient to notify physician of any decrease in effectiveness of medication.
  • Caution patient to avoid sudden position changes to prevent orthostatic hypotension.
  • Instruct patient to avoid intake of alcoholic beverages.

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