ATI Nitrates

Nitrates – Nitroglycerin and Isosorbide

Therapeutic Use

• Angina Pectoris Treatment:

  • Rapid-acting forms (e.g., transmucosal tablets, translingual spray, sublingual tablets) treat acute angina attacks.

  • Longer-acting forms (regular tablets, immediate release, sustained release) prevent angina attacks.

  • IV nitroglycerin is used for severe unstable angina, controlling perioperative blood pressure, and treating heart failure after acute myocardial infarction (MI).

Adverse Drug Reactions

• Common Reactions:

  • Severe headache (often initially, diminishes with continued use).

  • Orthostatic hypotension.

  • Tachycardia.

  • Rapid tolerance develops to all forms, leading to decreased effectiveness.

Interventions

• Application Guidelines:

  • Caregivers should not touch ointment while applying.

  • Monitor headache duration and severity; recommend mild analgesics PRN.

  • Record baseline blood pressure and pulse; reassess when nitrate reaches peak effect.

  • Monitor heart rate in clients on nitrates.

  • Administer beta blockers or calcium channel blockers as prescribed to manage tachycardia.

  • Watch for signs of medication tolerance.

  • Administer the smallest necessary amount; use intermittent scheduling for transdermal and long-acting forms.

Administration

• Forms of Nitroglycerin:

  • Available as sublingual tablets, sustained-release capsules/tablets, translingual spray, transmucosal tablets, transdermal ointment/patch, and IV form.

• Isosorbide Types:

  • Isosorbide dinitrate: regular, chewable, sublingual, or sustained-release tablets.

  • Isosorbide mononitrate: sustained and immediate release tablets or capsules.

• Sublingual Administration:

  • Place under the tongue when chest pain starts; call 911 if no relief in 5 minutes, can take a second and third dose (5 minutes apart).

  • Sublingual spray: 1-2 sprays, no more than 3 doses in 15 minutes.

• Regulations for Transdermal Use:

  • Do not swallow transdermal or transmucosal tablets; may moisten mouth to facilitate dissolution.

  • Store sublingual tablets in a dark, tightly closed container for up to 24 months post-opening.

  • Transdermal patches are preventive; apply to hairless areas and rotate placements.

  • Remove patches for 10-12 hours daily to prevent tolerance (apply in the morning, remove at night).

  • Topical ointment: measured (e.g., 2 inches = 30 mg) applied to dry skin and covered with transparent dressing.

  • Gradually taper doses of long-acting forms to avoid increased chest pain.

• IV Administration:

  • Infuse continuously using a glass bottle and specific tubing only.

Client Instructions

• Headaches Management:

  • Use over-the-counter analgesics for unrelieved headaches (most resolve within 20 minutes).

• Safety Precautions:

  • Report dizziness or syncope to the provider.

  • Rise slowly from lying to standing to prevent injury.

  • Avoid hazardous activities (like driving) if dizziness occurs.

  • Monitor pulse; report tachycardia outside prescribed limits.

• Transdermal and Sublingual Management:

  • Remove transdermal forms part of each day.

  • Take only the necessary number of sublingual tablets.

Contraindications

• Conditions to Avoid:

  • Allergy or tolerance to nitroglycerin or isosorbide.

  • Pregnancy and lactation.

  • Increased intracranial pressure.

  • Severe anemia or pericardial tamponade.

  • Uncorrected hypovolemia.

Precautions

• At-Risk Populations:

  • Individuals with head trauma, glaucoma, cardiomyopathy, severe liver disease, dry mouth conditions, recent MI, or older adults.

Interactions

• Potential Drug Interactions:

  • Increased risk of hypotension with other antihypertensives or alcohol.

  • Severe hypotension when combined with phosphodiesterase-5 (PDE5) inhibitors (e.g., sildenafil).

  • Anti-cholinergic medications may reduce sublingual nitroglycerin absorption.