Dosing & Uses
Dosage Forms & Strengths
infusion solution
- 25mg/250mL
- 50mg/250mL
- 100mg/250mL
injectable solution
- 5mg/mL
Angina
If intolerant of or unresponsive to SL NTG
5 mcg/min
Increase by 5 mcg/min q3-5min up to 20 mcg/min, THEN
Increase by 10 mcg/min
May later increase by 20 mcg/min
Higher dosages required for PVC admin sets
Uninterrupted infusion >24 hours produces tolerance
Renal Failure
CrCl: 10-50 mL/min: Administer q24-72hr
CrCl: <10 mL/min: Administer q72-96hr
Other Indications & Uses
Angina pectoris, perioperative HTN, CHF in the setting of MI, induction of intra-operative hypotension
Off-label: hypertensive crisis, variceal bleeds (with vasopressin), sympathomimetic-induced cardiopulmonary toxicities
Interactions
Interaction Checker
No Results
Contraindicated
Serious - Use Alternative
Significant - Monitor Closely
Minor
Contraindicated (12)
- avanafil
nitroglycerin IV, avanafil. Mechanism: additive vasodilation. Contraindicated. Potentially fatal hypotension.
- bromocriptine
bromocriptine decreases effects of nitroglycerin IV by pharmacodynamic antagonism. Contraindicated.
- cabergoline
cabergoline decreases effects of nitroglycerin IV by pharmacodynamic antagonism. Contraindicated.
- dihydroergotamine
dihydroergotamine decreases effects of nitroglycerin IV by pharmacodynamic antagonism. Contraindicated.
- dihydroergotamine intranasal
dihydroergotamine intranasal decreases effects of nitroglycerin IV by pharmacodynamic antagonism. Contraindicated.
- ergoloid mesylates
ergoloid mesylates decreases effects of nitroglycerin IV by pharmacodynamic antagonism. Contraindicated.
- ergotamine
ergotamine decreases effects of nitroglycerin IV by pharmacodynamic antagonism. Contraindicated.
- methylergonovine
methylergonovine decreases effects of nitroglycerin IV by pharmacodynamic antagonism. Contraindicated.
- riociguat
nitroglycerin IV, riociguat. Either increases effects of the other by additive vasodilation. Contraindicated. Coadministration of nitrates or nitric oxide donors is contraindicated due to risk of hypotension.
- sildenafil
nitroglycerin IV, sildenafil. Mechanism: additive vasodilation. Contraindicated. Potentially fatal hypotension.
- tadalafil
nitroglycerin IV, tadalafil. Mechanism: additive vasodilation. Contraindicated. Potentially fatal hypotension.
- vardenafil
nitroglycerin IV, vardenafil. Mechanism: additive vasodilation. Contraindicated. Potentially fatal hypotension.
Serious - Use Alternative (5)
- cabergoline
nitroglycerin IV increases effects of cabergoline by decreasing metabolism. Avoid or Use Alternate Drug. Risk of increased SBP, angina pectoris.
- ergoloid mesylates
nitroglycerin IV increases effects of ergoloid mesylates by decreasing metabolism. Avoid or Use Alternate Drug. Risk of increased SBP, angina pectoris.
- ergotamine
nitroglycerin IV increases effects of ergotamine by decreasing metabolism. Avoid or Use Alternate Drug. Risk of increased SBP, angina pectoris.
- lofexidine
lofexidine, nitroglycerin IV. Either increases effects of the other by pharmacodynamic synergism. Avoid or Use Alternate Drug. Avoid coadministration with other drugs that decrease pulse or blood pressure to mitigate risk of excessive bradycardia and hypotension.
- methylergonovine
nitroglycerin IV increases effects of methylergonovine by decreasing metabolism. Avoid or Use Alternate Drug. Risk of increased SBP, angina pectoris.
Monitor Closely (6)
- arginine
nitroglycerin IV, arginine. Mechanism: additive vasodilation. Use Caution/Monitor. Possible hypotension.
- benazepril
nitroglycerin IV, benazepril. Either increases effects of the other by pharmacodynamic synergism. Use Caution/Monitor. Both drugs lower blood pressure. Monitor blood pressure.
- bretylium
nitroglycerin IV, bretylium. Either increases effects of the other by pharmacodynamic synergism. Modify Therapy/Monitor Closely. Each drug may cause hypotension.
- bupivacaine implant
nitroglycerin IV, bupivacaine implant. Either increases toxicity of the other by Other (see comment). Use Caution/Monitor. Comment: Local anesthetics may increase the risk of developing methemoglobinemia when concurrently exposed to drugs that also cause methemoglobinemia.
- dapsone topical
nitroglycerin IV increases toxicity of dapsone topical by altering metabolism. Modify Therapy/Monitor Closely. May induce methemoglobinemia.
- tetracaine
tetracaine, nitroglycerin IV. Other (see comment). Use Caution/Monitor. Comment: Monitor for signs of methemoglobinemia when methemoglobin-inducing drugs are coadministered.
Minor (5)
- acetylcysteine
acetylcysteine increases effects of nitroglycerin IV by Other (see comment). Minor/Significance Unknown. Comment: Acetylcysteine may enhance vasodilatory effects of nitroglycerin.
- acetylcysteine (Antidote)
acetylcysteine (Antidote) increases effects of nitroglycerin IV by Other (see comment). Minor/Significance Unknown. Comment: Acetylcysteine may enhance vasodilatory effects of nitroglycerin.
- ethanol
nitroglycerin IV, ethanol. Mechanism: pharmacodynamic synergism. Minor/Significance Unknown. Possible hypotension.
- heparin
nitroglycerin IV decreases effects of heparin by unspecified interaction mechanism. Minor/Significance Unknown.
- metronidazole
nitroglycerin IV, metronidazole. Mechanism: decreasing metabolism. Minor/Significance Unknown. Disulfiram like reaction.
Adverse Effects
Common
Headache
Hypotension
Tachycardia
Dyspnea
Dizziness
Lightheadedness
Blurred vision
Flushing
N/V
Nervousness
Xerostomia
Serious
Methemoglobinemia (rare)
Syncope
Prolonged bleeding time
Exfoliative dermatitis
Unstable angina
Rebound hypertension
Thrombocytopenia
Warnings
Contraindications
Recent use (within several days) of PDE-5 inhibitors (eg, avanafil, sildenafil, tadalafil, or vardenafil) may cause dangerously low hypotension; the time course of the interaction appears to be related to the PDE-5 inhibitor half-life
Riociguat; coadministration may cause hypotension
Narrow angle glaucoma (controversial: may not be clinically significant)
Hypersensitivity
Symptomatic hypotension, uncorrected hypovolemia, increased intracranial pressure (head trauma, cerebral hemorrhage), severe anemia, constrictive pericarditis, pericardial tamponade, restrictive cardiomyopathy
Cautions
Use caution in alcohol use, hyperthyroidism, hypertrophic cardiomyopathy, postural hypotension, severe renal impairment, hepatic impairment
Gradually decrease dose to avoid withdrawal reaction
May need 10-12 hr/day nitrate-free interval to avoid tolerance development
Doses ~ 200 mcg/min
Some products contain alcohol and propylene glycol
Remove topical forms when starting IV infusion
Use glass bottles and non-PVC (polyvinyl chloride) tubing to avoid adsorption of drug to delivery devices; use of PVC tubing in infusion sets may lead to loss of active ingredient due to adsorption of nitroglycerin to PVC tubing; dosage is affected; adsorption by PVC tubing is increased when tubing is long, flow rates are low, and nitroglycerin concentration of solution is high; delivered fraction of solution's original nitroglycerin content has been 20-60% in published studies; fraction varies with time during single infusion, and no simple correction factor can be used; if intravenous nitroglycerin is administered through non-adsorptive tubing, doses based upon published reports will generally be too high; some in-line intravenous filters also adsorb nitroglycerin and should be avoided
Solutions containing dextrose without electrolytes should not be administered through the same administration set as blood, as this may result in pseudoagglutination or hemolysis
Intravenous administration of solutions may cause fluid overloading resulting in dilution of serum electrolyte concentrations, overhydration and congested states of pulmonary edema; risk of dilutional states is inversely proportional to electrolyte concentrations of injections; risk of solute overload causing congested states with peripheral and pulmonary edema is directly proportional to electrolyte concentration of injections
Severe hypotension and shock may occur with even small doses of nitroglycerin; monitor patients who may be volume depleted or, for whatever reason, are already hypotensive; hypotension induced by nitroglycerin may be accompanied by paradoxical bradycardia and increased angina pectoris
Nitrate therapy may aggravate angina caused by hypertrophic cardiomyopathy
Tolerance development and occurrence of cross tolerance to other nitro compounds reported
Administer nitroglycerin in 5% dextrose Injection only via infusion pump that can maintain constant infusion rate
Monitor patients with known sub-clinical or overt diabetes mellitus when using solutions containing dextrose
Cases of methemoglobinemia reported with moderate doses of organic nitrates; when methemoglobinemia is diagnosed, discontinue treatment of nitroglycerin; if condition not reversed, treat with methylene blue, 1-2 mg/kg intravenously
Protect from freezing and light
Do not change brands unintentionally as not all are bioequivalent
Treat drug-induced headache with aspirin or acetaminophen
Provide nitrate-free interval (10-12 hr or overnight) to avoid development of tolerance
Use supportive treatment in overdose; there is no specific antidote for overdose; risk of overdose can be minimized by close monitoring during treatment
Drug interaction overview
- The vasodilating effects of nitroglycerin may be additive with those of other antihypertensives. (e.g., beta-blockers, calcium channel blockers and tricyclic antidepressants) and may cause increased hypotensive effects
- Concomitant use of nitroglycerin in 5% dextrose injection concomitant use with phosphodiesterase inhibitors (e.g. sildenafil, tadalafil, or vardenafil) in any form is contraindicated
- Concomitant use of nitroglycerin in 5% dextrose injection with riociguat, a soluble guanylate cyclase stimulator, can cause hypotension and is contraindicated
- Marked symptomatic orthostatic hypotension reported when calcium channel blockers and organic nitrates used in combination
- Nitroglycerin at higher dosages may interfere with anticoagulant effect of heparin; intravenous nitroglycerin can induce heparin resistance
Pregnancy & Lactation
Pregnancy Category: C
Lactation: Developmental and health benefits of breastfeeding should be considered along with the mother’s clinical need for nitroglycerin and any potential adverse effects on breastfed child from nitroglycerin or from underlying maternal condition
Pregnancy Categories
A: Generally acceptable. Controlled studies in pregnant women show no evidence of fetal risk.
B: May be acceptable. Either animal studies show no risk but human studies not available or animal studies showed minor risks and human studies done and showed no risk. C: Use with caution if benefits outweigh risks. Animal studies show risk and human studies not available or neither animal nor human studies done. D: Use in LIFE-THREATENING emergencies when no safer drug available. Positive evidence of human fetal risk. X: Do not use in pregnancy. Risks involved outweigh potential benefits. Safer alternatives exist. NA: Information not available.Pharmacology
Mechanism of Action
Organic nitrate which causes systemic venodilation, decreasing preload
Cellular mechanism: enters vascular smooth muscle and is converted to nitric oxide (NO) which induces synthesis of cGMP and vasodilation
Relaxes smooth muscle via dose-dependent dilation of arterial and venous beds to reduce both preload and afterload, and myocardial O2 demand
Also improves coronary collateral circulation. Lower BP, increased HR, occasional paradoxical bradycardia
Pharmacokinetics
Half-life: 1-4 min
Onset: 1-3 min
Duration: 3-5 min
Protein bound: 60%
Vd: 3 L/kg
Metabolism: Mainly in liver, extrahepatic sites (vascular wall, RBC)
Metabolites: 1,3-glyceryl dinitrate, 1,2-glyceryl dinitrate, and glyceryl mononitrate (inactive)
Clearance: 5.5-11 L/min
Excretion: Urine
Dialyzable: No
Administration
IV Compatibilities
Additive: aminophylline, dobutamine, dopamine, furosemide, lidocaine, verapamil
Syringe: heparin
Y-site: amiodarone, diltiazem, dobutamine, dopamine, famotidine, lidocaine, pancuronium, ranitidine, sodium nitroprusside, streptokinase, tacrolimus, vecuronium
IV Incompatibilities
Additive: hydralazine, phenytoin
Syringe: caffeine
Y-site: alteplase, hydralazine
IV Preparation
Solution: 50 mg in 250 mL (200 mcg/mL) D5W or NS
IV Administration
3 mL/hr (10 mcg/min)
Only use glass IV bottles and administration sets
Images
| BRAND | FORM. | UNIT PRICE | PILL IMAGE |
|---|---|---|---|
| Nitro-Dur transdermal - | 0.3 mg/hr transdermal system |  | |
| nitroglycerin intravenous - | 50 mg/10 mL (5 mg/mL) vial |  | |
| nitroglycerin translingual - | 400 mcg/spray solution |  | |
| nitroglycerin translingual - | 400 mcg/spray solution |  | |
| nitroglycerin transdermal - | 0.4 mg/hr transdermal system |  | |
| nitroglycerin transdermal - | 0.6 mg/hr transdermal system |  | |
| nitroglycerin transdermal - | 0.2 mg/hr transdermal system |  | |
| nitroglycerin transdermal - | 0.1 mg/hr transdermal system |  | |
| nitroglycerin transdermal - | 0.6 mg/hr transdermal system |  | |
| nitroglycerin transdermal - | 0.4 mg/hr transdermal system |  | |
| nitroglycerin transdermal - | 0.2 mg/hr transdermal system |  | |
| nitroglycerin transdermal - | 0.4 mg/hr transdermal system |  | |
| nitroglycerin transdermal - | 0.6 mg/hr transdermal system |  | |
| nitroglycerin transdermal - | 0.2 mg/hr transdermal system |  | |
| nitroglycerin transdermal - | 0.2 mg/hr transdermal system |  | |
| nitroglycerin transdermal - | 0.6 mg/hr transdermal system |  | |
| nitroglycerin transdermal - | 0.4 mg/hr transdermal system |  | |
| nitroglycerin transdermal - | 0.4 mg/hr transdermal system |  | |
| nitroglycerin transdermal - | 0.2 mg/hr transdermal system |  | |
| nitroglycerin transdermal - | 0.1 mg/hr transdermal system |  | |
| nitroglycerin transdermal - | 0.1 mg/hr transdermal system |  | |
| nitroglycerin oral - | 2.5 mg capsule |  | |
| nitroglycerin oral - | 9 mg capsule |  | |
| nitroglycerin oral - | 6.5 mg capsule |  | |
| Nitro-Time oral - | 9 mg capsule | | |
| Nitro-Time oral - | 6.5 mg capsule | | |
| Nitro-Time oral - | 2.5 mg capsule | | |
| Rectiv rectal - | 0.4 % (w/w) ointment |  | |
| nitroglycerin sublingual - | 0.6 mg tablet |  | |
| nitroglycerin sublingual - | 0.4 mg tablet |  | |
| nitroglycerin sublingual - | 0.4 mg tablet |  | |
| nitroglycerin sublingual - | 0.3 mg tablet |  | |
| nitroglycerin sublingual - | 0.4 mg tablet |  | |
| nitroglycerin sublingual - | 0.6 mg tablet |  | |
| nitroglycerin sublingual - | 0.6 mg tablet |  | |
| nitroglycerin sublingual - | 0.3 mg tablet |  | |
| nitroglycerin sublingual - | 0.6 mg tablet |  | |
| nitroglycerin sublingual - | 0.3 mg tablet |  | |
| nitroglycerin sublingual - | 0.4 mg tablet |  | |
| nitroglycerin sublingual - | 0.4 mg tablet |  | |
| nitroglycerin sublingual - | 0.4 mg tablet |  | |
| nitroglycerin sublingual - | 0.4 mg tablet |  | |
| Nitrostat sublingual - | 0.4 mg tablet | | |
| Nitrostat sublingual - | 0.6 mg tablet |  | |
| Nitrostat sublingual - | 0.4 mg tablet |  | |
| Nitrostat sublingual - | 0.3 mg tablet | | |
| Nitro-Bid transdermal - | 2 % ointment |  | |
| Nitro-Bid transdermal - | 2 % ointment |  | |
| Nitro-Bid transdermal - | 2 % ointment |  | |
| Nitrolingual translingual - | 400 mcg/spray solution |  | |
| Nitromist translingual - | 400 mcg/spray aerosol |  |
Copyright © 2010 First DataBank, Inc.
Patient Handout
nitroglycerin sublingual
NITROGLYCERIN POWDER PACKET - SUBLINGUAL
(NYE-troe-GLIS-er-in)
COMMON BRAND NAME(S): Gonitro
USES: This medication is used to relieve chest pain (angina) in people that have a certain heart condition (coronary artery disease). It may also be used before physical activities (such as exercise, sexual activity) to help prevent chest pain.Nitroglycerin belongs to a class of drugs known as nitrates. Angina occurs when the heart muscle is not getting enough blood. This drug works by relaxing and widening blood vessels so blood can flow more easily to the heart.
HOW TO USE: Ask your doctor now for exact instructions on how to use your nitroglycerin and when to call for emergency medical help (911).Carefully read the Instructions for Use if available from your pharmacist before you start using nitroglycerin and each time you get a refill. If you have any questions, ask your doctor or pharmacist.If you are using this medication to relieve chest pain once it occurs, use it as soon as possible. If your chest pain has not improved or if it has worsened 5 minutes after you use this drug, call emergency medical help (911).Sit down before using this medication. Holding the packet upright and as close to your mouth as possible, tear open the packet and pour all of the powder under your tongue. Close your mouth right away and breathe normally through your nose. Let all of the powder dissolve before you swallow. Do not rinse your mouth or spit for 5 minutes after taking a dose.The dosage is based on your medical condition and response to treatment. A dose of this medication may be either 1 or 2 packets. Follow your doctor's instructions about how many packets you should take for each dose. After you take your first dose of nitroglycerin powder, you may take 1 more packet every 5 minutes, if needed. Do not take more than 3 packets of nitroglycerin powder within 15 minutes.If you are using this medication to prevent chest pain before physical activities, use it 5 to 10 minutes before the activity.If this medication is used very often, it may not work as well. Talk with your doctor if this medication stops working well.
SIDE EFFECTS: Headache, dizziness, lightheadedness, nausea, flushing, and burning/tingling under the tongue may occur. If any of these effects last or get worse, tell your doctor or pharmacist promptly.Headache is often a sign that this medication is working. Your doctor may recommend treating headaches with an over-the-counter pain reliever (such as acetaminophen, aspirin). If the headaches continue or become severe, tell your doctor promptly.To reduce the risk of dizziness and lightheadedness, get up slowly when rising from a sitting or lying position.Remember that this medication has been prescribed because your doctor has judged that the benefit to you is greater than the risk of side effects. Many people using this medication do not have serious side effects.Tell your doctor right away if you have any serious side effects, including: fainting, fast/irregular/pounding heartbeat.A very serious allergic reaction to this drug is rare. However, get medical help right away if you notice any symptoms of a serious allergic reaction, including: rash, itching/swelling (especially of the face/tongue/throat), severe dizziness, trouble breathing.This is not a complete list of possible side effects. If you notice other effects not listed above, contact your doctor or pharmacist.In the US -Call your doctor for medical advice about side effects. You may report side effects to FDA at 1-800-FDA-1088 or at www.fda.gov/medwatch.In Canada - Call your doctor for medical advice about side effects. You may report side effects to Health Canada at 1-866-234-2345.
PRECAUTIONS: Before using this medication, tell your doctor or pharmacist if you are allergic to it; or to similar drugs (such as isosorbide mononitrate); or to nitrites; or if you have any other allergies. This product may contain inactive ingredients, which can cause allergic reactions or other problems. Talk to your pharmacist for more details.Before using this medication, tell your doctor or pharmacist your medical history, especially of: recent head injury, anemia, low blood pressure, other heart problems (such as recent heart attack).This drug may make you dizzy. Alcohol or marijuana (cannabis) can make you more dizzy. Do not drive, use machinery, or do anything that needs alertness until you can do it safely. Limit alcoholic beverages. Talk to your doctor if you are using marijuana (cannabis).Before having surgery, tell your doctor or dentist about all the products you use (including prescription drugs, nonprescription drugs, and herbal products).Older adults may be more sensitive to the side effects of this medication, especially dizziness and lightheadedness, which could increase the risk of falls.During pregnancy, this medication should be used only when clearly needed. Discuss the risks and benefits with your doctor.It is unknown if this medication passes into breast milk or if it may harm a nursing infant. Consult your doctor before breast-feeding.
DRUG INTERACTIONS: Drug interactions may change how your medications work or increase your risk for serious side effects. This document does not contain all possible drug interactions. Keep a list of all the products you use (including prescription/nonprescription drugs and herbal products) and share it with your doctor and pharmacist. Do not start, stop, or change the dosage of any medicines without your doctor's approval.Some products that may interact with this drug are: drugs used to treat erectile dysfunction-ED or pulmonary hypertension (such as sildenafil, tadalafil), certain drugs to treat migraine headaches (ergot alkaloids such as ergotamine), riociguat, vericiguat.This medication may interfere with certain lab tests (such as blood cholesterol levels), possibly causing false test results. Make sure lab personnel and all your doctors know you use this drug.
OVERDOSE: If someone has overdosed and has serious symptoms such as passing out or trouble breathing, call 911. Otherwise, call a poison control center right away. US residents can call their local poison control center at 1-800-222-1222. Canada residents can call a provincial poison control center. Symptoms of overdose may include: slow heartbeat, vision changes, severe nausea/vomiting, sweating, cold/clammy skin, bluish fingers/toes/lips.
NOTES: Do not share this medication with others.
MISSED DOSE: Not applicable.
STORAGE: Store at room temperature away from light and moisture. Do not store in the bathroom. Keep all medications away from children and pets.Do not flush medications down the toilet or pour them into a drain unless instructed to do so. Properly discard this product when it is expired or no longer needed. Consult your pharmacist or local waste disposal company.
MEDICAL ALERT: Your condition can cause complications in a medical emergency. For information about enrolling in MedicAlert, call 1-888-633-4298 (US) or 1-800-668-1507 (Canada).
Information last revised October 2022. Copyright(c) 2023 First Databank, Inc.
IMPORTANT: HOW TO USE THIS INFORMATION: This is a summary and does NOT have all possible information about this product. This information does not assure that this product is safe, effective, or appropriate for you. This information is not individual medical advice and does not substitute for the advice of your health care professional. Always ask your health care professional for complete information about this product and your specific health needs.
Formulary
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