Nitroglycerin

Aka: Nitroglycerin

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II. History

  1. Albert Nobel stabilized Nitroglycerin for dynamite
    1. Some postulate that he died of Nitroglycerin toxicity

III. Medications

  1. Short Acting Nitroglycerin (Sublingual Nitroglycerin)
    1. Peak Levels: 1-2 minutes
    2. Duration: 30 to 60 minutes
  2. Long Acting Nitroglycerin (Isosorbide Dinitrate)
    1. Onset: 5 minutes for sublingual (30 minutes oral)
    2. Duration: 1 to 4 hours for sublingual (4-6 hours for oral, 8 hours for sustained release)
  3. Intravenous Nitroglycerin
    1. Onset in 2 minutes
    2. Duration 3 to 5 minutes
  4. Transdermal Nitroglycerin
    1. Peak levels: 30 to 60 minutes
    2. Duration: 12-14 hours per day (until patch removed)
  5. Nitroglycerin Paste (Ointment)
    1. Onset: 1 hour
    2. Duration: 2 to 12 hours

IV. Indications

  1. Angina Pectoris
  2. Acute Myocardial Infarction
  3. Left Ventricular Failure (Cardiogenic Shock, Congestive Heart Failure)

V. Contraindications

  1. Aortic Stenosis
  2. Pulmonary Hypertension
  3. Hypotension
    1. Avoid when systolic Blood Pressure <90 to 100 mmHg or more than 30 mmHg below baseline
    2. Hypotension due to nitrates is typically transient after single doses and responds to small fluid boluses
  4. Phosphodiesterase Inhibitor (e.g. Sildenafil, Tadalafil, Vardenafil)
  5. Guanylate Cyclase Simulator (Riociguat)
  6. Restrictive Cardiomyopathy (or Pericardial Tamponade, constrictive Pericarditis)
  7. Right sided Myocardial Infarction (subtype of inferior Myocardial Infarction)
    1. Caution in inferior STEMI with ST Elevation in V1 and ST depression in V2
    2. Hypertensive patients with MI, regardless of distribution, are unlikely to have adverse effects with Nitroglycerin
    3. Little evidence to support a broad avoidance of nitrates in inferior MI in normotensive or hypertensive patients
      1. Wilkinson-stokes (2023) Emerg Med J 40(2): 108-13 [PubMed]

VI. Mechanism

  1. Relaxes vascular Smooth Muscle
  2. Venous Dilation (more than Nitroprusside)
    1. Inhibits venous return (Preload)
      1. Decreases intra-myocardial wall tension
      2. Decreases intraventricular work
    2. Reduces left ventricular filling pressure
      1. Decreases myocardial oxygen demand
      2. Reduces Myocardial Ischemia
    3. Cardiac Output
      1. Increased in Congestive Heart Failure
      2. Decreased or normal if no Heart Failure
  3. Arterial Dilation (less than Nitroprusside)
    1. Relieves Angina
    2. Dilates large coronary arteries
    3. Antagonizes vasospasm
    4. Increases coronary collateral Blood Flow
      1. Increases perfusion to ischemic Myocardium
    5. Decreases Systemic Vascular Resistance
  4. Esophageal Spasm also responds to nitrates
    1. Pain relief with Nitroglycerin is not always Angina

VII. Drug Interactions

  1. Phosphodiesterase Inhibitors (e.g. Sildenafil, Tadalafil, Vardenafil)
    1. Profound hypotensive reaction
    2. Do not use with Nitroglycerin!
    3. Nitrates may be used >24 hours after Sildenafil or vardenafil or >48 hours after Tadalafil
  2. Guanylate Cyclase Simulator (Riociguat)
  3. Tissue Plasminogen Activator (Alteplase, tPA)
    1. IV Nitroglycerin may reduce plasma concentrations
  4. Heparin
    1. IV Nitroglycerin may reduce Anticoagulant response

VIII. Adverse Effects

  1. Headache
  2. Methemoglobinemia
  3. Hypoxemia (Ventilation-perfusion mismatch)
  4. Hypotension
    1. Risk Factors
      1. Aortic Stenosis
      2. Pulmonary Hypertension
      3. Hypovolemia
      4. PDE5 Inhibitor (e.g. Sildenafil)
      5. Right-sided Myocardial Infarction
    2. Prevention
      1. Administer Intravenous Fluid bolus
      2. Reduce Nitrate dose
      3. Consider Atropine if Bradycardia present
  5. Rebound Tachycardia
  6. Peripheral Edema

IX. Safety

  1. Pregnancy Category C
  2. Unknown safety in Lactation

X. References

  1. Orman and Mattu in Herbert (2017) EM:Rap 17(7): 6-7
  2. Olson (2020) Clinical Pharmacology, Medmaster Miami, p. 70-1

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Cost: Medications

nitroglycerin (on 12/21/2022 at Medicaid.Gov Survey of pharmacy drug pricing)
NITROGLYCERIN 0.1 MG/HR PATCH Generic $0.48 each
NITROGLYCERIN 0.2 MG/HR PATCH Generic $0.54 each
NITROGLYCERIN 0.3 MG TABLET SL Generic $0.14 each
NITROGLYCERIN 0.4 MG TABLET SL Generic $0.13 each
NITROGLYCERIN 0.4 MG/HR PATCH Generic $0.68 each
NITROGLYCERIN 0.6 MG TABLET SL Generic $0.21 each
NITROGLYCERIN 0.6 MG/HR PATCH Generic $0.78 each
NITROGLYCERIN 400 MCG SPRAY Generic $17.06 per gram
FPNotebook does not benefit financially from showing this medication data or their pharmacy links. This information is provided only to help medical providers and their patients see relative costs. Insurance plans negotiate lower medication prices with suppliers. Prices shown here are out of pocket, non-negotiated rates. See Needy Meds for financial assistance information. GoodRx is another tool for finding lower drug prices.

Ontology: Nitroglycerin (C0017887)

Definition (NCI_NCI-GLOSS) In medicine, a substance used as a drug to treat certain heart conditions and to widen the openings in blood vessels. Nitroglycerin is being studied as a way to help chemotherapy work better by making tumor cells more sensitive to the drugs. It is a type of vasodilator.
Definition (NCI) An organic nitrate with vasodilator activity. Nitroglycerin is converted into nitric oxide (NO) in smooth muscle and activates guanylyl cyclase, thereby increasing cGMP concentration, and resulting in smooth muscle relaxation. Dilatation of the veins results in decreased venous return to the heart, thereby decreasing left ventricular volume (reduced preload) and decreasing myocardial oxygen requirements. Arteriolar relaxation reduces arteriolar resistance (reduced afterload), thereby decreasing myocardial oxygen demands. In addition, nitroglycerine causes coronary artery dilatation, thereby improving myocardial blood distribution.
Definition (CSP) volatile vasodilator which relieves angina pectoris by stimulating guanylate cyclase and lowering cytosolic calcium; an explosive compound rendered safe when compounded in tablets with mannitol.
Definition (MSH) A volatile vasodilator which relieves ANGINA PECTORIS by stimulating GUANYLATE CYCLASE and lowering cytosolic calcium. It is also sometimes used for TOCOLYSIS and explosives.
Concepts Pharmacologic Substance (T121) , Organic Chemical (T109)
MSH D005996
SnomedCT 71759000, 387623004, 319379008, 387404004
LNC LP18092-4, MTHU003375
English Glyceryl Trinitrate, Nitroglycerin, Trinitrate, Glyceryl, 1,2,3-Propanetriol, trinitrate, Glyceryl trinitr [generic add], nitroglycerin, Glyceryl trinitrate [generic additions], NITROGLYCERIN, 1,2,3-propanetriol trinitrate, nitroglycerin (medication), Nitroglycerin [Chemical/Ingredient], nitroglycerol, nitroglycerine, glyceryl trinitrate, Glyceryl trinitrate (product), Glyceryl trinitrate [generic additions] (product), Glyceryl trinitrate, Nitroglycerol, GTN - Glyceryl trinitrate, Glyceryl trinitrate product, Nitroglycerin (product), Nitroglycerin (substance), Glyceryl trinitrate [generic additions] (substance)
Swedish Nitroglycerin
Czech nitroglycerin, glyceryltrinitrát
Finnish Glyseryylitrinitraatti
French Trinitrate de glycéryle, Trinitrate de glycérol, Trinitroglycérol, Nitroglycérine, Nitroglycérol, Trinitrine, Trinitroglycérine
Russian GLITSERIL TRINITRAT, NITROGLITSERIN, ГЛИЦЕРИЛ ТРИНИТРАТ, НИТРОГЛИЦЕРИН
Japanese トリニトログリセリン, ニトログリセリン, ニトログリセロール
Croatian NITROGLICERIN
Polish Nitrogliceryna, Trójazotan glicerolu, Nitrocard
Spanish trinitrato de glicerilo (agregados genéricos) (producto), trinitrato de glicerilo, trinitrato de glicerilo (producto), trinitrato de glicerilo (agregados genéricos), gliceriltrinitrato, nitroglicerina (producto), nitroglicerina (sustancia), nitroglicerina, nitroglicerol, Nitroglicerina, Trinitrato de Glicerilo
German Glyzerintrinitrat, Nitroglycerin
Italian Nitroglicerina
Portuguese Nitroglicerina, Trinitrato de Gliceril
Derived from the NIH UMLS (Unified Medical Language System)

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