• Acute (translingual, SL, ointment) and long-term prophylactic (oral, transdermal) management of angina pectoris.
• PO: Adjunct treatment of HF.
• IV: Adjunct treatment of acute MI.
• Production of controlled hypotension during surgical procedures.
• Treatment of HF.

Contraindicated in:

• Hypersensitivity
• ↑intracranial pressure
• Severe anemia
• Pericardial tamponade
• Constrictive pericarditis
• Uncorrected hypovolemia
• Alcohol intolerance (large IV doses only)
• Acute circulatory failure/shock
• Concurrent use of PDE-5 inhibitor (avanafil, sildenafil, tadalafil, vardenafil) or riociguat.

Use Cautiously in:

• Head trauma or cerebral hemorrhage
• Glaucoma
• Hypertrophic cardiomyopathy
• Severe liver impairment
• Malabsorption or hypermotility (PO)
• Cardioversion (remove transdermal patch before procedure)
• OB: May compromise maternal/fetal circulation
• Lactation: Safety not established in breastfeeding
• Pedi: Safety and effectiveness not established in children.

CV: hypotension, tachycardia, syncope.

Derm: contact dermatitis (transdermal), flushing.

EENT: blurred vision.

GI: abdominal pain, nausea, vomiting.

Neuro: dizziness, headache, apprehension, restlessness, weakness.
Misc: alcohol intoxication (large IV doses only), tolerance.

Drug-Drug:

• Concurrent use of avanafil, sildenafil, tadalafil, or vardenafil may result in severe hypotension (do not use within 24 hr of isosorbide dinitrate or mononitrate); concurrent use contraindicated.
• Concurrent use of riociguat may result in severe hypotension; concurrent use contraindicated.
• Additive hypotension with antihypertensives, acute ingestion of alcohol, beta blockers, calcium channel blockers, haloperidol, or phenothiazines.
• Agents having anticholinergic properties (tricyclic antidepressants, antihistamines, phenothiazines) may ↓ absorption of translingual or sublingual nitroglycerin.

(Generic available)

• Extended-release capsules: 2.5 mg; 6.5 mg; 9 mg;
• Sublingual tablets: 0.3 mg; 0.4 mg; 0.6 mg;
• Translingual spray: 0.4 mg/spray in 4.9-g bottle (60 doses) or 14.6-g bottle (200 doses) (Nitrolingual); 0.4 mg/spray in 8.5-g bottle (230 doses) (Nitromist);
• Transdermal patch: 0.1 mg/hr; 0.2 mg/hr; 0.3 mg/hr; 0.4 mg/hr; 0.6 mg/hr; 0.8 mg/hr;
• Transdermal ointment: 2%;
• Solution for injection: 5 mg/mL;
• Premixed infusion: 25 mg/250 mL D5W; 50 mg/250 mL D5W; 100 mg/250 mL D5W;

• SL (Adults): Tablets: 0.3–0.6 mg; may repeat every 5 min for 2 additional doses for acute attack; may also be used prophylactically 5–10 min before activities that may precipitate an acute attack.
• Translingual Spray (Adults): 1–2 sprays; may be repeated every 5 min for 2 additional doses for acute attack; may also be used prophylactically 5–10 min before activities that may precipitate an acute attack.
• PO (Adults): 2.5–9 mg every 8–12 hr.
• IV (Adults): 5 mcg/min; ↑ by 5 mcg/min every 3–5 min to 20 mcg/min; if no response, ↑ by 10–20 mcg/min every 3–5 min (dosing determined by hemodynamic parameters; max: 200 mcg/min).
• Transdermal (Adults): Ointment: 1–2 in. every 6–8 hr. Transdermal patch: 0.2–0.4 mg/hr initially; may titrate up to 0.4–0.8 mg/hr. Patch should be worn 12–14 hr/day and then taken off for 10–12 hr/day.

nitroglycerin extended-release capsules: Nitro-Time

nitroglycerin intravenous: Nitro-Bid IV

nitroglycerin sublingual tablets: Nitrostat

Nitroglycerin Transdermal Ointment: Nitro-Bid

nitroglycerin transdermal patch: Nitro-Dur

nitroglycerin translingual spray: Nitrolingual, Nitromist

• Increases coronary blood flow by dilating coronary arteries and improving collateral flow to ischemic regions.
• Produces vasodilation (venous greater than arterial).
• Decreases left ventricular end-diastolic pressure and left ventricular end-diastolic volume (preload).
• Reduces myocardial oxygen consumption.

• Relief or prevention of anginal attacks.
• Increased cardiac output.
• Reduction of BP.

Therapeutic Classification: antianginals

Pharmacologic Classification: nitrates

Absorption: Well absorbed after oral, buccal, and sublingual administration. Also absorbed through skin. Orally administered nitroglycerin is rapidly metabolized, leading to ↓ bioavailability.

Distribution: Unknown.

Metabolism/Excretion: Undergoes rapid and almost complete metabolism by the liver; also metabolized by enzymes in bloodstream.

Half-life: 1–4 min.

nitroglycerin intravenous: Nitroject

nitroglycerin transdermal patch: Trinipatch

nitroglycerin translingual spray: Rho-Nitro

(cardiovascular effects)

• Instruct patient to take medication as directed, even if feeling better. Take missed doses as soon as remembered unless next dose is scheduled within 2 hr (6 hr with extended-release preparations). Do not double doses. Do not discontinue abruptly; gradual dose reduction may be necessary to prevent rebound angina.
  • Caution patient to change positions slowly to minimize orthostatic hypotension. First dose should be taken while in a sitting or reclining position, especially in geriatric patients.
  • Advise patient to avoid concurrent use of alcohol with this medication. Patient should also consult health care professional before taking OTC medications while taking nitroglycerin.
  • Inform patient that headache is a common side effect that should decrease with continuing therapy. Aspirin or acetaminophen may be ordered to treat headache. Notify health care professional if headache is persistent or severe.
  • Advise patient to notify health care professional if dry mouth or blurred vision occurs.
• Advise females of reproductive potential to notify health care professional if pregnancy is planned or suspected or if breastfeeding.
• Acute Anginal Attacks: Advise patient to sit down and use medication at first sign of attack. Relief usually occurs within 5 min. Dose may be repeated if pain is not relieved in 5–10 min. Call health care professional or go to nearest emergency room if anginal pain is not relieved by 3 tablets in 15 min.
• SL: Inform patient that tablets should be kept in original glass container or in specially made metal containers, with cotton removed to prevent absorption. Tablets lose potency in containers made of plastic or cardboard or when mixed with other capsules or tablets. Exposure to air, heat, and moisture also causes loss of potency. Instruct patient not to open bottle frequently, handle tablets, or keep bottle of tablets next to body (i.e., shirt pocket) or in automobile glove compartment. Advise patient that tablets should be replaced 6 mo after opening to maintain potency.
• Lingual Spray: Instruct patient to lift tongue and spray dose under tongue (Nitrolingual, NitroMist) or on tongue (NitroMist).

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