Nitroglycerin (Transdermal)

Nitroglycerin ointment or skin patch is a drug used to treat and prevent attacks of chest pain (angina) resulting from coronary artery disease.

Overview

Nitroglycerin belongs to a class of drugs known as nitrates. This medicine works by relaxing the blood vessels and increasing the supply of oxygen and blood to the heart while slowing its workload. Using this drug as prescribed by the healthcare provider and on a long-term basis, may help prevent angina attacks from occurring. Nevertheless, nitroglycerin is available only with a physician's prescription and usually comes in patch, ointment, and extended release dosage forms.

Conditions Treated?

  • Angina (chest pain)

Type Of Medicine?

  • A nitrate vasodilator

Side Effects

A) For the consumer

Along with its many benefits, this drug may cause some unpleasant side effects among patients. Although not all of these symptoms may occur, it's important to seek medical treatment right away if they do occur.

Patients should check with their doctor immediately if they notice any of the following symptoms:

More common

  • Lightheadedness

Less common

  • Arm, back, or jaw pain

Rare

-Bluish-colored lips, palms, or fingernails

  • Dark urine

Incidence not known

  • Burning, blistering, crusting, dryness, or flaking of the skin

Symptoms of overdose

A person should get emergency help right away if any of the below symptoms of overdose occur:

  • Blurred or loss of vision

Some side effects may appear that may not need any medical attention. These signs and symptoms usually go away on their own during treatment as a patient's body adjusts to the drug. The healthcare provider should tell his or her patient about ways to stop or reduce some of these side effects. Nevertheless, patients should consult their doctor if any of the below side effects continue or become bothersome or if they've any questions about them:

Rare

-Burning, itching, redness, swelling, skin rash, or soreness at the application site

  • Body aches or pain

Some patients may experience other symptoms not found in this guide. If a patient notice other symptoms besides the ones provided above, he or she should check with their healthcare professional right away for further diagnosis and treatment. A patient may also call their doctor for medical advice about side effects or may report them to the FDA at 1-800-FDA-1088.

B) For healthcare providers

General

  • The frequent and most reported side effect is a headache

Cardiovascular

  • Common (1%-10%): Angina level may increase, hypotension, tachycardia, paradoxical bradycardia, blood pressure may decrease, orthostatic hypotension, and facial flushing

Nervous system

  • Very common among patients (10% and above): Headache (may rise up to 64%)

Dermatologic

  • Uncommon (0.1%-1%): Erythema, dermatitis contact, pruritus, burning, eczema, irritation, and urticaria

Gastrointestinal

  • Common (1%-10%): Vomiting, nausea

Other

  • Common (1%-10%): Fatigue and asthenia

Psychiatric

  • Common (1%-10%): Insomnia

Hypersensitivity

  • Rare (less than 0.1%): Anaphylaxis and hypersensitivity reactions

Respiratory

  • Very rare (less than 0.01%): Impairment of respiration

Ocular

  • Rare (less than 0.1%): Blurred vision

Hematologic

  • Very rare (less than 0.01%): Methemoglobinemia

Musculoskeletal

  • Frequency not reported: Muscle twitching

Dosage

The dose of this drug varies from patient to patient. Therefore, it's important to follow doctor's orders or prescription or the directions on the label at all times. The below information provides only the average doses of this particular medication. If a patient's dose is different, they shouldn't change it unless allowed by the doctor.

All the same, the amount of drug a person takes depends on the effect of the medication. Also, the series of doses a patient takes every day, the time scheduled between doses, and the period a person should take these drugs very much depends on the underlying medical problem being treated.

For prevention of angina:

A) For transdermal dose form (ointment):

  • Adults—At first use about 7.5 mg (milligrams) or one-half inch of ointment at least twice every day. Apply the first dose first thing in the morning after waking up, and the second dose after 6 hours. Also worth knowing, the doctor may increase a person's dose as he or she sees fit.
  • Children—Use and dosage application should be determined by the healthcare provider.

B) For transdermal dose form (skin patch):

  • Adults—Apply a single patch once every day in the morning. Let the patch stay in place for about 12-14 hours.
  • Children—Use and dose should be determined by the healthcare provider.

Important: If a person skips a dose of this drug, apply it as soon as possible. However, if it's almost time for the next dose, skip the missed dose and resume the normal dosing schedule.

If a person forgets to put on or change a patch, wear one as soon as possible. If it's almost time to wear the next patch, wait until then to put on a new patch and skip the one missed. Don't apply extra patches to cover the missed dose.

Interactions

Although some drugs shouldn't be used together at all, sometimes two different drugs may be used together even if the patient might get an interaction. On this occasion, the healthcare provider may change the dose or other precautions may be required. Before taking this particular medicine, it's important to tell the healthcare provider if a person is taking any of the below medications.

These interactions are chosen based on their potential significance and aren't necessarily all-inclusive.
Using this drug with any of the below medications is not recommended. The healthcare professional may choose not to treat his or her patients with this medicine or may change some of the drugs they might be taking.

  • Avanafil

Using this drug with any of the below medications is also not recommended, but may be required on some occasions. If both drugs are prescribed together, the healthcare provider may change a patient's dose or how often they use one or both medicines altogether.

  • Recombinant

And finally, using this drug with any of the below medicines may trigger an increased risk of certain side effects, but using both drugs may be the best option for patients. If both drugs are prescribed together, the healthcare provider may change the patient's dose or how often they use one or both medicines altogether.

  • Aspirin

Other interactions

Some drugs shouldn't be used at or around the time of eating food or eating certain kinds of food because interactions may occur. Mixing tobacco or alcohol with some medicines can also make patients experience interactions. The below interactions are chosen based on their potential significance and aren't necessarily all-inclusive.

Other health complications

The occurrence of some medical problems may affect the use of this specific drug. It's important for patients to check with their doctor if they experience any of the below medical issues.

  • Congestive heart failure

Warnings

  • Shock and severe hypotension may occur with even small doses of nitroglycerin. Healtchare providers should closely monitor patients who may be volume depleted or who are already hypotensive. Frequently hypotension induced by nitroglycerin usually draws other health conditions, such as increased angina pectoris and paradoxical bradycardia.
  • Nitrate therapy may heighten the chest pain triggered by hypertrophic cardiomyopathy.
  • Tolerance development and occurrence of cross tolerance to other nitro compounds have been reported. Tolerance is when the same dose no longer produces the same effect as required. To stop this from occurring, nitroglycerin-free intervals of 10-12 hours between doses are recommended. Nevertheless, if the patient is experiencing some chest pain, it's acceptable to use another dose and seek urgent medical help.
  • In many industrial workers who have a prolonged exposure to presumably very high doses of organic nitrate, tolerance takes precedence. Acute myocardial infarction, chest pain, and even sudden death have occurred upon temporary withdrawal of nitrates from many of these workers, which clearly demonstrate the actual existence of true physical dependence.
  • Lower concentrations of Nitroglycerin in 5% Dextrose injection may increase the potential precision of dosing, which in turn may increase the total fluid levels a patient should take. Total fluid load is usually a significant factor to give some careful consideration into, especially when treating patients with a compromised function of the liver, kidney, or heart.
  • Some clinical trials in patients experiencing chest pain during the first 12 hours showed signs of decreased exercise tolerance and hemodynamic rebound. Nevertheless, the importance of making all of these observations to determine the intravenous nitroglycerin reaction in patients is not known.
  • Headache, lightheadedness, dizziness, and low blood pressure may occur. This may affect a person's ability to operate machinery or drive. Hot weather, alcohol, and exercise may further worsen these effects and result in a person fainting. Episodes of blurred vision may also occur.
  • Occasionally some flushing, allergic reactions, a headache, severe dizziness, or persistent nausea or vomiting may occur. Patients should seek treatment right away.
  • Alcohol toxicity has been reported when high-dose of nitroglycerin injection are taken together with alcohol, or when patients take certain drugs, like disulfiram and cephalosporin antibiotics, together with nitroglycerin and alcohol at the same time. Patients are strongly advised not to drink alcohol while taking this medicine.
  • May not be suitable for some people like the elderly and those with a history of stroke or bleeding in the brain. Also those with glaucoma, migraines, anemia, or swelling of the heart sac may develop some severe side effects from this drug. Persons who might be using erectile dysfunction drugs are restricted from using this particular medicine.
  • Usually toxic to children and pets, so make sure to store well and keep out of reach.
  • Patients with certain medical conditions such as kidney or liver problems, seizures, diabetes, or heart disease or people who take other medicines are more at risk of experiencing a wider range of side effects.
  • Patients taking this drug to suppress symptoms of angina should keep it on hand at all times. It's also important for them to refill their prescription before they run out of nitroglycerin.
  • Patients should talk to their healthcare provider about taking this drug 5-10 minutes before any activity that typically results in chest pain.
  • Patients experiencing severe chest pain or symptoms of a heart attack should check with their healthcare provider right away. It's important to seek immediate medical treatment particularly if the chest pain lasts more than five minutes.
  • Always sit and stand up slowly when rising from a seated or lying down position as this drug may cause a drop in blood pressure.
  • Patients should contact their doctor immediately if they develop a slow heartbeat or new or severe and worsening chest pain after taking medication.
  • Sometimes this drug may cause a stinging or burning effect in the mouth.
  • Patients who use drugs for erectile dysfunction such as Cialis, Viagra, or Levitra should not take them together with nitroglycerin. Combining both drugs may potentially drop a person's blood pressure. It's also important for patients to first talk to the doctor or pharmacist before taking any of these medications, as some may not be compatible with nitroglycerin.
  • A person shouldn't take this drug if they've circulation complications, experience shock, have severe anemia, or an unpleasant feeling of pressure inside their head.
  • Patients who think will be using this medicine for a long time should ensure their doctor checks their progress at regular visits to make sure the drug is working normally. Blood tests may be required to check for unwanted effects.
  • Patients shouldn't stop using this drug without checking with their healthcare provider first. The healthcare provider may want his or her patient to gradually reduce the amount of dose prescribed before stopping it completely.
  • Patients should tell their doctor that they're using nitroglycerin before having an MRI (magnetic resonance imaging) scan. Skin burns may occur on the area where the patch is placed during procedure. A patient may ask the doctor if the patch should be removed before having an MRI scan. Nevertheless, a patient may be asked to wear a new patch after the procedure.

Storage

  • Store this drug in a closed container at room temperature, away from moisture, heat, and direct light. Also keep from freezing.
  • Keep out of the reach of children and pets
  • Don't keep expired medicine or medicine no longer needed
  • It's important for patients to ask their healthcare professional about ways to dispose of any medicine they no longer use
  • After removing a used patch, fold it in half with the sticky sides together, and throw it away in a place where children and pets can't find it

Summary

Nitroglycerin is a nitrate that widens blood vessels, which in turn makes it easier for blood to flow through and easier for the heart to pump normally. It's used to prevent and treat angina or chest pain, although it may also be used for other purposes not mentioned in this guide. Before taking this drug, patients should tell their doctor if they usually have any unusual or allergic reactions from this medicine or any other drug. And if they experience any other types of allergies from dyes, foods, preservatives, or animals. Patients should also tell their doctor if they're breastfeeding to weigh the potential benefits against the potential risks to which a child may be subjected.

Healthcare professionals caution against the use of this drug if a person is allergic to it or if they're using it to treat pulmonary arterial hypertension (PAH), such as tadalafil (Adcirca), riociguat (Adempas), or sildenafil (Revatio). Also, patients who take erectile dysfunction medications like Cialis, Viagra, Stendra, or Levitra among others are also cautioned not to use those drugs while taking nitroglycerin. Using erectile dysfunction drugs concomitantly with nitroglycerin may bring about a sudden and severe decrease in blood pressure altogether. Nevertheless, if a patient develops any unusual or disturbing side effects from the drug, a healthcare specialist should be consulted right away for diagnosis purposes and treatment of any and all medical conditions.