Drugs List

Therapeutic Indications

Uses

Angina - unstable and refractory to treatment
Congestive heart failure secondary to acute myocardial infarction
Intra-operative hypertension
Maintaining controlled hypotension during surgery
Myocardial ischaemia associated with cardiac surgery

Administration

For intravenous administration.

Contraindications

Aortic stenosis
Cardiac tamponade
Cerebrovascular haemorrhage
Constrictive pericarditis
Hypertrophic obstructive cardiomyopathy
Hypotension
Hypovolaemia
Hypoxia
Mitral stenosis
Raised intracranial pressure
Severe anaemia
Toxic pulmonary oedema

Precautions and Warnings

Children under 18 years
Hypothermia
Predisposition to narrow angle glaucoma
Breastfeeding
Hypothyroidism
Malnutrition
Pregnancy
Recent myocardial infarction
Severe hepatic disorder
Severe renal disorder

Contains polyethylene glycol
Monitor blood pressure continuously
Must be diluted before use
Methaemoglobinaemia may develop with prolonged administration
Monitor cardiac function by ECG
Monitor haemodynamics of circulation
Monitor heart rate
Avoid abrupt withdrawal
Maximum treatment 3 days

Pregnancy and Lactation

Pregnancy

Use glyceryl trinitrate with caution in pregnancy.

Glyceryl trinitrate is primarily used for treatment and prevention of angina and therefore experience of use in pregnancy is limited. Glyceryl trinitrate should not be used during pregnancy particularly during the first trimester unless the potential benefits outweigh the unknown risks to the foetus (Briggs, 2015). Schaefer (2007) comments that nitrates may be used in pregnancy for appropriate indications and toxic affects on the foetus have not been reported. Briggs (2015) adds that with smaller doses of nitrates a transient decrease in the mother's blood pressure may occur but does not seem to be sufficient to affect placental perfusion.

The use of all medication in pregnancy should be avoided whenever possible; particularly in the first trimester. Non-drug treatments should also be considered. When essential, a medication with the best safety record over time should be chosen, employing the lowest effective dose for the shortest possible time. Polypharmacy should be avoided. Teratogens taken in the pre-embryonic period, often quoted as lasting until 14 to 17 days post-conception, are believed to have an all-or-nothing effect. Where drugs have a short half-life, and when the date of conception is certain, this may allow women to be reassured where drug exposure has occurred within this time frame. Further advice may be available from the UK National Teratology Information Service (NTIS) and through ToxBase, available via password on the internet ( www.toxbase.org ) or if this is unavailable at the backup site ( www.toxbasebackup.org ).

Lactation

Use glyceryl trinitrate with caution in breastfeeding.

Infusions of glyceryl trinitrate have not been studied during breastfeeding.

Studies with other topical preparations (ointment) have been used to treat anal fissures on nursing mothers and there were no reported effects in the breastfed infant whilst a number of the known side effects (headache, dizziness, lightheaded) where reported in the mothers.

It is recommended that infants be observed for flushing and discomfort following breastfeeding, since it is not known if glyceryl trinitrate is secreted in the breast milk. Hale (2014) recommends monitoring for methaemoglobinaemia and breastfeeding with caution at increased dosages with prolonged exposure, particularly in infants younger than 6 months.

Toxic effects on the infant have not been reported; Schaefer (2007) states that data would argue against a toxic risk for the breastfed infant due to the short half-life of the drug and its usually brief use

Neonates, infants born prematurely, those with low birth weight, those with an unstable gastrointestinal function or who have serious illnesses may require special consideration. For any infant, if a drug is prescribed to the nursing mother, it should be at the lowest practical dose and for the shortest time. When drug administration is unavoidable and breastfeeding is to continue, minimisation of exposure of the infant to the drug may sometimes be achieved by timing the maternal doses to just after a feeding episode. Infants exposed to drugs via breast milk should be monitored for unusual signs or symptoms. Interactions between the drug received by the infant from the mother's milk and medication prescribed for the infant should also be considered, for example, when the drug given to the infant may prevent metabolism of the drug received via breast milk.
Specialist advice is available from the UK Drugs in Lactation Advisory Service at https://www.midlandsmedicines.nhs.uk/content.asp?section=6&subsection=17&pageIdx=1

Side Effects

Aggravation of angina
Asthenia
Bradyarrhythmias
Bradycardia-paradoxical
Circulatory collapse
Contact dermatitis
Dizziness
Erythema
Exfoliative dermatitis
Flushing
Glaucoma (closed angle)
Heartburn
Hyperhidrosis
Hypotension
Irritation (localised)
Local burning
Nausea
Pallor
Palpitations
Postural hypotension
Pruritus
Rash
Restlessness
Somnolence
Syncope
Tachycardia
Throbbing headache
Transient hypoxaemia
Vomiting

Presentation

Concentrate for solution for infusion of glyceryl trinitrate.

Drugs List

Therapeutic Indications

Uses

Angina - unstable and refractory to treatment
Congestive heart failure secondary to acute myocardial infarction
Intra-operative hypertension
Maintaining controlled hypotension during surgery
Myocardial ischaemia associated with cardiac surgery

Dosage

Continuous monitoring of the patient, including blood pressure and pulse rate, is required throughout treatment to assess the response to the drug and adjust the dosage accordingly.

Adults

Children

Neonates

Administration

For intravenous administration.

Contraindications

Aortic stenosis
Cardiac tamponade
Cerebrovascular haemorrhage
Constrictive pericarditis
Hypertrophic obstructive cardiomyopathy
Hypotension
Hypovolaemia
Hypoxia
Mitral stenosis
Raised intracranial pressure
Severe anaemia
Toxic pulmonary oedema

Precautions and Warnings

Children under 18 years
Hypothermia
Predisposition to narrow angle glaucoma
Breastfeeding
Hypothyroidism
Malnutrition
Pregnancy
Recent myocardial infarction
Severe hepatic disorder
Severe renal disorder

Contains polyethylene glycol
Monitor blood pressure continuously
Must be diluted before use
Methaemoglobinaemia may develop with prolonged administration
Monitor cardiac function by ECG
Monitor haemodynamics of circulation
Monitor heart rate
Avoid abrupt withdrawal
Maximum treatment 3 days

Pregnancy and Lactation

Pregnancy

Use glyceryl trinitrate with caution in pregnancy.

Glyceryl trinitrate is primarily used for treatment and prevention of angina and therefore experience of use in pregnancy is limited. Glyceryl trinitrate should not be used during pregnancy particularly during the first trimester unless the potential benefits outweigh the unknown risks to the foetus (Briggs, 2015). Schaefer (2007) comments that nitrates may be used in pregnancy for appropriate indications and toxic affects on the foetus have not been reported. Briggs (2015) adds that with smaller doses of nitrates a transient decrease in the mother's blood pressure may occur but does not seem to be sufficient to affect placental perfusion.

The use of all medication in pregnancy should be avoided whenever possible; particularly in the first trimester. Non-drug treatments should also be considered. When essential, a medication with the best safety record over time should be chosen, employing the lowest effective dose for the shortest possible time. Polypharmacy should be avoided. Teratogens taken in the pre-embryonic period, often quoted as lasting until 14 to 17 days post-conception, are believed to have an all-or-nothing effect. Where drugs have a short half-life, and when the date of conception is certain, this may allow women to be reassured where drug exposure has occurred within this time frame. Further advice may be available from the UK National Teratology Information Service (NTIS) and through ToxBase, available via password on the internet ( www.toxbase.org ) or if this is unavailable at the backup site ( www.toxbasebackup.org ).

Lactation

Use glyceryl trinitrate with caution in breastfeeding.

Infusions of glyceryl trinitrate have not been studied during breastfeeding.

Studies with other topical preparations (ointment) have been used to treat anal fissures on nursing mothers and there were no reported effects in the breastfed infant whilst a number of the known side effects (headache, dizziness, lightheaded) where reported in the mothers.

It is recommended that infants be observed for flushing and discomfort following breastfeeding, since it is not known if glyceryl trinitrate is secreted in the breast milk. Hale (2014) recommends monitoring for methaemoglobinaemia and breastfeeding with caution at increased dosages with prolonged exposure, particularly in infants younger than 6 months.

Toxic effects on the infant have not been reported; Schaefer (2007) states that data would argue against a toxic risk for the breastfed infant due to the short half-life of the drug and its usually brief use

Neonates, infants born prematurely, those with low birth weight, those with an unstable gastrointestinal function or who have serious illnesses may require special consideration. For any infant, if a drug is prescribed to the nursing mother, it should be at the lowest practical dose and for the shortest time. When drug administration is unavoidable and breastfeeding is to continue, minimisation of exposure of the infant to the drug may sometimes be achieved by timing the maternal doses to just after a feeding episode. Infants exposed to drugs via breast milk should be monitored for unusual signs or symptoms. Interactions between the drug received by the infant from the mother's milk and medication prescribed for the infant should also be considered, for example, when the drug given to the infant may prevent metabolism of the drug received via breast milk.
Specialist advice is available from the UK Drugs in Lactation Advisory Service at https://www.midlandsmedicines.nhs.uk/content.asp?section=6&subsection=17&pageIdx=1

Side Effects

Aggravation of angina
Asthenia
Bradyarrhythmias
Bradycardia-paradoxical
Circulatory collapse
Contact dermatitis
Dizziness
Erythema
Exfoliative dermatitis
Flushing
Glaucoma (closed angle)
Heartburn
Hyperhidrosis
Hypotension
Irritation (localised)
Local burning
Nausea
Pallor
Palpitations
Postural hypotension
Pruritus
Rash
Restlessness
Somnolence
Syncope
Tachycardia
Throbbing headache
Transient hypoxaemia
Vomiting

Overdosage

It is strongly recommended that the UK National Poisons Information Service be consulted on cases of suspected or actual overdose where there is doubt over the degree of risk or about appropriate management.

The following number will direct the caller to the relevant local centre (0844) 892 0111

Information may be obtained if you have access to ToxBase the primary clinical toxicology database of the National Poisons Information Service. This is available via password on the internet ( www.toxbase.org ) or if this is unavailable at the backup site ( www.toxbasebackup.org ).

Further Information

Last Full Review Date: June 2016

Reference Sources

Drugs During Pregnancy and Lactation: Treatment Options and Risk Assessment, 2nd edition (2007) ed. Schaefer, C., Peters, P. and Miller, R. Elsevier, London.

Drugs in Pregnancy and Lactation: A Reference Guide to Fetal and Neonatal Risk, 10th edition (2015) ed. Briggs, G., Freeman, R. Wolters Kluwer Health, Philadelphia.

Medications and Mothers' Milk, Sixteenth Edition (2014) Hale, T and Rowe, H, Hale Publishing, Plano, Texas.

Summary of Product Characteristics: Glyceryl Trinitrate 5mg/ml Sterile Concentrate. Hospira UK Ltd. Revised September 2015.

NICE Evidence Services Available at: www.nice.org.uk Last accessed: 25 August 2017