Glyceryl trinitrate oromucosal
- Drugs List
- Therapeutic Indications
- Dosage
- Administration
- Contraindications
- Precautions and Warnings
- Pregnancy and Lactation
- Side Effects
- Monograph
Presentation
Metered dose spray of glyceryl trinitrate.
Drugs List
Therapeutic Indications
Uses
Prinzmetal angina
Prophylaxis of angina pectoris
Treatment of angina pectoris
Dosage
Adults
Treatment of acute attack
One or two 400microgram metered doses to be sprayed under the tongue while the breath is held on onset of attack.
A maximum of three 400microgram metered doses can be given at any one time.
Prophylaxis of angina pectoris
One or two 400microgram metered doses sprayed under the tongue immediately prior to or within 2 to 3 minutes of the start of the event.
Administration
For sublingual administration the bottle should be held vertically with the valve head uppermost. The spray orifice should be placed as close to the mouth as possible. The first dose should be sprayed under the tongue and the mouth should be closed immediately after each dose. The spray should not be inhaled. During application the patient should rest, ideally in the sitting position.
Contraindications
Children under 18 years
Systolic blood pressure < 90mmHg
Aortic stenosis
Cardiac tamponade
Cardiogenic shock
Cerebrovascular haemorrhage
Circulatory failure
Constrictive pericarditis
G6PD deficiency
Head trauma
Hypertrophic obstructive cardiomyopathy
Hypovolaemia
Mitral stenosis
Narrow angle glaucoma
Raised intracranial pressure
Severe anaemia
Severe bradycardia
Toxic pulmonary oedema
Precautions and Warnings
Hypothermia
Low cardiac filling pressures
Predisposition to narrow angle glaucoma
Predisposition to orthostatic hypotension
Breastfeeding
Cerebrovascular disorder
Hypothyroidism
Hypoxia
Malnutrition
Migraine
Pregnancy
Severe hepatic impairment
Severe renal impairment
Lack of effect may indicate early myocardial infarction
Advise ability to drive/operate machinery may be affected by side effects
Some formulations may contain alcohol
Advise patient to seek medical help if symptoms unresolved after 3 doses
Some preparations are flammable: Advise patient not to use near naked flame
Monitor patients at risk of glaucoma for increases in intraocular pressure
Cross tolerance to other nitrates may develop
Hypotensive effects may be potentiated by alcohol
Caution is advised when treating ambulant patients with the combination of angina and moderate to severe valvular aortic stenosis.
Glyceryl trinitrate could compromise myocardial blood supply in patients with left ventricular hypertrophy associated with aortic stenosis because of the detrimental effects of tachycardia and decreased aortic diastolic pressure.
Pregnancy and Lactation
Pregnancy
Use glyceryl trinitrate with caution in pregnancy.
There is limited data available regarding the use of glyceryl trinitrate in pregnancy. Animal studies do not indicate harmful effects on pregnancy, embryofoetal development, parturition or postnatal development.
Some manufacturers advise only administering glyceryl trinitrate if the expected benefit to the mother is greater than any possible risk to the foetus. Schaefer (2015) comments that nitrates may be used in pregnancy for appropriate indications.
Lactation
Use glyceryl trinitrate with caution in breastfeeding.
It is not known if glyceryl trinitrate or its metabolites are excreted in human milk. Schaefer (2015) states that short term use is justifiable for relevant indications. The short half-life of the drug and temporary use suggest no toxic risk to the breastfeeding infant.
Some manufacturers recommend making a decision whether to discontinue or abstain from breastfeeding or glyceryl trinitrate therapy, taking into account the benefit of breastfeeding for the child and the benefit of therapy for the woman.
Side Effects
Allergic skin reactions
Asthenia
Bradyarrhythmias
Bradycardia-paradoxical
Cerebral ischaemia
Circulatory collapse
Cyanosis
Decrease in blood pressure
Dizziness
Drowsiness
Exfoliative dermatitis
Facial flushing
Halitosis
Headache
Heartburn
Methaemoglobinaemia
Nausea
Orthostatic hypotension
Rash
Respiration worsening
Restlessness
Stinging
Syncope
Tachycardia
Taste disturbances
Tolerance to this drug and cross tolerance to other nitrates
Tongue blistering
Transient hypoxaemia
Vertigo
Vomiting
Worsening of angina
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: February 2019
Reference Sources
Drugs During Pregnancy and Lactation: Treatment Options and Risk Assessment, 3rd edition (2015) ed. Schaefer, C., Peters, P. and Miller, R. Elsevier, London.
Summary of Product Characteristics: Glyceryl trinitrate spray 400mcg/metered dose, sublingual spray. Aspire Pharma Ltd. Revised June 2017.
Summary of Product Characteristics: Glytrin 400 micrograms per metered dose. Aspire Pharma Ltd. Revised December 2017.
Summary of Product Characteristics: Nitrolingual Pump Spray 400micrograms per dose. Intrapharm. Revised January 2018.
Summary of Product Characteristics: Nitromin 400micrograms per actuation sublingual spray. EGIS pharmaceuticals uk Ltd. Revised November 2014.
NICE Evidence Services Available at: www.nice.org.uk Last accessed: 12 February 2019
US National Library of Medicine. Toxicology Data Network. Drugs and Lactation Database (LactMed).
Available at: https://toxnet.nlm.nih.gov/cgi-bin/sis/htmlgen?LACT
Nitroglycerin Last revised: 31 October 2018
Last accessed: 12 February 2019
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