Drugs List

Therapeutic Indications

Uses

Angina - unstable and refractory to treatment
Congestive heart failure (resistant to other treatment)
Congestive heart failure secondary to acute myocardial infarction
Heart failure with cardiac surgery- Vasodilatation and inotropic support
Intra-operative hypertension
Prinzmetal angina

Unlicensed Uses

Hypertension - crisis

Administration

For intravenous infusion only.

Administer using a syringe pump with glass syringe, a micro drip infusion pump or a similar device that allows continuous controlled infusion rate. Glass or polythene containers are required for delivery of the solution. Rate of infusion is individually determined according to condition and haemodynamic response. It is also recommended to consult the dosage chart that is provided with the preparation.

Contraindications

Aortic stenosis
Cardiac tamponade
Cerebrovascular haemorrhage
Circulatory failure
Constrictive pericarditis
Head trauma
Hypertrophic obstructive cardiomyopathy
Hypovolaemia
Hypoxia
Mitral stenosis
Raised intracranial pressure
Severe anaemia
Severe hypotension
Toxic pulmonary oedema

Precautions and Warnings

Children under 18 years
Hypothermia
Breastfeeding
Congestive cardiac failure secondary to mechanical obstruction
Hypothyroidism
Malnutrition
Narrow angle glaucoma
Pregnancy
Recent myocardial infarction
Severe hepatic disorder
Severe renal disorder

Monitor blood pressure continuously
Methaemoglobinaemia may develop with prolonged administration
Monitor haemodynamics of circulation
Monitor heart rate
Cross tolerance to other nitrates may develop
Reduce dose or discontinue if symptoms of severe bradycardia occur
Tolerance may develop with continued use
Hypotensive effects may be potentiated by alcohol

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, 2011). Schaefer (2007) comments that nitrates may be used in pregnancy for appropriate indications and toxic affects on the foetus have not been reported. Briggs (2011) 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 (2010) recommends monitoring for methemoglobinemia 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

Abdominal pain
Apprehension
Bradycardia-paradoxical
Diaphoresis
Dizziness
Flushing
Glaucoma (closed angle)
Headache
Heartburn
Hypotension
Hypoxaemia
Methaemoglobinaemia
Muscle twitch
Nausea
Palpitations
Postural hypotension
Rash
Restlessness
Retrosternal discomfort
Syncope
Tachycardia
Vomiting

Presentation

Infusions of glyceryl trinitrate

Drugs List

Therapeutic Indications

Uses

Angina - unstable and refractory to treatment
Congestive heart failure (resistant to other treatment)
Congestive heart failure secondary to acute myocardial infarction
Heart failure with cardiac surgery- Vasodilatation and inotropic support
Intra-operative hypertension
Prinzmetal angina

Unlicensed Uses

Hypertension - crisis

Dosage

Dosage should be titrated to individual requirements.

Continuous monitoring of the patient is required throughout treatment to assess the response to the drug and adjust the dosage accordingly.

Initialise therapy at a lower rate and gradually increase until the desired clinical response is achieved.

Adults

Children

Neonates

Administration

For intravenous infusion only.

Administer using a syringe pump with glass syringe, a micro drip infusion pump or a similar device that allows continuous controlled infusion rate. Glass or polythene containers are required for delivery of the solution. Rate of infusion is individually determined according to condition and haemodynamic response. It is also recommended to consult the dosage chart that is provided with the preparation.

Contraindications

Aortic stenosis
Cardiac tamponade
Cerebrovascular haemorrhage
Circulatory failure
Constrictive pericarditis
Head trauma
Hypertrophic obstructive cardiomyopathy
Hypovolaemia
Hypoxia
Mitral stenosis
Raised intracranial pressure
Severe anaemia
Severe hypotension
Toxic pulmonary oedema

Precautions and Warnings

Children under 18 years
Hypothermia
Breastfeeding
Congestive cardiac failure secondary to mechanical obstruction
Hypothyroidism
Malnutrition
Narrow angle glaucoma
Pregnancy
Recent myocardial infarction
Severe hepatic disorder
Severe renal disorder

Monitor blood pressure continuously
Methaemoglobinaemia may develop with prolonged administration
Monitor haemodynamics of circulation
Monitor heart rate
Cross tolerance to other nitrates may develop
Reduce dose or discontinue if symptoms of severe bradycardia occur
Tolerance may develop with continued use
Hypotensive effects may be potentiated by alcohol

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, 2011). Schaefer (2007) comments that nitrates may be used in pregnancy for appropriate indications and toxic affects on the foetus have not been reported. Briggs (2011) 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 (2010) recommends monitoring for methemoglobinemia 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

Abdominal pain
Apprehension
Bradycardia-paradoxical
Diaphoresis
Dizziness
Flushing
Glaucoma (closed angle)
Headache
Heartburn
Hypotension
Hypoxaemia
Methaemoglobinaemia
Muscle twitch
Nausea
Palpitations
Postural hypotension
Rash
Restlessness
Retrosternal discomfort
Syncope
Tachycardia
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: September 2013

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, 9th edition (2011) ed. Briggs, G., Freeman, R. and Yaffe, S. Lippincott Williams & Wilkins, Philadelphia.

Martindale: The Complete Drug Reference, 37th edition (2011) ed. Sweetman, S. Pharmaceutical Press, London.

Medications and Mothers' Milk, 14th Edition (2010) Hale, T. Hale Publishing, Amarillo, Texas.

Summary of Product Characteristics: Glyceryl Trinitrate 1mg/ml solution for infusion. Hameln Pharmaceuticals Ltd. Revised June 2009.

Summary of Product Characteristics: Nitrocine. UCB Pharma Ltd. Revised March 2013.

Summary of Product Characteristics: Nitronal. Merck Serano. Revised December 2011.

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

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: September 7, 2013
Last accessed: September 5, 2013