Drug reference
Acute myocardial infarction ▶BY INTRAVENOUS INJECTION ▶Adult: 30–50 mg (max. per dose 50 mg), dose to be given over 10 seconds and Initiated within 6 hours of symptom onset, dose varies according to body weight— consult product literature
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Aortic stenosis. cardiac tamponade . constrictive pericarditis. hypertrophic cardiomyopathy. hypotensive conditions. hypovolaemia. marked anaemia. mitral stenosis. raised intracranial pressure due to cerebral haemorrhage. raised intracranial pressure due to head trauma. toxic pulmonary oedema
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Heart failure due to obstruction. hypothermia. hypothyroidism. hypoxaemia. malnutrition. metal- containing transdermal systems should be removed before magnetic resonance imaging procedures, cardioversion, or diathermy. recent history of myocardial infarction. susceptibility to angle-closure glaucoma. tolerance. ventilation and perfusion abnormalities CAUTIONS, FURTHER INFORMATION ▶Tolerance Many patients on long-acting or transdermal nitrates rapidly develop tolerance (with reduced therapeutic effects). Reduction of blood-nitrate concentrations to low levels for 4 to 12 hours each day usually maintains effectiveness in such patients. If tolerance is suspected during the use of transdermal patches they should be left off for 8–12 hours (usually overnight) in each 24 hours; in the case of modified- release tablets of isosorbide dinitrate (and conventional formulations of isosorbide mononitrate), the second of the two daily doses should be given after about 8 hours rather than after 12 hours. Conventional formulations of isosorbide mononitrate should not usually be given more Cardiovascular system than twice daily unless small doses are used; modified- release formulations of isosorbide mononitrate should only be given once daily, and used in this way do not produce tolerance. ▶Elderly Prescription potentially inappropriate (STOPP criteria) if prescribed a long-acting nitrate with persistent postural hypotension i.e. recurrent drop in systolic blood pressure 20 mmHg (risk of syncope and falls). See also Prescribing in the elderly p. 33.
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Contra-indicated in nitrate hypersensitivity.
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→Appendix 1: tenecteplase
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▶Uncommon Drowsiness. hemiparesis. venous thrombosis ▶Common or very common Arrhythmias. asthenia. cerebral ischaemia. dizziness. drowsiness. flushing. headache. hypotension. nausea. vomiting ▶Uncommon Circulatory collapse. diarrhoea. skin reactions . syncope
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Manufacturer advises avoid breast- feeding for 24 hours after dose (express and discard milk during this time). No information available— manufacturers advise use only if potential benefit outweighs risk.
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In general, manufacturers advise caution in severe impairment.
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Manufacturers advise use with caution in severe impairment.
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Monitor blood pressure and heart rate during intravenous infusion.
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There can be variation in the licensing of different medicines containing the same drug. Powder and solvent for solution for injection ▶Metalyse (Boehringer Ingelheim Ltd) Cardiovascular system Tenecteplase 10000 unit Metalyse 10,000unit powder and solvent for solution for injection vials | 1 vial P £602.70 NITRATES Nitrates Overview Nitrates have a useful role in angina. Although they are potent coronary vasodilators, their principal benefit follows from a reduction in venous return which reduces left ventricular work. Unwanted effects such as flushing, headache, and postural hypotension may limit therapy, especially when angina is severe or when patients are unusually sensitive to the effects of nitrates. Sublingual glyceryl trinitrate p. 232 is one of the most effective drugs for providing rapid symptomatic relief of angina, but its effect lasts only for 20 to 30 minutes; the 300-microgram tablet is often appropriate when glyceryl trinitrate is first used. The aerosol spray provides an alternative method of rapid relief of symptoms for those who find difficulty in dissolving sublingual preparations. Duration of action may be prolonged by transdermal preparations (but tolerance may develop). Isosorbide dinitrate p. 233 is active sublingually and is a more stable preparation for those who only require nitrates infrequently. It is also effective by mouth for prophylaxis; although the effect is slower in onset, it may persist for several hours. Duration of action of up to 12 hours is claimed for modified-release preparations. The activity of isosorbide dinitrate may depend on the production of active metabolites, the most important of which is isosorbide mononitrate p. 234. Isosorbide mononitrate itself is also licensed for angina prophylaxis; modified-release formulations (for once daily administration) are available. Glyceryl trinitrate or isosorbide dinitrate may be tried by intravenous injection when the sublingual form is ineffective in patients with chest pain due to myocardial infarction or severe ischaemia. Intravenous injections are also useful in the treatment of congestive heart failure. Nitrates f
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Avoid abrupt withdrawal. eiiii F 231
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30–50 mg (max. per dose 50 mg), dose to be
First-line fragment. Read the complete Indications and Dose section above.
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