Names and pronunciation
Transderm , Minitran, Nitro- Dur, Trinipatch
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Drug reference
Transderm , Minitran, Nitro- Dur, Trinipatch
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Func. class.: Coronary vasodilator, antianginal
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Chem. class.: Nitrate
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ACTION: Decreases preload and after- load, which are responsible for decreas- ing left ventricular end-diastolic pressure, systemic vascular resistance; dilates coro- nary arteries, improves blood flow through coronary vasculature, dilates arterial and venous beds systemically
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USES: Chronic stable angina pectoris, prophylaxis of angina pain, HF, acute MI, controlled hypotension for surgical pro- cedures, anal fissures
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CONTRAINDICATIONS: Hyper- sensitivity to this product or nitrites; severe anemia, increased intracranial pressure, cerebral hemorrhage, closed-angle glaucoma, cardiac tampon- ade, cardiomyopathy, constrictive peri- carditis Precautions: Pregnancy, breastfeeding, children, postural hypotension, severe renal/hepatic disease, acute MI, abrupt discontinuation, hyperthyroidism
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SIDE EFFECTS CNS: Headache, flushing, dizziness CV: Postural hypotension, tachycardia, collapse, syncope, palpitations GI: Nausea, vomiting INTEG: Pallor, sweating, rash
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INTERACTIONS • Severe hypotension, CV collapse: alcohol Increase: effects of β-blockers, diuretics, antihypertensives, calcium channel blockers Increase: fatal hypotension—avanafil, sildenafil, tadalafil, vardenafil; do not use together Increase: nitrate level—aspirin Decrease: heparin—IV nitroglycerin Drug/Lab Test Increase: urine catecholamine, urine VMA False increase: cholesterol
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DOSAGE AND ROUTES • Adult: IV: Run at 5 mcg/min, may increase by 5 mcg/min q3-5min, up to 100 mcg/min, may be used (hyperten- sion in HF, MI, surgery); SL Dissolve tab under tongue when pain begins; may repeat q5min until relief occurs; take ≤3 tabs/15 min; use 1 tab prophy- lactically 5-10 min before activities; TOP 1-2 inches q8hr, increase to 4 inches q4hr as needed; TRANS PATCH apply a patch daily to a site free of hair; remove patch at bedtime to provide 10-12 hr nitrate-free interval to avoid tolerance Anal fissures (Rectiv) • Adult: Rectal Apply 1 inch of 0.4% ointment q12hr × 3 wk
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Available forms: SL tabs 0.3, 0.4, 0.6 mg; topical oint 2%; trans syst 0.1, 0.2, 0.3, 0.4, 0.6, 0.8 mg/hr; inj sol 5 mg/mL rectal ointment 0.4% (Rectiv); SL powder 400 mcg; SL/translingual spray 400 mcg/spray
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Administer: • Topical ointment should be measured on papers supplied; use paper to spread on nonhairy area of chest, abdomen, thigh skin; thin layer spread over 2-3 inches; do not rub PO route • Swallow sus rel products whole; do not break, crush, or chew • With 8 oz water on empty stomach (oral tablet) 1 hr before or 2 hr after meals • SL: should be dissolved under tongue, or between gum and cheek, not swal- lowed • Aerosol sprayed under tongue (ni- trolingual), not inhaled; prime before 1st-time use or if product has not been used in >6 wk; press valve head with forefinger Transdermal route • Apply new TD patch daily; remove after 12-14 hr to prevent tolerance Rectal route • Cover finger with plastic wrap, dispos- able glove, or finger cot; lay finger along- side 1-inch dosing line on carton; squeeze tube until equal to 1-inch dosing line; insert covered finger gently into anal canal no further than 1st finger joint and apply to sides; wash hands thoroughly; if too painful, apply directly to outside of anus Continuous IV INFUSION route • Diluted in D5, D5W, 0.9% NaCl for infu- sion to 200-400 mcg/mL, depending on patient’s fluid status; common dilution 50 mg/250 mL, use controlled infusion de- vice; titrate to patient response; do not use filters Y-site compatibilities: Acyclovir, alfent- anil, amikacin, aminocaproic acid, ami- nophylline, amiodarone, amphotericin N B cholesteryl, amphotericin B lipid complex, amphotericin B liposome, anidulafungin, argatroban, ascorbic acid, atenolol, atracurium, atropine, azaTHIO- prine, aztreonam, benztropine, bivaliru- din, bleomycin, bumetanide, buprenor- phine, butorphanol, calcium chloride/ gluconate, CARBOplatin, caspofungin, cefamandole, ceFAZolin, cefmetazole, cefonicid, cefoperazone, cefotaxime, cefoTEtan, cefOXitin, cefTAZidime, cefti- zoxime, cefTRIAXone, cefuroxime, ceph- alothin, cephapirin, chloramphenicol, chlorproMAZINE, cimetidine, cisatracu- rium, CISplatin, clindamycin, cloNIDine, cyanocobalamin, cyclophosphamide, cycloSPORINE, cytarabine, DACTINo- mycin, dexamethasone, digoxin, diltia zem, diphenhydrAMINE, DOBUTamine, DOCEtaxel, DOPamine, doxacurium, DOXOrubicin, doxycycline, drotrecogin alfa, enalaprilat, ePHEDrine, EPINEPH- rine, epirubicin, epoetin alfa, eptifiba- tide, ertapenem, erythromycin, esmolol, etoposide, famotidine, fenoldopam, fen- taNYL, fluconazole, fludarabine, fluoro- uracil, folic acid, ganciclovir, gatifloxa- cin, gemcitabine, gemtuzumab, gentamicin, glycopyrrolate, granisetron, heparin, hydrocortisone, HYDROmor- phone, hydrOXYzine, IDArubicin, ifos- famide, imipenem-cilastatin, indometha- cin, insulin (regular), irinotecan, isoproterenol, ketorolac, labetalol, lido- caine, linezolid, LORazepam, magnesium sulfate, mannitol, mechlorethamine, meperidine, metaraminol, methicillin, methotrexate, methoxamine, methyldo- pate, methylPREDNISolone, metoclo- pramide, metroNIDAZOLE, mezlocillin, micafungin, miconazole, midazolam, milrinone, minocycline, mitoXANtrone, morphine, moxalactam, mycophenolate, nafcillin, nalbuphine, naloxone, nesirit- ide, netilmicin, niCARdipine, nitroprus- side, norepinephrine, octreotide, ondan- setron, oxacillin, oxaliplatin, oxytocin, PACLitaxel, palonosetron, pamidronate, pancuronium, pantoprazole, papaverine, PEMEtrexed, penicillin G potassium/ sodium, pentamidine, pentazocine, PENTobarbital, PHENobarbital, phentol- amine, phenylephrine, phytonadione, piperacillin, piperacillin-tazobactam, polymyxin B, potassium chloride, pro- cainamide, prochlorperazine, prometha- zine, propofol, propranolol, protamine, pyridoxine, quiNIDine, quinupristin-dal- fopristin, ranitidine, remifentanil, rito- drine, rocuronium, sodium bicarbonate, succinylcholine, SUFentanil, tacrolimus, teniposide, theophylline, thiamine, thio- pental, thiotepa, ticarcillin, ticarcillin- clavulanate, tigecycline, tirofiban, tobra- mycin, tolazoline, trimetaphan, urokinase, vancomycin, vasopressin, vecuronium, verapamil, vinCRIStine, vinorelbine, voriconazole, warfarin, zole- dronic acid
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Assess: • Chest pain/angina: duration, time started, activity being performed, character • Hypotensive episodes: Orthostatic B/P, pulse before and after administration • Tolerance if taken over long period • Headache, light-headedness, de- creased B/P; may indicate a need for de- creased dosage • Pregnancy/breastfeeding: use only if clearly needed; cautious use in breast- feeding
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Evaluate: • Therapeutic response: decrease, pre- vention of anginal pain
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CLINICAL CONSIDERATIONS
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Patient and caregiver information: • To place SL tab under tongue and wait to dissolve, or spray on or under tongue • To keep tabs in original container; to replace q6mo because effectiveness is lost; to keep away from heat, moisture, light • That if 3 SL tabs in 15 min do not re- lieve pain, to seek immediate medical attention • To avoid alcohol • That product may cause headache; that tolerance usually develops; to use nonopioid analgesic • That product may be taken before stressful activity: exercise, sexual activity • That SL may sting when product comes in contact with mucous membranes • To avoid hazardous activities if dizzi- ness occurs • To comply with complete medical regimen • To make position changes slowly to prevent fainting • Never to use erectile dysfunction prod- ucts (sildenafil, tadalafil, vardenafil); may cause severe hypotension, death HIGH ALERT
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PHARMACOKINETICS Metabolized by liver, excreted in urine, half-life 1-4 min SL: Onset 1-3 min, duration 30 min TRANSDERMAL: Onset 30 min-1 hr, duration 12-24 hr AEROSOL: Onset 2 min, duration 30-60 min TOPICAL OINT: Onset 30-60 min, dura- tion 2-12 hr IV: Onset 1-2 min, duration 3-5 min
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• Adult: IV: Run at 5 mcg/min, may increase by 5 mcg/min q3-5min, up to 100 mcg/min, may be used (hyperten- sion in HF, MI, surgery); SL Dissolve tab under tongue when pain begins; may repeat q5min until relief occurs; take ≤3 tabs/15 min; use 1 tab prophy- lactically 5-10 min before activities; TOP 1-2 inches q8hr, increase to 4 inches q4hr as needed; TRANS PATCH apply a patch daily to a site free of hair; remove patch at bedtime to provide 10-12 hr nitrate-free interval to avoid tolerance Anal fissures (Rectiv)
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• Adult: Rectal Apply 1 inch of 0.4% ointment q12hr × 3 wk
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