soe SOR bide dye NYE
Prevention and treatment of angina pectoris; for congestive heart failure; to
relieve pain, dysphagia, and spasm in esophageal spasm with GE
Hypersensitivity to isosorbide dinitrate or any component; hypersensitivity
to organic nitrates; concurrent use with sildenafil; angle-closure glaucoma
(intraocular pressure may be increased); head trauma or cerebral hemorrhage
(increase intracranial pressure); severe anemia
Severe hypotension can occur. Use with caution in volume depletion,
hypotension, and right ventricular infarctions. Paradoxical bradycardia and
increased angina pectoris can accompany hypotension. Postural hypotension can
also occur. Tolerance does develop to nitrates and appropriate dosing is needed
to minimize this. Safety and efficacy have not been established in pediatric
patients. Nitrate may aggravate angina caused by hypertrophic cardiomyopathy.
Avoid concurrent use with sildenafil.
Incidence of reactions are not reported.
Central nervous system: Headache (most common), lightheadedness (related to
blood pressure changes), syncope (uncommon), dizziness, restlessness
Gastrointestinal: Nausea, vomiting, bowel incontinence, xerostomia
Genitourinary: Urinary incontinence
Hematologic: Methemoglobinemia (rare, overdose)
Neuromuscular & skeletal: Weakness
Ocular: Blurred vision
Miscellaneous: Cold sweat
The incidence of hypotension and adverse cardiovascular events may be
increased when used in combination with sildenafil
Symptoms of overdose which are most common include hypotension, throbbing
headache, tachycardia, and flushing. Methemoglobinemia may occur with massive
doses; hypotension may aggravate symptoms of cardiac ischemia or cerebrovascular
disease and may even cause seizures (rare).
Treatment consists of placing patient in recumbent position and administering
fluids; alpha-adrenergic vasopressors may be required; treat methemoglobinemia
with oxygen and methylene blue at a dose of 1-2 mg/kg I.V. slowly.
Sildenafil: Significant reduction of systolic and diastolic blood pressure
with concurrent use. Do not give sildenafil within 24 hours of a nitrate
Stimulation of intracellular cyclic-GMP results in vascular smooth muscle
relaxation of both arterial and venous vasculature. Increased venous pooling
decreases left ventricular pressure (preload) and arterial dilatation decreases
arterial resistance (afterload). Therefore, this reduces cardiac oxygen demand
by decreasing left ventricular pressure and systemic vascular resistance by
dilating arteries. Additionally, coronary artery dilation improves collateral
flow to ischemic regions; esophageal smooth muscle is relaxed via the same
Onset of action:
Sublingual tablet: 2-10 minutes
Chewable tablet: 3 minutes
Oral tablet: 45-60 minutes
Sustained release tablet: 30 minutes
Sublingual tablet: 1-2 hours
Chewable tablet: 0.5-2 hours
Oral tablet: 4-6 hours
Sustained release tablet: 6-12 hours
Metabolism: Extensive in the liver to conjugated metabolites, including
isosorbide 5-mononitrate (active) and 2-mononitrate (active)
Half-life: Parent drug: 1-4 hours; Metabolite (5-mononitrate): 4 hours
Elimination: In urine and feces
Adults (elderly should be given lowest recommended daily doses initially and
titrate upward): Oral:
Congestive heart failure:
Initial dose: 10 mg 3 times/day
Target dose: 40 mg 3 times/day
Maximum dose: 80 mg 3 times/day
Sublingual: 2.5-10 mg every 4-6 hours
Chew: 5-10 mg every 2-3 hours
Tolerance to nitrate effects develops with chronic exposure
Dose escalation does not overcome this effect. Tolerance can only be overcome
by short periods of nitrate absence from the body. Short periods (14 hours) or
nitrate withdrawal help minimize tolerance.
Hemodialysis: During hemodialysis, administer dose postdialysis or administer
supplemental 10-20 mg dose
Peritoneal dialysis: Supplemental dose is not necessary
Monitor for orthostasis
Concomitant use of sildenafil (Viagra®) may precipitate
acute hypotension, myocardial infarction, or death. Nitrates used in right
ventricular infarction may induce acute hypotension. Nitrate use in severe
pericardial effusion may reduce cardiac filling pressure and precipitate cardiac
tamponade. In the management of heart failure, the combination of isosorbide
dinitrate and hydralazine confers beneficial effects on disease progression and
|Mental Health: Effects
on Mental Status|
May cause dizziness
Effects on Psychiatric
|Dental Health: Local
No information available to require special precautions
Effects on Dental Treatment|
No effects or complications reported
Take as directed, at the same time each day. Do not chew or swallow
sublingual tablets; allow them to dissolve under your tongue. Do not change
brands without consulting prescriber. Do not discontinue abruptly. Keep
medication in original container, tightly closed. Avoid alcohol; combination may
cause severe hypotension. Take medication while sitting down and use caution
when changing position (rise from sitting or lying position slowly). May cause
dizziness; use caution when driving or engaging in hazardous activities until
response to drug is known. If chest pain is unresolved in 15 minutes, seek
emergency medical help at once. Report acute headache, rapid heartbeat, unusual
restlessness or dizziness, muscular weakness, or blurring vision.
Pregnancy/breast-feeding precautions: Inform prescriber if you are or intend
to be pregnant. Consult prescriber if breast-feeding.
8- to 12-hour nitrate-free interval is needed each day to prevent
Capsule, sustained release: 40 mg
Chewable: 5 mg, 10 mg
Oral: 5 mg, 10 mg, 20 mg, 30 mg, 40 mg
Sublingual: 2.5 mg, 5 mg, 10 mg
Sustained release: 40 mg
Aderka D, Garfinkel D, Bograd H, et al,
"Isosorbide Dinitrate-Induced Hemolysis in G-6-PD-Deficient Subjects," Acta
Haematol, 1983, 69(1):63-4.
"Hemodynamic Attenuation and the Nitrate-Free Interval: Alternative Dosing Strategies for Transdermal Nitroglycerin,"
Am J Cardiol, 1985, 56(17):321-71.
Nakashima E, Rigod JF, Lin ET, et al,
"Pharmacokinetics of Nitroglycerin and Its Dinitrate Metabolites Over a Thirty-Fold Range of Oral Doses,"
Clin Pharmacol Ther, 1990, 47(5):592-8.
"Eccentric Dosing With Isosorbide-5-Mononitrate in Angina Pectoris," Am J
Cardiol, 1993, 72(12):871-6.
Parker JO, Fanell B, Lahey KA, et al,
"Effect of Intervals Between Doses on the Development to Tolerance to Isosorbide Dinitrate,"
N Engl J Med, 1987, 316(23):1440-4.
"Visual Hallucinations and Suicidal Ideation Attributed to Isosorbide Dinitrate,"
Psychosomatics, 1987, 28(10):555-6.
Silfvast T, Kinnunen A, and Varpula T,
"Laryngeal Oedema After Isosorbide Dinitrate Spray and Sublingual Nifedipine,"
BMJ, 1995, 311(6999):232.
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