isosorbide nitrates

(eye soe sor' bide)

isosorbide dinitrate
Apo-ISDN (CAN), Cedocard SR (CAN), Dilatrate SR, Isordil, Isordil Tembids,
Isordil Titradose, Sorbitrate

isosorbide mononitrate
ISMO, Imdur, Isotrate ER, Monoket

Pregnancy Category C

Drug classes
Antianginal
Nitrate
Vasodilator

Therapeutic actions
Relaxes vascular smooth muscle with a resultant decrease in venous return and decrease
in arterial BP, which reduces left ventricular workload and decreases myocardial oxygen
consumption.

Indications
• Dinitrate: Treatment and prevention of angina pectoris
• Mononitrate: Prevention of angina pectoris

Contraindications and cautions

• Contraindicated with allergy to nitrates, severe anemia, head trauma, cerebral
hemorrhage, hypertrophic cardiomyopathy, narrow-angle glaucoma, postdural
hypotension
• Use cautiously with pregnancy, lactation, acute MI, CHF.

Available forms
Dinitrate: tablets—5, 10, 20, 30, 40 mg; SR tablets—40 mg; SR capsules—40 mg; SL
tablets—2.5, 5, 10 mg; chewable tablets—5, 10 mg
Mononitrate: Tablets—10, 20 mg; ER tablets —30, 60, 120 mg

Dosages
ADULTS
To avoid tolerance to drug, take short-acting products bid or tid with last dose no later
than 7 PM and sustained-release products once daily or bid at 8 PM and 2 PM. This
creates a nitrate-free period.
Isosorbide dinitrate
 • Angina pectoris: Starting dose, 2.5–5 mg sublingual, 5-mg chewable tablets, 5- to
20-mg oral tablets. For maintenance, 10–40 mg q 6 hr oral tablets or capsules;
sustained release, initially 40 mg, then 40–80 mg PO q 8–12 hr.
• Acute prophylaxis: Initial dosage, 5–10 mg sublingual or chewable tablets q 2–3
hr.
Isosorbide mononitrate
• Prevention of angina: 20 mg PO bid given at least 7 hr apart; ER tablets—30–
60 mg/day PO may be increased to 120 mg/day if needed. In smaller patients,
start with 5 mg (one-half of 10-mg tablet) but then increase to at least 10 mg by
day 2 or 3 of therapy. Dose with first dose when waking and second dose 7 hr
later. This creates a nitrate-free period and minimizes tolerance to drug.
PEDIATRIC PATIENTS
Safety and efficacy not established.

Pharmacokinetics
Route Onset Duration
Oral 15–45 min 4 hr
SL 2–5 min 1–2 hr

Metabolism: Hepatic; T1/2: 5 min, then 2–5 hr

Distribution: May cross placenta; may enter breast milk
Excretion: Urine

Adverse effects
• CNS: Headache, apprehension, restlessness, weakness, vertigo, dizziness,
faintness
• CV: Tachycardia, retrosternal discomfort, palpitations, hypotension, syncope,
collapse, orthostatic hypotension, angina, rebound hypertension, atrial
fibrillation, postdural hypertension
• Dermatologic: Rash, exfoliative dermatitis, cutaneous vasodilation with flushing
• GI: Nausea, vomiting, incontinence of urine and feces, abdominal pain
• GU: Dysuria, impotence, urinary frequency
• Other: Muscle twitching, pallor, perspiration, cold sweat, arthralgia, bronchitis

Interactions
Drug-drug
• Increased systolic BP and decreased antianginal effect if taken concurrently with
ergot alkaloids
Drug-lab test
• False report of decreased serum cholesterol if done by the Zlatkis-Zak color
reaction

Nursing considerations
CLINICAL ALERT!
Name confusion has occurred between Isordil (isosorbide) and Plendil
(felodipine); use caution.
Assessment
• History: Allergy to nitrates, severe anemia, GI hypermobility, head trauma,
cerebral hemorrhage, hypertrophic cardiomyopathy, pregnancy, lactation
• Physical: Skin color, temperature, lesions; orientation, reflexes, affect; P, BP,
orthostatic BP, baseline ECG, peripheral perfusion; R, adventitious sounds; liver
evaluation, normal output; CBC, Hgb

Interventions
• Give sublingual preparations under the tongue or in the buccal pouch; discourage
the patient from swallowing.
• Create a nitrate-free period to minimize tolerance.
• Give chewable tablets slowly, only 5 mg initially because severe hypotension can
occur; ensure that patient does not chew or crush sustained-release preparations.
• Give oral preparations on an empty stomach, 1 hr before or 2 hr after meals; take
with meals if severe, uncontrolled headache occurs.
• Keep life support equipment readily available if overdose occurs or cardiac
condition worsens.
• Gradually reduce dose if anginal treatment is being terminated; rapid
discontinuation can lead to problems of withdrawal.

Teaching points
• Place sublingual tablets under your tongue or in your cheek; do not chew or
swallow the tablet. Take the isosorbide before chest pain begins, when activities
or situation may precipitate an attack. Take oral isosorbide dinitrate on an empty
stomach, 1 hr before or 2 hr after meals; do not chew or crush sustained-release
preparations.
• These side effects may occur: Dizziness, light-headedness (may be transient; use
care to change positions slowly); headache (lie down in a cool environment, rest;
over-the-counter preparations may not help; take drug with meals); flushing of the
neck or face (reversible).
• Report blurred vision, persistent or severe headache, rash, more frequent or more
severe angina attacks, fainting.

Adverse effects in Italic are most common; those in Bold are life-threatening.