Nitroglycerin

General

• Type: vasodilator; stimulates cGMP production causing vascular smooth muscle relaxation
• Dosage Forms: SL, IV
• Common Trade Names: Nitrolingual, NitroMist, Nitrostat

Adult Dosing

Angina, acute

• 0.3 - 0.6mg SL q5min, max: 3 doses within 15 min
• IV form: 5 mcg/min IV, increase 5-20 mcg/min q3-5min.

Hypertension

• 5-200 mcg/min IV, start 5 mcg/min IV and increase 5 mcg/min q3-5min

Pediatric Dosing

Hypertension/CHF

• 1-5 mcg/kg/min IV, start 0.25-0.5 mcg/kg/min, max: 20 mcg/kg/min

Special Populations

• Pregnancy Rating: C
• Lactation: safety unknown
• Renal Dosing
  • Adult: no adjustment
  • Pediatric: no adjustment
• Hepatic Dosing
  • Adult: not defined
  • Pediatric: not defined

Contraindications

• Allergy to class/drug
• Pericardial tamponade
• Severe anemia
• Sildenafil use within the past 24 hours or tadalafil within the past 48 hours
• Methemoglobinemia
• Caution in hypotension

Adverse Reactions

Serious

• hypotension
• bradycardia
• methemoglobinemia

Common

• headache
• dizziness
• flushing
• hypotension
• reflex tachycardia
• edema

Pharmacology

• Half-life: 1-3 min
• Metabolism: liver, erythrocytes, vascular walls
• Excretion: urine
• Mechanism of Action: stimulates cGMP production resulting in vascular smooth muscle relaxation

Indications by Condition

The following table is automatically generated from disease/condition pages across WikEM.

Indication	Dose	Context	Route	Population
Congestive heart failure	0.4 mg SL q5min x3; or IV drip start 10-20 mcg/min, titrate to BP (keep >95)	Preload/afterload reduction (1st line for hypertensive HF)	SL/IV drip	Adult
Flash pulmonary edema	800mcg IV load over 2 min, then 100mcg/min maintenance (titrate up PRN)	High-dose NTG for vasodilation; may start at 100mcg/min then rapidly titrate to 400mcg/min for 2 min	IV	Adult
Flash pulmonary edema	0.4mg SL q5min while setting up IV drip	Interim nitroglycerin while IV drip is being prepared	SL	Adult
Hypertensive emergency	5-200 mcg/min	Antihypertensive (preload reduction)	IV drip	Adult
Non-ST-elevation myocardial infarction	0.4mg SL q5min x3, then IV infusion if ongoing ischemia	Decrease preload; use cautiously in inferior MI or with sildenafil	SL/IV	Adult
Pulmonary edema	0.4mg SL q5min, or IV starting 50mcg/min titrate rapidly to 150mcg/min+	First-line vasodilator; reduce preload	SL/IV	Adult
ST-segment elevation myocardial infarction	0.4 mg SL q5min x3 or IV drip titrated to pain relief	Vasodilator for ischemic pain	SL/IV	Adult
Unstable angina	0.4mg SL q5min x3, then 5-200mcg/min IV if ongoing pain	Vasodilator for ischemia	SL/IV	Adult
Volume overload	5mcg/min IV, titrate by 5-10mcg/min q5min (max 200mcg/min)	Vasodilator for acute pulmonary edema with hypertension	IV	Adult

External Links

• EMCrit: Sympathetic Crashing Acute Pulmonary Edema (SCAPE)