Isosorbide Dinitrate

Allergies to nitrates, head trauma/cerebral hemorrhage (potential contraindication), hypertrophic cardiomyopathy, increased intraocular pressure, postural hypotension, acute myocardial infarction (MI), congestive heart failure, hyperthyroidism

Inability to relieve chest pain after 3 doses may signal acute MI necessitating emergency management

Tolerance to extended-release formulation may develop, rendering formulation ineffective after a few weeks

Do not change brands unintentionally; formulations are not all bioequivalent

Severe hypotension, particularly with upright posture, may occur with even small doses; use with caution in patients who may be volume depleted or who are already hypotensive; hypotension induced by isosorbide dinitrate may be accompanied by paradoxical bradycardia and increased angina pectoris

Nitrate therapy may aggravate angina caused by hypertrophic cardiomyopathy

Treat drug-induced headache with aspirin or acetaminophen

Provide nitrate-free interval (10-12 hours or overnight) to prevent development of tolerance

Use supportive treatment in overdose

Avoid use of extended release formulation in acute MI or acute heart failure; adverse events are not easily reversible if they develop

Avoid use in patients with hypertrophic cardiomyopathy with outflow tract obstruction; nitrates may reduce preload, which may cause exacerbation of obstruction and cause hypotension or syncope and/or worsening of heart failure