Abdulqadir Nashwan 1

Abdulqadir Nashwan

ANTIANGINAL DRUGS
THE HASHEMITE UNIVERSITY PHARMA PROJECT FACULTY OF NURSING AbdulQadir Nashwan

References:
1. Diane S. Aschenbrenner., et al., 2002. Drug Therapy in Nursing. Lippincotts. USA. 2. Amy M. Karch., 2003 , Nursing Drug Guide. Lippincotts. USA.

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Outlines:
1. Introduction. 2. Nitroglycerin.

3. Isosorbide.
4. Study Questions.

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Introduction :
Chest pain that results from ischemia is termed Angina . Angina is usually intermittent and substernal, although the pain may radiate, such as to the left arm or left shoulder. There are two types of Angina : 1. Stable Angina 2. Unstable Angina

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Summary of selected Antianginal Drugs:

1. Nitrates: Nitroglycerin

Isosorbide dinitrate (isordil )

2. Beta-blocker Atenolol 3. Calcium channel blocker Nifedipine (adalat )

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Nitroglycerin

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Action:
Nitroglycerin relaxes vascular smooth muscle and dilates both arterial and venous vessels. Dilation of veins is more predominant than dilation of arteries, resulting in peripheral pooling of blood and decreased preload. BP will decrease as a result of venous dilation. Reflex tachycardia may follow the drop in BP.
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Arteriolar dilation reduces systemic vascular resistance and arterial pressure, thus reducing afterload.
Myocardial oxygen consumption is decreased. Nitroglycerin redistributes blood flow in the heart, improving circulation to ischemic areas.

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Tolerance
Tolerance to the vascular and antianginal effects may develop.

This is minimized by starting with as small a dose as possible and removing the nitroglycerin (paste or transdermal patches) from the patient for 10 to 12 hours a day.
The SL and translingual spray forms of the drug are the least likely to produce tolerance. The transmucosal form also appears to produce minimal tolerance.

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Indications:
Therapeutic uses of nitroglycerin vary by the route of administration.. Given sublingually or by transmucosal or translingual spray, it is used to treat acute angina. It also is used through topical, transdermal, translingual spray, and transmucosal or oral methods to prevent recurrent angina.

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 When given IV, it is used to treat hypertension secondary to surgical procedures; to treat CHF associated with acute MI; and to treat angina unresponsive to organic nitrates or beta-blockers. Unlabeled uses:
1. Providing adjunctive treatment of Raynaud disease (topical)

2. Managing hypertensive crisis (IV)

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Phamacokinetics:
Is absorbed rapidly SL, it also is absorbed through the skin. Metabolism occurs in the liver. The drug has an extensive first-pass effect when given orally. It is excreted in the urine. Absorption of SL products depends on salivary secretion; dry mouth will decrease absorption. The drug is absorbed directly into the vascular system via this route; it is not swallowed and absorbed through the gut, thus bypassing the firstpass effect.
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Absorption of transdermal products is through the skin and into the vascular system.
Oitments and transdermal systems provide a gradual release of drug into the circulatory system.

Transdermal absorption will be increased with:

physical exercise. elevated external temperatures (eg., saunas).

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Adverse effects:
The most common adverse effect of nirtoglycerin is headache, which may be persistent and severe. CV: Tachycardia, retrosternal discomfort, palpitations, hypotension, syncope, collapse, orthostatic hypotension. CNS: dizziness, vertigo, anxiety, and weakness.

Skin: dermatitis (topical application).

Local burning under the tongue (SL)

Drug interactions:
Decreased pharmacological effects of Heparin.
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 The IV route is contraindicated in :

1. Hypotension 2. Uncorrected hypovolemia

3. Inadequate cerebral circulation

4. Increased ICP 5. Pericardial tamponade

6. constrictive pericarditis

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Contraindications and precautions:

Hypersensitivity to nitrates. Closed angle glaucoma ( IOP may increased).

Orthostatic hypotension.
1st hours to days of acute MI (SL). Head trauma or cerebral hemorrhage ( may increase ICP). And allergy to adhesives (transdermal).

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Maximizing Therapeutic Effects

1. Sublingual Tablets. 2. Topical Ointment and Transdermal Patches. 3. Translingual Spray. 4. Transmucosal Tablets. 5. Intravenous (IV).

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 Sublingual Tablets:
1. The nurse should place one tablet under the patients tongue where it should be allowed to dissolve. 2. It is important to administer a tablet every 5 min, up to three in 15 min if necessary, to achieve full therapeutic effect. 3. The nurse should have the patient sit or lie down to allow for rest and decrease the O2 needs of the heart. 4. It is a good idea to keep tablets in the original dark bottle and keep the lid on when not in use to prevent deterioration and loss of efficacy. 5. Avoid exposure of tablets to high temperatures.
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 Topical Ointment and Transdermal Patches:

1. The nurse should apply to areas that DO NOT have excessive hair, and not subject to much movement, to promote absorption. 2. Change sites slightly to decrease the chance of local irritation and sensitization. 3. The nurse should apply to the chest, upper arm, or upper thigh to promote absorption and increase onset of systemic action.

4. DO NOT apply to distal parts of extremities ( i.e., near the hands or feet)
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For you
Spread a thin layer of topical ointment on
the skin using the applicator.

Do not rub or massage the area.

Cover with plastic wrap held in place

with adhesive tape.

Wash your hands after application.

Keep the tube tightly closed.

Rotate the sites frequently to prevent local
irritation.

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 Translingual Spray:
1. The nurse should spray nitroglycerin onto or under the tongue to promote absorption. 2. DO NOT allow the patient to inhale the drug. 3. If used to treat acute angina, the nurse should spray one or two metered doses. 4. The dose may be repeated but NOT more than three times in 15 min. 5. If used prophylactically, the nurse should administer one metered dose 5 to 10 min before onset of activity that may precipitate angina.

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 Transmucosal Tablets:
1. The nurse should place one tablet between lip and gum above incisors or between cheek and gum to promote slow dissolving and extended absorption.

Intravenous(IV):
1. The nurse should use only a glass IV bottles for the diluted drug solution to prevent loss of active drug into the tubing or bag , (by manufacturer).

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Minimizing adverse effects:

The nurse should assess the patients pulse and BP before administering drug therapy. It also is important to monitor for orthostatic hypotension and assist the patient to a standing position gradually when arising.

The nurse should treat any headache that develops with Aspirin or acetaminophen until tolerance to this adverse effect occurs.

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When withdrawing nitroglycerin as a treatment for angina, it is important to reduce the dosage gradually to prevent withdrawal reactions.

46 wk is the recommended withdrawal period for the transdermal preparations.

IN CPR
Remove transdermal system before attempting defibrillation or cardioversion, arcing may develop, which may concentrate local current, damaging the puddles and burning the patient.

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Isosorbide
Dinitrate

[ isordil ]

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Is a nitrate.
Like nitroglycerin, and is used for treating and preventing angina. It is NOT used to treat HTN. Is given SL or P.O . SL Isosorbide has a slower onset and a longer duration of action compared to SL nitroglycerin . Because SL isosorbide does NOT relieve chest pain as rapidly as introglycerin, Isosorbide is limited to treating acute angina in patients intolerant or unresponsive to SL nitroglycerin .

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Indications
Treatment and prevention of angina pectoris (dinitrate)
Prevention of angina pectoris (mononitrate)

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Study Questions
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1. Which the following describes an action of nitrates?

a. Smooth muscle contraction

b. Vasoconstriction
c. Smooth muscle relaxation d. Increased preload

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2. The result of nitrate administration is :

a. Decreased myocardial oxygen demand b. Increased myocardial oxygen demand c. Increased left ventricular EDV d. Increased atrial pressure

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4. An example of a long-acting nitrate is :

a. Nitroglycerin SL b. Nitroglycerin IV

c. Isosorbide PO
d. Nitroglycerin Transmucosal

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5. When teaching about nitrate administration, the nurse should instruct the client to : a. Change position slowly b. Take pulse daily c. Reduce salt intake

d. Chew the sustained-release tablets

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