Imdur (isosorbide mononitrate)
Prevention of angina pectoris due to coronary artery disease.
Initial: 30mg or 60mg qam
Titrate: Increase to 120mg qam after several days; rarely, 240mg qam may be required
Start at lower end of dosing range
Take qam on arising
Swallow tab whole w/ a half-glassful of fluid; do not crush or chew
Do not break 30mg tab
Tab, Extended-Release: 30mg*, 60mg*, 120mg *scored
Not useful in aborting acute anginal episode. Not recommended for use in patients w/ acute MI or congestive heart failure; perform careful clinical or hemodynamic monitoring if used in these conditions. Severe hypotension, particularly w/ upright posture, may occur; caution in volume depleted, hypotensive, or elderly patients. Nitrate-induced hypotension may be accompanied by paradoxical bradycardia and increased angina pectoris. May aggravate angina caused by hypertrophic cardiomyopathy. May develop tolerance. Chest pain, acute MI, and sudden death reported during temporary withdrawal.
Headache, dizziness, dry mouth, asthenia, cardiac failure, abdominal pain, earache, arrhythmia, hyperuricemia, arthralgia, purpura, anxiety, hypochromic anemia, atrophic vaginitis, bacterial infection.
Sildenafil amplifies vasodilatory effects that can result in severe hypotension. Additive vasodilating effects w/ other vasodilators (eg, alcohol). Marked symptomatic orthostatic hypotension reported w/ calcium channel blockers; dose adjustments of either class of agents may be necessary.
PREGNANCY AND LACTATION
Category B, caution in nursing.
MECHANISM OF ACTION
Nitrate vasodilator; relaxes vascular smooth muscle, producing dilatation of peripheral arteries and veins, especially the latter. Dilatation of the veins leads to reducing the left ventricular end-diastolic pressure and pulmonary capillary wedge pressure (preload). Arteriolar relaxation reduces systemic vascular resistance, systolic arterial pressure, and mean arterial pressure (afterload). It also dilates the coronary artery.
Absorption: Single Dose (60mg): Cmax=424-541ng/mL, Tmax=3.1-4.5 hrs, AUC=5990-7452ng•hr/mL. Multiple Dose: Cmax=557-572ng/mL (60mg), 1151-1180ng/mL (120mg); Tmax=2.9-4.2 hrs (60mg), 3.1-3.2 hrs (120mg); AUC=6625-7555ng•hr/mL (60mg), 14,241-16,800ng•hr/mL (120mg). Distribution: Vd=0.6-0.7L/kg (IV); plasma protein binding (5%). Metabolism: Liver; denitration and glucuronidation. Elimination: Urine (96%, 2% unchanged), feces (1%); T1/2=6.3-6.6 hrs (60mg single dose), 6.2-6.3 hrs (60mg multiple dose), 6.2-6.4 hrs (120mg multiple dose).
Assess for drug hypersensitivity, hypotension, volume depletion, angina caused by hypertrophic cardiomyopathy, pregnancy/nursing status, possible drug interactions, and any other conditions where treatment is cautioned or contraindicated.
Monitor for hypotension w/ paradoxical bradycardia and increased angina pectoris, tachycardia, aggravation of angina caused by hypertrophic cardiomyopathy, tolerance, manifestations of true physical dependence (eg, chest pain, acute MI), and other adverse reactions.
Inform about the risks and benefits of therapy. Counsel to carefully follow the prescribed schedule of dosing. Advise that daily headaches may accompany treatment and instruct to avoid altering schedule of treatment as the headaches are a marker of the activity of the medication and loss of headache may be associated w/ loss of antianginal efficacy. Inform that treatment may be associated w/ lightheadedness on standing, especially just after rising from a recumbent/seated position and may be more frequent w/ alcohol consumption.
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