Nitrolingual Pumpspray

Name: Nitrolingual Pumpspray

How should this medicine be used?

Nitroglycerin comes as a spray to use on or under the tongue. The spray is usually used as needed, either 5 to 10 minutes before activities that may cause attacks of angina or at the first sign of an attack. Follow the directions on your prescription label carefully, and ask your doctor or pharmacist to explain any part you do not understand. Use nitroglycerin exactly as directed. Do not use more or less of it or use it more often than prescribed by your doctor.

Nitroglycerin may not work as well after you have used it for some time or if you have used many doses. Use the fewest number of sprays needed to relieve the pain of your attacks. If your angina attacks happen more often, last longer, or become more severe at any time during your treatment, call your doctor.

Talk to your doctor about how to use nitroglycerin spray to treat angina attacks. Your doctor will probably tell you to sit down and use one dose of nitroglycerin when an attack begins. If your symptoms do not improve very much or if they worsen after you use this dose you may be told to call for emergency medical help right away. If your symptoms do not go away completely after you use the first dose, your doctor may tell you to use a second dose after 5 minutes have passed and a third dose 5 minutes after the second dose. Call for emergency medical help right away if your chest pain has not gone away completely 5 minutes after you use the third dose.

To use the spray, follow these steps:

  1. Sit down if possible, and hold the container without shaking it. Remove the plastic cap.
  2. If you are using the container for the first time, hold the container upright so that it is pointed away from yourself and others, and press the button 10 times when using Nitromist or 5 times when using Nitrolingual pumpspray to prime the container. If you are not using the container for the first time but have not used it within 6 weeks, press the button 2 times to reprime the container when using Nitromist or 1 time when using Nitrolingual pumpspray. If Nitrolingual has not been used in 3 months or longer, press the button up to 5 times to re-prime the container.
  3. Open your mouth. Hold the container upright, as close to your mouth as possible.
  4. Use your forefinger to press the button firmly. This will release a spray into your mouth. Do not inhale the spray.
  5. Close your mouth. Do not spit out the medication or rinse your mouth for 5 to 10 minutes.
  6. Replace the plastic cap on the container.
  7. Check the level of liquid in the container from time to time to be sure that you will always have enough medication on hand. Hold the container upright while you are checking. If the liquid reaches the top or middle of the hole on the side of the container, you should order more medication. If the liquid is at the bottom of the hole, the container will no longer dispense full doses of medication.

Do not try to open the container of nitroglycerin spray. This product may catch fire, so do not use near an open flame, and do not allow the container to be burned after use.

What should I do if I forget a dose?

Nitroglycerin spray is usually used as needed to treat episodes of angina; do not use it on a regularly scheduled basis.

Warnings

Included as part of the PRECAUTIONS section.

Clinical pharmacology

Mechanism Of Action

Nitroglycerin forms free radical nitric oxide (NO), which activates guanylate cyclase, resulting in an increase of guanosine 3',5'-monophosphate (cyclic GMP) in smooth muscle and other tissues. This eventually leads to dephosphorylation of myosin light chains, which regulates the contractile state in smooth muscle and results in vasodilatation.

Pharmacodynamics

The principal pharmacological action of nitroglycerin is relaxation of vascular smooth muscle. Although venous effects predominate, nitroglycerin produces, in a dose-related manner, dilation of both arterial and venous beds. Dilation of the postcapillary vessels, including large veins, promotes peripheral pooling of blood, decreases venous return to the heart, and reduces left ventricular end-diastolic pressure (preload). Nitroglycerin also produces arteriolar relaxation, thereby reducing peripheral vascular resistance and arterial pressure (after load), and dilates large epicardial coronary arteries; however, the extent to which this latter effect contributes to the relief of exertional angina is unclear.

Therapeutic doses of nitroglycerin may reduce systolic, diastolic and mean arterial blood pressure. Effective coronary perfusion pressure is usually maintained, but can be compromised if blood pressure falls excessively or increased heart rate decreases diastolic filling time.

Elevated central venous and pulmonary capillary wedge pressures, and pulmonary and systemic vascular resistance are also reduced by nitroglycerin therapy. Heart rate is usually slightly increased, presumably a reflex response to the fall in blood pressure. Cardiac index may be increased, decreased, or unchanged. Myocardial oxygen consumption or demand (as measured by the pressure-rate product, tension-time index, and stroke-work index) is decreased and a more favorable supply-demand ratio can be achieved. Patients with elevated left ventricular filling pressure and increased systemic vascular resistance in association with a depressed cardiac index are likely to experience an improvement in cardiac index. In contrast, when filling pressures and cardiac index are normal, cardiac index may be slightly reduced following nitroglycerin administration.

Pharmacokinetics

A liver reductase enzyme is of primary importance in the metabolism of nitroglycerin to glycerol di- and mononitrate metabolites and ultimately to glycerol and organic nitrate. Known sites of extrahepatic metabolism include red blood cells and vascular walls. In addition to nitroglycerin, 2 major metabolites, 1,2- and 1,3-dinitroglycerin are found in plasma. The mean elimination half-life of both 1,2- and 1,3-dinitroglycerin is about 40 minutes. The 1,2- and 1,3-dinitroglycerin metabolites have been reported to possess some pharmacological activity, whereas the glycerol mononitrate metabolites of nitroglycerin areessentially inactive. Higher plasma concentrations of the dinitro metabolites, with their nearly 8-fold longer elimination half-lives, may contribute significantly to the duration of pharmacologic effect.

In a pharmacokinetic study when a single 0.8 mg dose of Nitrolingual Pumpspray was administered to healthy volunteers (n = 24), the mean Cmax and tmax were 1.041pg/mL and 7.5 minutes, respectively. Additionally, in these subjects the mean area under the curve (AUC) was 12.769 pg/mL · min.

The volume of distribution of nitroglycerin following intravenous administration is 3.3 L/kg.

Drug Interactions

Aspirin: Coadministration of nitroglycerin with high dose aspirin (1000 mg) results in increased exposure to nitroglycerin. The vasodilatory and hemodynamic effects of nitroglycerin may be enhanced by concomitant administration of nitroglycerin with high dose aspirin.

Tissue-type plasminogen activator (t-PA): Concomitant administration of t-PA and intravenous nitroglycerin has been shown to reduce plasma levels of t-PA and its thrombolytic effect.

Clinical Studies

In a randomized, double-blind single-dose, 5-period cross-over study in 51 patients with exertional angina pectoris significant dose-related increases in exercise tolerance, time to onset of angina and ST-segment depression were seen following doses of 0.2, 0.4, 0.8 and 1.6 mg of nitroglycerin delivered by metered pumpspray as compared to placebo. The drug showed a profile of mild to moderate adverse events.

What happens if i miss a dose (nitrolingual, nitrolingual duo pack, nitromist, nitrostat, nitro-time)?

Since nitroglycerin is taken as needed, you may not be on a dosing schedule. If you are taking the medication regularly, take the missed dose as soon as you remember. Skip the missed dose if your next dose is less than 2 hours away. Do not take extra medicine to make up the missed dose.

Commonly used brand name(s)

In the U.S.

  • Gonitro
  • Nitrocot
  • Nitrolingual
  • NitroMist
  • Nitroquick
  • Nitrostat
  • Nitrotab
  • Nitro-Time

In Canada

  • Gen-Nitro
  • Nitrolingual Pumpspray

Available Dosage Forms:

  • Spray
  • Tablet, Extended Release
  • Tablet
  • Capsule, Extended Release
  • Packet

Therapeutic Class: Antianginal

Chemical Class: Nitrate

Uses For Nitrolingual Pumpspray

Nitroglycerin is used to prevent angina (chest pain) caused by coronary artery disease. This medicine is also used to relieve an angina attack that is already occurring.

Nitroglycerin belongs to the group of medicines called nitrates. It works by relaxing the blood vessels and increasing the supply of blood and oxygen to the heart while reducing its work load. When used regularly on a long-term basis, or just before exercise or a stressful event, this helps prevent angina attacks from occurring.

This medicine is available only with your doctor's prescription.

Proper Use of nitroglycerin

This section provides information on the proper use of a number of products that contain nitroglycerin. It may not be specific to Nitrolingual Pumpspray. Please read with care.

Take this medicine exactly as directed by your doctor. Do not take more of it, do not take it more often, and do not take it for a longer time than your doctor ordered.

This medicine comes with a patient information insert. Read and follow the instructions in the insert carefully. Ask your doctor if you have any questions.

Nitroglycerin is available as two types of products that are used for different reasons. The extended-release capsules are used every day on a specific schedule to prevent angina attacks. The oral spray, sublingual powder, and sublingual tablets work quickly to stop an angina attack that has already started or they can be used to prevent angina if you plan to exercise or expect a stressful event.

When you begin to feel an attack of angina starting (chest pains, tightness or squeezing in the chest), sit down. Then place a sublingual powder or tablet in your mouth or under your tongue. If you use the oral spray, you should spray it on or under the tongue. You may become dizzy, lightheaded, or faint soon after using a tablet or spray, so it is safer to sit rather than stand while the medicine is working. If you become dizzy or faint while sitting, take several deep breaths and bend forward with your head between your knees. Remain calm and you should feel better in a few minutes.

If you are taking the nitroglycerin sublingual powder: Empty the contents of a packet under your tongue. Close your mouth and breathe normally. Allow powder to dissolve without swallowing. Do not rinse or spit for 5 minutes after taking this medicine. Do not take more than 3 packets in 15 minutes. If you still have pain after you take a total of 3 packets, this is an emergency. Call 911. Do not drive yourself to the hospital.

Nitroglycerin sublingual tablets should not be chewed, crushed, or swallowed. They work much faster when absorbed through the lining of the mouth. Place the tablet under the tongue or between the cheek and gum, and let it dissolve. Do not eat, drink, smoke, or use chewing tobacco while a tablet is dissolving.

Nitroglycerin sublingual tablets usually give relief in 1 to 5 minutes. However, if the pain is not relieved, you may use a second tablet 5 minutes after you take the first tablet. If the pain continues for another 5 minutes, a third tablet may be used. If you still have chest pain after a total of 3 tablets, contact your doctor or go to a hospital emergency room right away. Do not drive yourself and call 911, if necessary.

You may administer 1 or 2 sprays of Nitroglycerin oral spray at the onset of chest pain. If the pain continues after 5 minutes, a third spray may be used. You must wait 5 minutes after the first 1 or 2 sprays before using a third spray. If you still have chest pain after a total of 3 sprays, contact your doctor or go to a hospital emergency room right away. Do not drive yourself and call 911 if necessary. Do not use more than 3 sprays in a 15-minute period.

Swallow the extended-release capsule whole. Do not split, crush, or chew it.

You should take the extended-release capsule first thing in the morning and follow the same schedule each day. This medicine works best if you have a "drug-free" period of time every day when you do not take it. Your doctor will schedule your doses during the day to allow for a drug-free time. Follow the schedule of dosing carefully so the medicine will work properly.

To use the oral spray:

  • Remove the plastic cap.
  • Do not shake the container.
  • If this is a new bottle or container, prime the pump before use by releasing a test spray. This must be done 5 or 10 times into the air away from your face and other people.
  • If this is an old bottle and you have not used it for more than 6 weeks, you must prime it again with 1 or 2 test sprays. If it is not been used within 3 months, prime it up to 5 sprays.
  • Hold the container upright with your forefinger on top of the grooved button. Open your mouth and bring the container as close to it as possible.
  • Press the button firmly with the forefinger to release the spray 1 or 2 times onto or under the tongue. Do not inhale or breathe in the spray.
  • Release the button and close your mouth, but do not swallow right away. Do not spit out the spray or rinse your mouth for at least 5 to 10 minutes.
  • If you need a third spray, you must wait 5 minutes after the second spray. Use exactly the same steps you used for the first spray. No more than 3 sprays should be given within 15 minutes.
  • Replace the cover after using the medicine.
  • Always place the spray bottle in an upright position if not in use. Also, check the fluid level of Nitromist® container regularly. If the fluid reaches the top or middle of the hole on the side of container, this is an indicator that you must get a refill.
  • Do not use the spray near heat, an open flame, or while smoking.

Dosing

The dose of this medicine will be different for different patients. Follow your doctor's orders or the directions on the label. The following information includes only the average doses of this medicine. If your dose is different, do not change it unless your doctor tells you to do so.

The amount of medicine that you take depends on the strength of the medicine. Also, the number of doses you take each day, the time allowed between doses, and the length of time you take the medicine depend on the medical problem for which you are using the medicine.

  • For prevention or treatment of angina:
    • For oral dosage form (extended-release capsules):
      • Adults—2.5 to 6.5 milligrams (mg) 3 to 4 times a day. Your doctor may increase your dose as needed.
      • Children—Use and dose must be determined by your doctor.
    • For sublingual dosage form (powder):
      • Adults—1 or 2 packets placed under the tongue at the first sign of an angina attack. 1 packet may be used every 5 minutes as needed, for up to 15 minutes. Do not take more than 3 packets in 15 minutes.
      • Children—Use and dose must be determined by your doctor.
    • For sublingual dosage form (spray):
      • Adults—1 or 2 sprays on or under the tongue at the first sign of an chest pain. Sprays may be repeated every 5 minutes as needed. You must wait 5 minutes before administering a third spray if 2 sprays are used initially. Do not use more than 3 sprays in 15 minutes. To prevent angina from exercise or stress, use 1 or 2 sprays 5 to 10 minutes before the activity.
      • Children—Use and dose must be determined by your doctor.
    • For sublingual dosage form (tablets):
      • Adults—1 tablet placed under the tongue or between the cheek and gum at the first sign of an angina attack. 1 tablet may be used every 5 minutes as needed, for up to 15 minutes. Do not take more than 3 tablets in 15 minutes. To prevent angina from exercise or stress, use 1 tablet 5 to 10 minutes before the activity.
      • Children—Use and dose must be determined by your doctor.

Missed Dose

If you miss a dose of this medicine, take it as soon as possible. However, if it is almost time for your next dose, skip the missed dose and go back to your regular dosing schedule. Do not double doses.

Storage

Keep out of the reach of children.

Do not keep outdated medicine or medicine no longer needed.

Ask your healthcare professional how you should dispose of any medicine you do not use.

Store the extended-release capsules in a closed container at room temperature, away from heat, moisture, and direct light.

Store the sublingual powder at room temperature, away from heat, moisture, and direct light.

Sublingual tablets should be kept in the original glass bottle. Screw the cap on tightly after each use and store the bottle at room temperature, away from heat, moisture, and direct light.

Store the oral spray at room temperature, away from heat and direct light. Do not freeze. Do not keep this medicine inside a car where it could be exposed to extreme heat or cold. Do not forcefully open the container or throw it into a fire, even if it is empty.

Precautions While Using Nitrolingual Pumpspray

If you will be taking this medicine for a long time, it is very important that your doctor check your progress at regular visits to make sure this medicine is working properly. Blood tests may be needed to check for unwanted effects.

Do not take avanafil (Stendra®), riociguat (Adempas®), sildenafil (Viagra®), tadalafil (Cialis®), or vardenafil (Levitra®) while you are using this medicine. Using these medicines together may cause blurred vision, dizziness, lightheadedness, or fainting. If you are taking these medicines and you have an angina attack, you must go to the hospital right away.

This medicine may cause headaches. These headaches are a sign that the medicine is working. Do not stop using the medicine or change the time you use it in order to avoid the headaches. If you have severe pain, talk with your doctor.

Dizziness, lightheadedness, or fainting may occur, especially when you get up quickly from a lying or sitting position. Getting up slowly may help. Also, lying down for a while may relieve dizziness or lightheadedness.

Dizziness, lightheadedness, or fainting is also more likely to occur if you drink alcohol, stand for long periods of time, exercise, or if the weather is hot. While you are taking this medicine, be careful to limit the amount of alcohol you drink. Also, use extra care during exercise or hot weather or if you must stand for long periods of time.

Do not stop using this medicine without checking first with your doctor. Your doctor may want you to gradually reduce the amount you are using before stopping it completely.

Blurred vision or dryness of the mouth may occur while using this medicine. Check with your doctor if this concerns you.

Serious skin reactions can occur with this medicine. Check with your doctor right away if you have cracks in the skin, feeling of warmth, loss of heat from the body, rash, red, swollen skin, redness of the face, neck, arms, and occasionally, upper chest, or scaly skin while you are using this medicine.

Make sure any doctor or dentist who treats you knows that you are using this medicine. You may need to stop using this medicine several days before you have medical tests.

Do not take other medicines unless they have been discussed with your doctor. This includes prescription or nonprescription (over-the-counter [OTC]) medicines and herbal or vitamin supplements.

Nitrolingual Pumpspray Side Effects

Along with its needed effects, a medicine may cause some unwanted effects. Although not all of these side effects may occur, if they do occur they may need medical attention.

Check with your doctor immediately if any of the following side effects occur:

Less common
  • Bloating or swelling of the face, arms, hands, lower legs, or feet
  • burning, crawling, itching, numbness, prickling, "pins and needles", or tingling feelings
  • difficult or labored breathing
  • feeling faint, dizzy, or lightheadedness
  • feeling of warmth or heat
  • flushing or redness of the skin, especially on the face and neck
  • headache
  • rapid weight gain
  • sweating
  • tightness in the chest
  • tingling of the hands or feet
  • unusual weight gain or loss
Rare
  • Bluish-colored lips, fingernails, or palms
  • dark urine
  • fever
  • pale skin
  • rapid heart rate
  • sore throat
  • unusual bleeding or bruising
  • unusual tiredness or weakness
Incidence not known
  • Arm, back, or jaw pain
  • blurred vision
  • chest pain or discomfort
  • chest tightness or heaviness
  • confusion
  • cough
  • cracks in the skin
  • difficulty with swallowing
  • dizziness, faintness, or lightheadedness when getting up suddenly from a lying or sitting position
  • fainting
  • fast, irregular, pounding, or racing heartbeat or pulse
  • feeling of constant movement of self or surroundings
  • feeling of warmth
  • hives, itching, or rash
  • increased sweating
  • loss of heat from the body
  • nausea or vomiting
  • puffiness or swelling of the eyelids or around the eyes, face, lips, or tongue
  • red, swollen skin
  • redness of the face, neck, arms, and occasionally, upper chest
  • scaly skin
  • sensation of spinning
  • weakness

Get emergency help immediately if any of the following symptoms of overdose occur:

Symptoms of overdose
  • Bluish-colored lips, fingernails, or palms
  • blurred or loss of vision
  • bulging soft spot on the head of an infant
  • change in consciousness
  • change in the ability to see colors, especially blue or yellow
  • cold, clammy skin
  • dark urine
  • difficulty breathing
  • disturbed color perception
  • dizziness or lightheadedness
  • double vision
  • fever
  • flushed skin
  • halos around lights
  • headache, severe and throbbing
  • increased sweating
  • loss of appetite
  • loss of consciousness
  • night blindness
  • overbright appearance of lights
  • pale skin
  • paralysis
  • slow or irregular heartbeat
  • sore throat
  • tunnel vision
  • unusual bleeding or bruising
  • unusual tiredness or weakness

Some side effects may occur that usually do not need medical attention. These side effects may go away during treatment as your body adjusts to the medicine. Also, your health care professional may be able to tell you about ways to prevent or reduce some of these side effects. Check with your health care professional if any of the following side effects continue or are bothersome or if you have any questions about them:

Less common
  • Abdominal or stomach pain
  • body aches or pain
  • congestion
  • hoarseness
  • lack or loss of strength
  • runny nose
  • sneezing
  • stuffy nose
  • tender, swollen glands in the neck
  • voice changes

Other side effects not listed may also occur in some patients. If you notice any other effects, check with your healthcare professional.

Call your doctor for medical advice about side effects. You may report side effects to the FDA at 1-800-FDA-1088.

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