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Isosorbide Mononitrate

    Brands

    DEA Class; Rx

    Common Brand Names; Imdur, Monoket, ISMO

    • Nitrates, Angina

    Organic nitrate that causes systemic venodilation, decreasing preload; enters vascular smooth muscle and is converted to nitric oxide, leading to activation of cyclic guanosine monophosphate and vasodilation

    Relaxes smooth muscle via dose-dependent dilation of arterial and venous beds to reduce both preload and afterload, as well as myocardial oxygen demand; also improves coronary collateral circulation, lowering blood pressure, increasing heart rate, and causing occasional paradoxical bradycardia

    Indicated for Prevention of angina pectoris caused by coronary artery disease

    Hypersensitivity to organic nitrates

    PDE-5 inhibitors (eg, avanafil, sildenafil, tadalafil, or vardenafil); concomitant use can cause severe hypotension, syncope, or myocardial ischemia

    Concomitant administration with guanylate stimulator riociguat (may cause hypotension)

    • Dizziness
    • Flushing
    • Headache
    • Hypotension
    • Methemoglobinemia
    • Nausea
    • Orthostatic hypotension
    • Palpitations
    • Restlessness
    • Syncope
    • Tachycardia
    • Vomiting

    Use caution in acute myocardial infarction, alcohol use, hyperthyroidism, increased intracranial pressure (eg, from head trauma or cerebral hemorrhage; potential contraindication), increased intraocular pressure, postural hypotension, volume depletion, Moderate hypotension, low systolic blood pressure (BP)

    Not recommended for use in patients with acute myocardial infarction or heart failure

    May cause CNS depression, which may in turn impair physical or mental abilities; caution patient about performing tasks that require mental alertness, including operating heavy machinery

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

    Do not change brands unintentionally; formulations are not all bioequivalent; extended release formulation not intended for the immediate relief of acute attacks of angina pectoris

    Treat drug-induced headache with aspirin or acetaminophen

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

    Severe hypotension may occur along with paradoxical bradycardia and increased angina pectoris; ethanol can cause severe hypotension with even small doses; avoid excessive, prolonged hypotension

    Withdraw gradually to prevent acute angina

    Discontinue if blurred vision develops

    Use supportive treatment to manage overdose

    Narrow-angle glaucoma (controversial: may not be clinically significant)

    Pregnancy category: C

    Lactation: Unknown whether drug crosses into breast milk; use caution

    Adults

    Immediate release: 5-10 mg PO twice daily initially (5 mg in small patients) given each dose 7 hr apart; increased to 10 mg PO q12hr by day 2 or 3; maintenance: 20 mg PO q12hr

    Extended release: 30-60 mg PO once daily in the morning initially; may be increased to 120 mg PO once daily; wait at least 3 days between increases; if warranted may increase up to 240 mg PO once daily (rare)

    Pediatric

    Safety and efficacy not established

    Isosorbide mononitrate

    tablet

    • 10mg
    • 20mg

    tablet, extended release

    • 30mg
    • 60mg
    • 120mg