Headache, which may be severe, is the most commonly reported side effect. Headache may be recurrent with each daily dose, especially at higher doses. Transient episodes of lightheadedness, occasionally related to blood pressure changes, may also occur. Adverse reactions to isosorbide dinitrate are generally dose-related, and almost all of these reactions are the result of isosorbide dinitrate's activity as a vasodilator.
Serum levels of ISDN reach their maxima 10 to 15 minutes after sublingual dosing. Bioavailability of ISDN after single sublingual doses is 40 to 50%.Multiple-dose studies of sublingual ISDN pharmacokinetics have not been reported; multiple-dose studies of ingested ISDN have observed progressive increases in bioavailability during chronic therapy.
No long-term studies in animals have been performed to evaluate the carcinogenic potential of isosorbide dinitrate. In a modified two-litter reproduction study, there was no remarkable gross pathology and no altered fertility or gestation among rats fed isosorbide dinitrate at 25 or 100 mg/kg/day.
Availability Rx Prescription only.
ALSO AVAILABLE Oral Titradose Tablets in the following dosage strengths:
Generic Name: isosorbide dinitrate Dosage Form: Sublingual Tablets R x only.
Wyeth Laboratories A Wyeth-Ayerst Company Philadelphia, PA 19101 CI 4370-3.
Attempts to overcome nitrate tolerance by dose escalation, even to doses far in excess of those used acuy, have consistently failed. In the large majority of these trials, active agents were no more effective than placebo after 24 hours (or less) of continuous therapy. Several well-controlled clinical trials have used exercise testing to assess the anti-anginal efficacy of continuously-delivered nitrates. This strategy is inappropriate for organic nitrates. Only after nitrates have been absent from the body for several hours has their anti-anginal efficacy been restored. Dosing regimens for most chronically used drugs are designed to provide plasma concentrations that are continuously greater than a minimally effective concentration.
Extremely rarely, ordinary doses of organic nitrates have caused methemoglobinemia in normal-seeming patients. Methemoglobinemia is so infrequent at these doses that further discussion of its diagnosis and treatment is deferred (see OVERDOSAGE ).
In industrial workers who have had long-term exposure to unknown (presumably high) doses of organic nitrates, tolerance clearly occurs. Chest pain, acute myocardial infarction, and even sudden death have occurred during temporary withdrawal of nitrates from these workers, demonstrating the existence of true physical dependence.
In one such trial, however, subjects receiving nitroglycerin had less exercise tolerance at the end of the daily dose-free interval than the parallel group receiving placebo. Few well-controlled clinical trials of organic nitrates have been designed to detect rebound or withdrawal effects. The incidence, magnitude, and clinical significance of similar phenomena in patients receiving ISDN have not been studied.
Treatment with isosorbide dinitrate may be associated with lightheadedness on standing, especially just after rising from a recumbent or seated position. This effect may be more frequent in patients who have also consumed alcohol.
Severe hypotension, particularly with upright posture, may occur with even small doses of isosorbide dinitrate. This drug should therefore be used with caution in patients who may be volume depleted or who, for whatever reason, are already hypotensive. Hypotension induced by isosorbide dinitrate may be accompanied by paradoxical bradycardia and increased angina pectoris.
10 mg, NDC, in bottles of 100 or 1,000.
Isordil Sublingual tablets may be used to abort an acute anginal episode, but its use is recommended only in patients who fail to respond to sublingual nitroglycerin. A patient anticipating activity likely to cause angina should take one Isordil Sublingual tablet (2.5 to 5 mg) about 15 minutes before the activity is expected to begin.
The vasodilating effects of isosorbide dinitrate may be additive with those of other vasodilators. Alcohol, in particular, has been found to exhibit additive effects of this variety.
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Other brands: IsoDitrate, Dilatrate-SR.
When methemoglobinemia is diagnosed, the treatment of choice is methylene blue, 1 to 2 mg/kg intravenously.
Pregnancy Category C Risk cannot be ruled out.
However, because the onset of action of sublingual ISDN is significantly slower than that of sublingual nitroglycerin, sublingual ISDN is not the drug of first choice for abortion of an acute anginal episode. Isordil (isosorbide dinitrate) Sublingual tablets are indicated for the prevention and treatment of angina pectoris due to coronary artery disease.
antianginal agents Nitrostat, nitroglycerin, isosorbide mononitrate, Ranexa, Imdur.
No specific antagonist to the vasodilator effects of isosorbide dinitrate is known, and no intervention has been subject to controlled studies as a therapy for isosorbide dinitrate overdose. Because the hypotension associated with isosorbide dinitrate overdose is the result of venodilatation and arterial hypovolemia, prudent therapy in this situation should be directed toward increase in central fluid volume. Passive elevation of the patient's legs may be sufficient, but intravenous infusion of normal saline or similar fluid may also be necessary.
Patients should resist the temptation to avoid headaches by altering the schedule of their treatment with isosorbide dinitrate, since loss of headache may be associated with simultaneous loss of anti-anginal efficacy. In particular, daily headaches sometimes accompany treatment with isosorbide dinitrate. Aspirin and/or acetaminophen, on the other hand, often successfully relieve isosorbide dinitrate-induced headaches with no deleterious effect on isosorbide dinitrate's anti-anginal efficacy. In patients who get these headaches, the headaches are a marker of the activity of the drug. Patients should be told that the anti-anginal efficacy of isosorbide dinitrate is strongly related to its dosing regimen, so the prescribed schedule of dosing should be followed carefully.
In patients with normal reductase function, significant production of methemoglobin should require even larger doses of isosorbide dinitrate. Nitrate ions liberated during metabolism of isosorbide dinitrate can oxidize hemoglobin into methemoglobin. In one study in which 36 patients received 2 to 4 weeks of continuous nitroglycerin therapy at 3.1 to 4.4 mg/hr (equivalent, in total administered dose of nitrate ions, to 4.8 to 6.9 mg of bioavailable isosorbide dinitrate per hour), the average methemoglobin level measured was 0.2%; this was comparable to that observed in parallel patients who received placebo. Even in patients totally without cytochrome b 5 reductase activity, however, and even assuming that the nitrate moieties of isosorbide dinitrate are quantitatively applied to oxidation of hemoglobin, about 1 mg/kg of isosorbide dinitrate should be required before any of these patients manifests clinically significant (≥10%) methemoglobinemia.
The daily dose-free interval sufficient to avoid tolerance to organic nitrates has not been well defined. Studies of nitroglycerin (an organic nitrate with a very short half-life) have shown that daily dose-free intervals of 10 to 12 hours are usually sufficient to minimize tolerance. Daily dose-free intervals that have succeeded in avoiding tolerance during trials of moderate doses ( e.g., 30 mg) of immediate-release ISDN have generally been somewhat longer (at least 14 hours), but this is consistent with the longer half-lives of ISDN and its active metabolites.
If one elects to use isosorbide dinitrate in these conditions, careful clinical or hemodynamic monitoring must be used to avoid the hazards of hypotension and tachycardia. The benefits of sublingual isosorbide dinitrate in patients with acute myocardial infarction or congestive heart failure have not been established.
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Store at room temperature, approximay 25° C (77° F) Protect from light Keep bottles tightly closed Dispense in a light-resistant, tight container Use carton to protect blisters from light.
5 mg, round, pink tablets imprinted "5" on one side and "W" on reverse side: NDC, bottles of 100.
Notwithstanding these observations, there are case reports of significant methemoglobinemia in association with moderate overdoses of organic nitrates. None of the affected patients had been thought to be unusually susceptible.
Similarly, it is not known which, if any, of these substances can usefully be removed from the body by hemodialysis. No data are available to suggest physiological maneuvers ( e.g., maneuvers to change the pH of the urine) that might accelerate elimination of isosorbide dinitrate and its active metabolites.
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The ill effects of isosorbide dinitrate overdose are generally the results of isosorbide dinitrate's capacity to induce vasodilatation, venous pooling, reduced cardiac output, and hypotension. These hemodynamic changes may have protean manifestations, including increased intracranial pressure, with any or all of persistent throbbing headache, confusion, and moderate fever; vertigo; palpitations; visual disturbances; nausea and vomiting (possibly with colic and even bloody diarrhea); syncope (especially in the upright posture); air hunger and dyspnea, later followed by reduced ventilatory effort; diaphoresis, with the skin either flushed or cold and clammy; heart block and bradycardia; paralysis; coma; seizures; and death.
Multiple-dose trials of ingested formulations of ISDN have shown that ISDN's anti-anginal efficacy is substantially attenuated by tolerance unless the daily regimen includes a dose-free interval of at least 14 hours. The daily dose-free interval necessary in any chronic regimen using sublingual ISDN is not known.
Hypotension occurs infrequently, but in some patients it may be severe enough to warrant discontinuation of therapy. Syncope, crescendo angina, and rebound hypertension have been reported but are uncommon.
Store at room temperature, approximay 25° C (77° F) Keep tightly closed Dispense in a tight container.
Classically, methemoglobinemic blood is described as chocolate brown, without color change on exposure to air. The diagnosis should be suspected in patients who exhibit signs of impaired oxygen delivery despite adequate cardiac output and adequate arterial pO 2. Methemoglobin levels are available from most clinical laboratories.
CSA Schedule N Not a controlled drug.
30 mg, NDC, in bottles of 100.
20 mg, NDC, in bottles of 100 or 500.
In the same trial, the anti-anginal effect of the sublingual nitroglycerin was evident for about an hour, while that of the sublingual ISDN lasted about 2 hours. In a controlled trial in which 0.4 mg of sublingual nitroglycerin took 1.9 minutes to begin to produce an anti-anginal effect, 5 mg of sublingual ISDN took 3.4 minutes to begin to produce a similar effect.
Isordil is contraindicated in patients who are allergic to isosorbide dinitrate or any of its other ingredients. Allergic reactions to organic nitrates are extremely rare, but they do occur.
Laboratory determinations of serum levels of isosorbide dinitrate and its metabolites are not widely available, and such determinations have, in any event, no established role in the management of isosorbide dinitrate overdose.
Safety and effectiveness in pediatric patients have not been established.
Angina aspirin, amlodipine, carvedilol, metoprolol, atenolol, Norvasc, Coreg, propranolol, Nitrostat, nitroglycerin, More.
Clearance is affected primarily by denitration to the 2-mononitrate (15 to 25%) and the 5-mononitrate (75 to 85%). Since the clearance exceeds hepatic blood flow, considerable extrahepatic metabolism must also occur. Once absorbed, the volume of distribution of isosorbide dinitrate is 2 to 4 L/kg, and this volume is cleared at the rate of 2 to 4 L/min, so ISDN's half-life in serum is about an hour.
Large controlled studies with other nitrates suggest that no dosing regimen with Isordil Sublingual tablets should be expected to provide more than about 12 hours of continuous anti-anginal efficacy per day.
At oral doses 35 and 150 times the maximum recommended human daily dose, isosorbide dinitrate has been shown to cause a dose-related increase in embryotoxicity (increase in mummified pups) in rabbits. There are no adequate, well-controlled studies in pregnant women. Isosorbide dinitrate should be used during pregnancy only if the potential benefit justifies the potential risk to the fetus.
Isordil (isosorbide dinitrate) Sublingual Tablets are available as follows:
As also noted under CLINICAL PHARMACOLOGY, the efficacy of daily doses after the first has never been demonstrated.
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There are no data suggesting what dose of isosorbide dinitrate is likely to be life-threatening in humans. In rats, the median acute lethal dose (LD 50 ) was found to be 1100 mg/kg.
Isosorbide dinitrate is freely soluble in organic solvents such as acetone, alcohol, and ether, but is only sparingly soluble in water. Isosorbide dinitrate is a white, crystalline, odorless compound which is stable in air and in solution, has a melting point of 70°C and has an optical rotation of +134° (c=1.0, alcohol, 20°C).
Dilatation of the coronary arteries also occurs. The principal pharmacological action of isosorbide dinitrate is relaxation of vascular smooth muscle and consequent dilatation of peripheral arteries and veins, especially the latter. Dilatation of the veins promotes peripheral pooling of blood and decreases venous return to the heart, thereby reducing 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). The relative importance of preload reduction, afterload reduction, and coronary dilatation remains undefined.
Multiple-dose trials of sublingual ISDN have not been reported.
With an overall half-life of about 5 hours, the 5-mononitrate is cleared from the serum by denitration to isosorbide, glucuronidation to the 5-mononitrate glucuronide, and denitration/hydration to sorbitol. The 2-mononitrate has been less well studied, but it appears to participate in the same metabolic pathways, with a half-life of about 2 hours. Both metabolites have biological activity, especially the 5-mononitrate.
Isosorbide dinitrate (ISDN) is 1,4:3,6-dianhydro-D-glucitol 2,5-dinitrate, an organic nitrate whose structural formula is.
Amplification of the vasodilatory effects of Isordil by sildenafil can result in severe hypotension. Appropriate supportive care has not been studied, but it seems reasonable to treat this as a nitrate overdose, with elevation of the extremities and with central volume expansion. The time course and dose dependence of this interaction have not been studied.
and whose molecular weight is 236.14. The organic nitrates are vasodilators, active on both arteries and veins.
Some clinical trials in angina patients have provided nitroglycerin for about 12 continuous hours of every 24-hour day. During the daily dose-free interval in some of these trials, anginal attacks have been more easily provoked than before treatment, and patients have demonstrated hemodynamic rebound and decreased exercise tolerance. The importance of these observations to the routine, clinical use of sublingual isosorbide dinitrate is not known.
Nitrate therapy may aggravate the angina caused by hypertrophic cardiomyopathy.
5 mg, NDC, in bottles of 100 or 1,000.
Data are not available to allow estimation of the frequency of adverse reactions during treatment with Isordil Sublingual tablets.
It is not known whether isosorbide dinitrate is excreted in human milk. Because many drugs are excreted in human milk, caution should be exercised when isosorbide dinitrate is administered to a nursing woman.
In other controlled trials, the anti-anginal efficacy of sublingual ISDN has persisted for periods ranging from 30 minutes up to 4 hours.
In the case of sublingual tablets, it is probably true that one of the daily dose-free intervals must be somewhat longer than 14 hours. Every dosing regimen for ISDN must provide a daily dose-free interval to minimize the development of this tolerance. As noted under Clinical Pharmacology, multiple-dose studies with ISDN and other nitrates have shown that maintenance of continuous 24-hour plasma levels results in refractory tolerance.
2.5 mg, round, yellow tablets imprinted "2.5" on one side and "W" on reverse side: NDC, bottles of 100.
40 mg, NDC, in bottles of 100.
From large, well-controlled studies of other nitrates, it is reasonable to believe that the maximal achievable daily duration of anti-anginal effect from isosorbide dinitrate is about 12 hours. No dosing regimen for isosorbide dinitrate has, however, ever actually been shown to achieve this duration of effect. In the absence of data from multiple-dose trials, and considering the capacity of organic nitrates to induce tolerance, it is not reasonable to assume that multiple sublingual ISDN tablets taken during the course of a day will all have similar effects.
Approval History 10+ years FDA approved 1959.
The 2.5 mg dosage strength also contains D&C Yellow 10 and FD&C Yellow 6, and the 5 mg dosage strength also contains FD&C Red 40. Each Isordil Sublingual tablet contains 2.5, 5, or 10 mg of isosorbide dinitrate. The inactive ingredients in each tablet are cellulose, lactose, magnesium stearate, and starch.
10 mg, round, white tablets imprinted "10" on one side and "Wyeth" on reverse side: NDC, bottles of 100.
In patients with renal disease or congestive heart failure, therapy resulting in central volume expansion is not without hazard. Treatment of isosorbide dinitrate overdose in these patients may be subtle and difficult, and invasive monitoring may be required.
Other reported clinical experience has not identified differences in responses between the elderly and younger patients. In general, dose selection for an elderly patient should be cautious, usually starting at the low end of the dosing range, reflecting the greater frequency of decreased hepatic, renal, or cardiac function, and of concomitant disease or other drug therapy. Clinical studies of Isordil (isosorbide dinitrate) Sublingual did not include sufficient numbers of subjects aged 65 and over to determine whether they respond differently from younger subjects.
As tolerance to isosorbide dinitrate develops, the effect of sublingual nitroglycerin on exercise tolerance, although still observable, is somewhat blunted.
The use of epinephrine or other arterial vasoconstrictors in this setting is likely to do more harm than good.Isordil