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Nitroglycerin

Pronunciation

Pronunciation

(nye troe GLI ser in)

Index Terms

  • Glyceryl Trinitrate
  • GTN
  • Nitroglycerol
  • Nitronal
  • NTG
  • TNG
  • Tridil

Dosage Forms

Excipient information presented when available (limited, particularly for generics); consult specific product labeling.

Aerosol Solution, Translingual:

NitroMist: 400 mcg/spray (4.1 g, 8.5 g) [contains menthol]

Generic: 400 mcg/spray (4.1 g, 8.5 g)

Capsule Extended Release, Oral:

Nitro-Time: 2.5 mg [contains brilliant blue fcf (fd&c blue #1), fd&c red #40, fd&c yellow #10 (quinoline yellow)]

Nitro-Time: 6.5 mg [contains brilliant blue fcf (fd&c blue #1), fd&c yellow #10 (quinoline yellow), fd&c yellow #6 (sunset yellow)]

Nitro-Time: 9 mg [contains fd&c yellow #10 (quinoline yellow), fd&c yellow #6 (sunset yellow)]

Generic: 2.5 mg, 6.5 mg, 9 mg

Ointment, Rectal:

Rectiv: 0.4% (30 g) [contains propylene glycol]

Ointment, Transdermal:

Nitro-Bid: 2% (1 g, 30 g, 60 g)

Patch 24 Hour, Transdermal:

Minitran: 0.1 mg/hr (30 ea); 0.2 mg/hr (30 ea); 0.4 mg/hr (30 ea); 0.6 mg/hr (30 ea)

Nitro-Dur: 0.1 mg/hr (30 ea, 100 ea); 0.2 mg/hr (30 ea, 100 ea); 0.3 mg/hr (1 ea, 30 ea, 100 ea); 0.4 mg/hr (30 ea, 100 ea); 0.6 mg/hr (30 ea, 100 ea); 0.8 mg/hr (30 ea, 100 ea)

Generic: 0.1 mg/hr (30 ea, 4350 ea); 0.2 mg/hr (30 ea, 4350 ea); 0.4 mg/hr (30 ea, 4350 ea); 0.6 mg/hr (30 ea, 4350 ea)

Solution, Intravenous:

Nitronal: 1 mg/mL (25 mL, 50 mL)

Generic: 25 mg (250 mL); 50 mg (250 mL, 500 mL); 100 mg (250 mL); 200 mg (500 mL); 5 mg/mL (10 mL)

Solution, Translingual:

Nitrolingual: 0.4 mg/spray (4.9 g, 12 g) [contains alcohol, usp]

Generic: 0.4 mg/spray (4.9 g, 12 g)

Tablet Sublingual, Sublingual:

Nitrostat: 0.3 mg, 0.4 mg, 0.6 mg

Brand Names: U.S.

  • Minitran
  • Nitro - Bid
  • Nitro - Dur
  • Nitro - Time
  • Nitrolingual
  • NitroMist
  • Nitronal
  • Nitrostat
  • Rectiv

Pharmacologic Category

  • Antianginal Agent
  • Antidote, Extravasation
  • Vasodilator

Pharmacology

Nitroglycerin forms free radical nitric oxide. In smooth muscle, nitric oxide activates guanylate cyclase which increases guanosine 3’5’ monophosphate (cGMP) leading to dephosphorylation of myosin light chains and smooth muscle relaxation. Produces a vasodilator effect on the peripheral veins and arteries with more prominent effects on the veins. Primarily reduces cardiac oxygen demand by decreasing preload (left ventricular end-diastolic pressure); may modestly reduce afterload; dilates coronary arteries and improves collateral flow to ischemic regions. For use in rectal fissures, intra-anal administration results in decreased sphincter tone and intra-anal pressure.

Distribution

Vd: ~3 L/kg

Metabolism

Extensive first-pass effect; metabolized hepatically to glycerol di- and mononitrate metabolites via liver reductase enzyme; subsequent metabolism to glycerol and organic nitrate; nonhepatic metabolism via red blood cells and vascular walls also occurs

Excretion

Urine (as inactive metabolites)

Onset of Action

Sublingual tablet: 1 to 3 minutes; Translingual spray: Similar to sublingual tablet; Extended release: ~60 minutes; Topical: 15 to 30 minutes; Transdermal: ~30 minutes; IV: Immediate

Peak effect: Sublingual tablet: 5 minutes; Translingual spray: 4 to 10 minutes; Extended release: 2.5 to 4 hours; Topical: ~60 minutes; Transdermal: 120 minutes; IV: Immediate

Duration of Action

Sublingual tablet: At least 25 minutes; Translingual spray: Similar to sublingual tablet; Extended release: 4 to 8 hours (Gibbons, 2002); Topical: 7 hours; Transdermal: 10 to 12 hours; IV: 3 to 5 minutes

Half-Life Elimination

~1 to 4 minutes

Protein Binding

60%

Use: Labeled Indications

Treatment or prevention of angina pectoris

Intravenous (IV) administration: Treatment or prevention of angina pectoris; acute decompensated heart failure (especially when associated with acute myocardial infarction); perioperative hypertension (especially during cardiovascular surgery); induction of intraoperative hypotension

Intra-anal administration (Rectiv ointment): Treatment of moderate-to-severe pain associated with chronic anal fissure

Use: Unlabeled

Short-term management of pulmonary hypertension (IV); esophageal spastic disorders; uterine relaxation; treatment of sympathomimetic vasopressor extravasation injury (alternative to phentolamine)

Contraindications

Hypersensitivity to organic nitrates or any component of the formulation (includes adhesives for transdermal product); concurrent use with phosphodiesterase-5 (PDE-5) inhibitors (avanafil, sildenafil, tadalafil, or vardenafil); concurrent use with riociguat

Additional contraindications for IV product: Hypersensitivity to corn or corn products (solutions containing dextrose); constrictive pericarditis; pericardial tamponade; restrictive cardiomyopathy

Additional contraindications for sublingual product and rectal ointment: Early myocardial infarction (sublingual product only; see Note); increased intracranial pressure; severe anemia

Additional contraindications for translingual product: Increased intracranial pressure; severe anemia; acute circulatory failure or shock (Nitrolingual only)

Canadian labeling: Additional contraindications for transdermal patch (not in US labeling): Acute circulatory failure associated with marked hypotension (shock and states of collapse); orthostatic hypotension; myocardial insufficiency due to obstruction (eg, presence of aortic or mitral stenosis or of constrictive pericarditis); increased intracranial pressure; increased intraocular pressure; severe anemia

Note: According to the 2013 American College of Cardiology Foundation/American Heart Association (ACCF/AHA) guidelines of the management of ST-elevation myocardial infarction (STEMI) and the 2013 ACCF/AHA guidelines for the management of unstable angina/non-ST-elevation myocardial infarction, avoid nitrates in the following conditions: Hypotension (SBP <90 mm Hg or ≥30 mm Hg below baseline), marked bradycardia or tachycardia, and right ventricular infarction. Sublingual nitroglycerin may be used as initial treatment of ongoing chest pain in patients who may have STEMI or UA/NSTEMI (Anderson, 2013; O'Gara, 2013).

Dosage

Note: Hemodynamic and antianginal tolerance often develop within 24 to 48 hours of continuous nitrate administration. Nitrate-free interval (10 to 12 hours/day) is recommended to avoid tolerance development; gradually decrease dose in patients receiving NTG for prolonged period to avoid withdrawal reaction.

Extravasation (sympathomimetic vasopressors), treatment (alternative to phentolamine; off-label use): Based on limited data in neonates; optimal dosing has not been established: Pediatrics and Adults: Topical 2% ointment: 4 mm/kg applied as a thin ribbon to the affected area has been reported in a case series; after 8 hours, if no improvement, the dose may be reapplied to the affected site (Wong, 1992). Application of a 1-inch strip on the affected site has also been described to be successful (Denkler, 1989); may also be considered for adults as an alternative to phentolamine (Hurst, 2004).

Angina/coronary artery disease: Adults:

Oral: Initial: 2.5 to 6.5 mg 3 to 4 times daily; may titrate up to 26 mg 4 times daily

IV: 5 mcg/minute, increase by 5 mcg/minute every 3 to 5 minutes to 20 mcg/minute; if no response at 20 mcg/minute, may increase by 10 to 20 mcg/minute every 3 to 5 minutes (generally accepted maximum dose: 400 mcg/minute)

According to the 2013 ACCF/AHA guideline for the management of unstable angina/non-ST-elevation myocardial infarction (off-label dosing): Initial: 10 mcg/minute, increase by 10 mcg/minute every 3 to 5 minutes until relief of symptoms or blood pressure response noted; if no response at 20 mcg/minute, may increase by 10 mcg/minute and later by 20 mcg/minute may be used (Anderson, 2013). The 2013 ACCF/AHA guidelines for STEMI also recommend an initial dose of 10 mcg/minute with subsequent titration to desired blood pressure effect (O'Gara, 2013).

Sublingual: 0.3 to 0.6 mg every 5 minutes for maximum of 3 tablets in 15 minutes; may also use prophylactically 5 to 10 minutes prior to activities which may provoke an attack

According to the 2013 ACCF/AHA guidelines for STEMI and the guidelines for the management of unstable angina/NSTEMI: If nitroglycerin is prescribed, advise the patient to take 1 dose promptly in response to chest pain. If pain is unrelieved or worsened 5 minutes after 1 dose, the patient or caregiver should call 9-1-1 immediately (Anderson, 2013; O'Gara, 2013).

Topical 2% ointment: 1/2” upon rising and 1/2” 6 hours later; if necessary, the dose may be doubled to 1” and subsequently doubled again to 2” if response is inadequate. Doses of 1/2” to 2” were used in clinical trials. Recommended maximum: 2 doses/day; include a nitrate free-interval ~10 to 12 hours/day.

Topical patch, transdermal: Initial: 0.2 to 0.4 mg/hour, titrate to 0.4 to 0.8 mg/hour; tolerance is minimized by using a patch-on period of 12 to 14 hours and patch-off period of 10 to 12 hours

Translingual 0.4 mg/spray: 1 to 2 sprays onto or under tongue approximately every 5 minutes for maximum of 3 sprays in 15 minutes, may also be used prophylactically 5 to 10 minutes prior to activities which may provoke an angina attack

According to the 2013 ACCF/AHA guidelines for STEMI and the guidelines for the management of unstable angina/NSTEMI: If nitroglycerin is prescribed, advise the patient to take 1 dose promptly in response to chest pain. If pain is unrelieved or worsened 5 minutes after 1 dose, the patient or caregiver should call 9-1-1 immediately (Anderson, 2013; O'Gara, 2013).

Anal fissure, chronic (0.4% ointment): Adults: Intra-anal: 1 inch (equals 1.5 mg of nitroglycerin) every 12 hours for up to 3 weeks

Esophageal spastic disorders (off-label use): Adults: Sublingual: 0.3 to 0.6 mg (Swamy, 1977)

Gastroesophageal variceal hemorrhage (off-label use): Adults: IV infusion: Initial: 40 mcg/minute, increase by 40 mcg/minute every 15 minutes if systolic blood pressure is >90 to 100 mm Hg, up to a maximum of 400 mcg/minute (Garcia-Tsao, 2007; Gimson, 1986; Westaby, 1989). Coadminister with vasopressin and use at the highest effective dose for a maximum of 24 hours to minimize the development of adverse effects (Garcia-Tsao, 2007).

Uterine relaxation (off-label use): Adults: IV bolus: 100 to 200 mcg; may repeat dose every 2 minutes as necessary (Axemo, 1998; Chandraharan, 2005)

Dosage adjustment in renal impairment: There are no dosage adjustments provided in the manufacturer’s labeling.

Dosage adjustment in hepatic impairment: There are no dosage adjustments provided in the manufacturer’s labeling.

Reconstitution

Nitronal (glyceryl trinitrate) 1 mg/mL (temporarily available in the U.S.):

To prepare a 100 mcg/mL solution: Withdraw 25 mL D5W from a 250 mL bottle of D5W and replace volume with 25 mg (25 mL) of Nitronal.

To prepare a 200 mcg/mL solution: Withdraw 50 mL D5W from a 250 mL bottle of D5W and replace volume with 50 mg (50 mL) of Nitronal.

Administration

IV: Prepare in glass bottles, EXCEL or PAB containers. Adsorption occurs to soft plastic (eg, PVC); use administration sets intended for nitroglycerin. Administer via infusion pump.

Intra-anal ointment: Using a finger covering (eg, plastic wrap, surgical glove, finger cot), place finger beside 1 inch measuring guide on the box and squeeze ointment the length of the measuring line directly onto covered finger. Insert ointment into the anal canal using the covered finger up to first finger joint (do not insert further than the first finger joint) and apply ointment around the side of the anal canal. If intra-anal application is too painful, may apply the ointment to the outside of the anus. Wash hands following application.

Extended release capsule: Swallow whole. Do not chew, break, or crush. Administer with a full glass of water.

Sublingual: Do not chew, crush, or swallow sublingual tablet. Place under tongue and allow to dissolve. Alternately, may be placed in the buccal pouch.

Topical ointment: Wash hands prior to and after use. Application site should be clean, dry, and hair-free. Apply to chest or back with the applicator or dose-measuring paper. Spread in a thin layer over a 2.25 x 3.5 inch area. Do not rub into skin. Tape applicator into place.

Drug extravasation management, (treatment), sympathomimetic vasopressors (alternative to phentolamine) (off-label use): Stop vesicant infusion immediately and disconnect IV line (leave needle/cannula in place); gently aspirate extravasated solution from the IV line (do NOT flush the line); remove needle/cannula; elevate extremity. Apply nitroglycerin ointment as a thin ribbon to the affected area (Wong, 1992). May also apply dry warm compresses (Hurst, 2004).

Topical patch, transdermal: Application site should be clean, dry and hair-free. Remove patch after 12 to 14 hours. Rotate patch sites. Dispose of any used of unused patches by folding adhesive ends together, replace in pouch or sealed container and discard properly in trash, away from children and pets.

Translingual spray: Do not shake container. Prior to initial use, the pump must be primed by spraying 5 times (Nitrolingual) or 10 times (Nitromist) into the air. Priming sprays should be directed away from patient and others. Release spray onto or under tongue. Close mouth immediately after administration; do not inhale spray. Do not expectorate or rinse the mouth for 5 to 10 minutes following administration. Content of the container should be checked periodically; when the container is held upright, the end of the pump should be covered by the fluid in the bottle or the remaining sprays will not deliver the intended dose. If pump is unused for 6 weeks, a single priming spray (Nitrolingual) or 2 priming sprays (Nitromist) should be completed. If pump is unused for 3 months, re-prime with up to 5 sprays (Nitrolingual).

Compatibility

Stable in D5LR, D51/2NS, D5NS, LR, 1/2NS.

Y-site administration: Incompatible with caffeine citrate, levofloxacin.

Compatibility in syringe: Incompatible with caffeine citrate, pantoprazole.

Storage

Extended-release capsules: Store at 25°C (77°F); excursions permitted to 15°C to 30°C (59°F to 86°F). Protect from moisture.

IV solution: Doses should be made in glass bottles, EXCEL® or PAB® containers. Adsorption occurs to soft plastic (eg, PVC). Nitroglycerin diluted in D5W or NS in glass containers is physically and chemically stable for 48 hours at room temperature and 7 days under refrigeration. In D5W or NS in EXCEL®/PAB® containers it is physically and chemically stable for 24 hours at room temperature.

Sublingual tablets, topical ointment, and rectal ointment: Store at 20°C to 25°C (68°F to 77°F)

Transdermal patch: Store at 15°C to 30°C (59°F to 86°F)

Translingual spray: Store at 25°C (77°F); excursions permitted to 15°C to 30°C (59°F to 86°F). Do not forcefully open or burn container after use. Do not spray toward flames.

Drug Interactions

Alcohol (Ethyl): May enhance the vasodilatory effect of Vasodilators (Organic Nitrates). Monitor therapy

Alfuzosin: May enhance the hypotensive effect of Nitroglycerin. Monitor therapy

Alteplase: Nitroglycerin may decrease the serum concentration of Alteplase. Monitor therapy

Amifostine: Blood Pressure Lowering Agents may enhance the hypotensive effect of Amifostine. Management: When amifostine is used at chemotherapy doses, blood pressure lowering medications should be withheld for 24 hours prior to amifostine administration. If blood pressure lowering therapy cannot be withheld, amifostine should not be administered. Consider therapy modification

Antipsychotic Agents (Second Generation [Atypical]): Blood Pressure Lowering Agents may enhance the hypotensive effect of Antipsychotic Agents (Second Generation [Atypical]). Monitor therapy

Barbiturates: May enhance the hypotensive effect of Blood Pressure Lowering Agents. Monitor therapy

Blood Pressure Lowering Agents: May enhance the hypotensive effect of Hypotension-Associated Agents. Monitor therapy

Brimonidine (Topical): May enhance the hypotensive effect of Blood Pressure Lowering Agents. Monitor therapy

Dapoxetine: May enhance the orthostatic hypotensive effect of Vasodilators (Organic Nitrates). Monitor therapy

Dapsone (Topical): May enhance the adverse/toxic effect of Methemoglobinemia Associated Agents. Monitor therapy

Diazoxide: May enhance the hypotensive effect of Blood Pressure Lowering Agents. Monitor therapy

DULoxetine: Blood Pressure Lowering Agents may enhance the hypotensive effect of DULoxetine. Monitor therapy

Ergot Derivatives: May diminish the vasodilatory effect of Nitroglycerin. This is of particular concern in patients being treated for angina. Nitroglycerin may increase the serum concentration of Ergot Derivatives. Avoid combination

Heparin: Nitroglycerin may diminish the anticoagulant effect of Heparin. Nitroglycerin may decrease the serum concentration of Heparin. Monitor therapy

Herbs (Hypotensive Properties): May enhance the hypotensive effect of Blood Pressure Lowering Agents. Monitor therapy

Hypotension-Associated Agents: Blood Pressure Lowering Agents may enhance the hypotensive effect of Hypotension-Associated Agents. Monitor therapy

Levodopa: Blood Pressure Lowering Agents may enhance the hypotensive effect of Levodopa. Monitor therapy

Molsidomine: May enhance the hypotensive effect of Vasodilators (Organic Nitrates). Monitor therapy

Molsidomine: May enhance the hypotensive effect of Blood Pressure Lowering Agents. Monitor therapy

Nicorandil: May enhance the hypotensive effect of Blood Pressure Lowering Agents. Monitor therapy

Nitric Oxide: May enhance the adverse/toxic effect of Methemoglobinemia Associated Agents. Combinations of these agents may increase the likelihood of significant methemoglobinemia. Management: Monitor patients for signs of methemoglobinemia (e.g., hypoxia, cyanosis) when nitric oxide is used in combination with other agents associated with development of methemoglobinemia. Avoid lidocaine/prilocaine. Monitor therapy

Obinutuzumab: May enhance the hypotensive effect of Blood Pressure Lowering Agents. Management: Consider temporarily withholding blood pressure lowering medications beginning 12 hours prior to obinutuzumab infusion and continuing until 1 hour after the end of the infusion. Consider therapy modification

Pentoxifylline: May enhance the hypotensive effect of Blood Pressure Lowering Agents. Monitor therapy

Phosphodiesterase 5 Inhibitors: May enhance the vasodilatory effect of Vasodilators (Organic Nitrates). Avoid combination

Prilocaine: Methemoglobinemia Associated Agents may enhance the adverse/toxic effect of Prilocaine. Combinations of these agents may increase the likelihood of significant methemoglobinemia. Management: Monitor patients for signs of methemoglobinemia (e.g., hypoxia, cyanosis) when prilocaine is used in combination with other agents associated with development of methemoglobinemia. Avoid lidocaine/prilocaine in infants receiving such agents. Monitor therapy

Prostacyclin Analogues: May enhance the hypotensive effect of Blood Pressure Lowering Agents. Monitor therapy

Riociguat: Vasodilators (Organic Nitrates) may enhance the hypotensive effect of Riociguat. Avoid combination

Rosiglitazone: Vasodilators (Organic Nitrates) may enhance the adverse/toxic effect of Rosiglitazone. Specifically, a greater risk of ischemia and other adverse effects has been associated with this combination in some pooled analyses. Monitor therapy

Sodium Nitrite: Methemoglobinemia Associated Agents may enhance the adverse/toxic effect of Sodium Nitrite. Combinations of these agents may increase the likelihood of significant methemoglobinemia. Monitor therapy

Test Interactions

IV formulation: Due to propylene glycol content, triglyceride assays dependent on glycerol oxidase may be falsely elevated.

Adverse Reactions

Frequency not defined:

Cardiovascular: Bradycardia, flushing, hypotension, orthostatic hypotension, peripheral edema, syncope, tachycardia

Central nervous system: Headache (common), dizziness, lightheadedness

Gastrointestinal: Nausea, vomiting, xerostomia

Neuromuscular & skeletal: Paresthesia, weakness

Respiratory: Dyspnea, pharyngitis, rhinitis

Miscellaneous: Diaphoresis

<1% (Limited to important or life-threatening): Allergic reactions, anaphylactoid reaction, application site irritation (patch), blurred vision, cardiovascular collapse, contact dermatitis (ointment, patch), crescendo angina, exfoliative dermatitis, fixed drug eruption (ointment, patch), methemoglobinemia (rare; overdose), pallor, palpitation, rash, rebound hypertension, restlessness, shock, vertigo

Warnings/Precautions

Concerns related to adverse effects:

• Headache: Dose-related headaches may occur, especially during initial dosing.

• Hypotension/bradycardia: Severe hypotension can occur; paradoxical bradycardia and increased angina pectoris can accompany hypotension. Orthostatic hypotension can also occur; ethanol can accentuate this. Use with caution in volume depletion, preexisting hypotension, constrictive pericarditis, aortic or mitral stenosis, and extreme caution with inferior wall MI and suspected right ventricular involvement. The Canadian labeling contraindicates use in myocardial insufficiency due to obstruction such as constrictive pericarditis and aortic or mitral stenosis. According to the ACCF/AHA, avoid use in patients with severe hypotension (SBP <90 mm Hg or ≥30 mm Hg below baseline), marked bradycardia or tachycardia, and right ventricular MI (ACCF/AHA [Anderson, 2013]; ACCF/AHA [O'Gara, 2013]).

• Increased intracranial pressure: Nitroglycerin may precipitate or aggravate increased intracranial pressure and subsequently may worsen clinical outcomes in patients with neurologic injury (eg, intracranial hemorrhage, traumatic brain injury). The Canadian labeling contraindicates use with increased intracranial pressure.

Disease-related concerns:

• Hypertrophic cardiomyopathy (HCM): Avoid use in patients with HCM with outflow tract obstruction; nitrates may reduce preload, exacerbating obstruction and cause hypotension or syncope and/or worsening of heart failure (ACCF/AHA [Gersh, 2011]).

Concurrent drug therapy issues:

• Drug-drug interactions: Potentially significant interactions may exist, requiring dose or frequency adjustment, additional monitoring, and/or selection of alternative therapy. Consult drug interactions database for more detailed information.

Dosage form specific issues:

• Intra-anal ointment: Use caution when treating rectal anal fissures with nitroglycerin in patients with suspected or known significant cardiovascular disorders (eg, cardiomyopathies, heart failure, acute MI); intra-anal nitroglycerin administration may decrease systolic blood pressure and decrease arterial vascular resistance.

• Long-acting agents: Avoid use of long-acting agents in acute MI or acute HF; cannot easily reverse effects if adverse events develop.

• Propylene glycol: Some dosage forms may contain propylene glycol; large amounts are potentially toxic and have been associated hyperosmolality, lactic acidosis, seizures and respiratory depression; use caution (AAP, 1997; Zar, 2007).

• Transdermal patches: May contain conducting metal (eg, aluminum); remove patch prior to MRI.

Other warnings/precautions:

• Tolerance: Appropriate dosing is needed to minimize tolerance development.

Monitoring Parameters

Blood pressure, heart rate; consult individual institutional policies and procedures

Pregnancy Risk Factor

B/C (product specific)

Pregnancy Considerations

Animal reproduction studies have not been conducted with all products; adverse events were not observed in animal reproduction studies conducted using the ointment. Nitroglycerin crosses the placenta (David, 2000). Concentrations following application of a transdermal patch 0.4 mg/hour were low but detectable in the fetal serum (fetal/maternal ratio: 0.23) (Bustard, 2003). Nitroglycerin may be used in pregnancy when immediate relaxation of the uterus is needed (ACOG, 2006; Axemo, 1998; Chandraharan, 2005). Intravenous nitroglycerin may be used to treat pre-eclampsia with pulmonary edema (ESG, 2011).

Patient Education

• Discuss specific use of drug and side effects with patient as it relates to treatment. (HCAHPS: During this hospital stay, were you given any medicine that you had not taken before? Before giving you any new medicine, how often did hospital staff tell you what the medicine was for? How often did hospital staff describe possible side effects in a way you could understand?)

• Patient may experience tingling of mouth. Have patient report immediately to prescriber severe dizziness, syncope, significant headache, tachycardia, bradycardia, flushing, blurred vision, xerostomia, hyperhidrosis, pallor, intolerable nausea, arrhythmia, akathisia, considerable asthenia, angina, or severe skin irritation (HCAHPS).

• Educate patient about signs of a significant reaction (eg, wheezing; chest tightness; fever; itching; bad cough; blue skin color; seizures; or swelling of face, lips, tongue, or throat). Note: This is not a comprehensive list of all side effects. Patient should consult prescriber for additional questions.

Intended Use and Disclaimer: Should not be printed and given to patients. This information is intended to serve as a concise initial reference for healthcare professionals to use when discussing medications with a patient. You must ultimately rely on your own discretion, experience and judgment in diagnosing, treating and advising patients.

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