Nitrogard Side Effects

Generic Name: nitroglycerin

Note: This page contains side effects data for the generic drug nitroglycerin. It is possible that some of the dosage forms included below may not apply to the brand name Nitrogard.

It is possible that some side effects of Nitrogard may not have been reported. These can be reported to the FDA here. Always consult a healthcare professional for medical advice.

For the Consumer

Applies to nitroglycerin: capsule extended release, spray, tablet, tablet extended release

As well as its needed effects, nitroglycerin (the active ingredient contained in Nitrogard) may cause unwanted side effects that require medical attention.

If any of the following side effects occur while taking nitroglycerin, check with your doctor immediately:

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
  • shortness of breath
  • sweating
  • tightness in the chest
  • tingling of the hands or feet
  • unusual weight gain or loss
  • wheezing
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
  • increased sweating
  • itching
  • loss of heat from the body
  • nausea or vomiting
  • puffiness or swelling of the eyelids or around the eyes, face, lips, or tongue
  • rash
  • red, swollen skin
  • redness of the face, neck, arms, and occasionally, upper chest
  • scaly skin
  • sensation of spinning
  • skin rash
  • weakness

If any of the following symptoms of overdose occur while taking nitroglycerin, get emergency help immediately:

Symptoms of overdose
  • 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
  • disturbed color perception
  • double vision
  • flushed skin
  • halos around lights
  • headache, severe and throbbing
  • increased sweating
  • loss of appetite
  • loss of consciousness
  • night blindness
  • overbright appearance of lights
  • paralysis
  • slow or irregular heartbeat
  • tunnel vision

Some nitroglycerin side effects may not need any medical attention. As your body gets used to the medicine these side effects may disappear. Your health care professional may be able to help you prevent or reduce these side effects, but do check with them if any of the following side effects continue, or if you are concerned 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

For Healthcare Professionals

Applies to nitroglycerin: buccal tablet extended release, intravenous solution, oral capsule extended release, rectal ointment, sublingual spray, sublingual tablet, transdermal film extended release, transdermal ointment

Nervous system

Nervous system side effects commonly include headaches and lightheadedness in 2 to 50% of patients, which may be severe, but may become less intense after 2 weeks of therapy. Some intravenous preparations of nitroglycerin (the active ingredient contained in Nitrogard) contain alcohol. Rare cases of alcohol intoxication have been reported in some patients after prolonged, high dose administration of intravenous nitroglycerin.[Ref]

Headaches are the result of intracranial vasodilation and increased intracranial pressure. Rare cases of increased intracranial pressure, resulting in papilledema, diplopia, 6th cranial nerve palsy, and decreased mental status have been reported.

Rare cases of Wernicke's encephalopathy have been reported, thought to be due to the ethyl alcohol and propylene glycol vehicle used in some intravenous preparations of nitroglycerin.

A case of ageusia associated with transdermal nitroglycerin has been reported.[Ref]

Cardiovascular

In a review of 17 cases of hypotensive bradycardia following nitroglycerin (the active ingredient contained in Nitrogard) administration, no reliable factors to predict this side effect were found. The mechanism is thought to be vasovagal; atropine is an effective countermeasure. There is evidence that right ventricular (RV) dysfunction, particularly in the event of RV myocardial infarction (MI), may predispose patients to develop hypotension during nitroglycerin administration. These patients are extremely sensitive to changes in preload and may have preexisting bradycardia. Therefore, caution is recommended if nitroglycerin is necessary in patients with RV or inferior wall MI.

Rare cases of A-V block, including complete heart block, thought to be vasovagally-mediated after nitroglycerin administration, have been reported.

Nitroglycerin may aggravate angina associated with hypertrophic cardiomyopathy.

Nitroglycerin may induce vasodilation in poorly ventilated areas of the lung, which may result in hypoxemia.

In some cases, coronary artery stenoses have appeared paradoxically worsened angiographically after administration of nitroglycerin. The mechanism by which nitroglycerin may induce myocardial ischemia is not known. It may cause coronary artery vasodilation and a local "steal phenomenon" or it may cause a greater degree of venous pooling than coronary artery dilation, resulting in an imbalance of myocardial perfusion.

Nitroglycerin transdermal patches should be removed prior to DC cardioversion. Cases of electrical arcing from the paddles to the aluminum patch backing have been reported.

Some intravenous preparations of nitroglycerin, such as Tridil, contain 100 mEq/L potassium (K+), which may cause hyperkalemia and an increased risk of arrhythmias. When using such preparations, monitor the serum K+ and heart rhythm closely.[Ref]

Cardiovascular side effects include bradycardia, hypotension, or syncope in less than 5% of patients. Hypotension associated with intravenous nitroglycerin is reported in up to 18% of patients, but may be more likely in cases of right ventricular or inferior wall infarction. Nitroglycerin may induce reflex tachycardia in less than 1% of patients.

Rarely, myocardial ischemia or pedal edema have been associated with nitroglycerin.

Rare cases of increased arteriolar-alveolar (Aa) O2 differences have been reported. It is recommended that nitroglycerin be given with caution to patients with pneumonia and preexisting lung disease.

Tolerance to the cardiovascular effects of nitrates has been reported.[Ref]

Gastrointestinal

Gastrointestinal complaints of mild nausea occur in less than 1% after orally-ingested nitroglycerin (the active ingredient contained in Nitrogard) [Ref]

Hematologic

An unusual hematologic side effect is the development of methemoglobinemia, almost exclusively reported after doses greater than 30 mcg/kg/min were given for several days. Nitroglycerin (the active ingredient contained in Nitrogard) may prolong bleeding times via a prostacyclin mechanism.[Ref]

Methemoglobinemia may be asymptomatic, but should be suspected if the patient's blood appears dark to gross examination or if the patient appears cyanotic. Patients with ischemic heart disease may experience angina pectoris. The diagnosis is confirmed by measurement of arterial methemoglobin concentration, and therapy consist of withdrawal of nitroglycerin, if possible, oxygen therapy, and 1 to 2 mg/kg of 1% methylene blue intravenously over 10 minutes. If the response is inadequate, methylene blue may be repeated in 1 hour.[Ref]

Dermatologic

Dermatologic reactions have occasionally been associated with transdermal patches. Cases of mild and severe contact dermatitis manifest as erythema, pruritus, and burning have been reported, as well as rare cases of lichen planus. Hypersensitivity rashes have rarely been associated with orally administered nitroglycerin (the active ingredient contained in Nitrogard) [Ref]

The cause of some cases of dermatitis may not be nitroglycerin, per se, but another material used in the patch itself.[Ref]

References

1. Sorkin EM, Brogden RN, Romankiewicz JA "Intravenous glyceryl trinitrate (nitroglycerin). A review of its pharmacological properties and therapeutic efficacy." Drugs 27 (1984): 45-80

2. Shorey J, Bhardwaj N, Loscalzo J "Acute Wernicke's encephalopathy after intravenous infusion of high- dose nitroglycerin." Ann Intern Med 101 (1984): 500

3. Abrams J "Nitroglycerin and long-acting nitrates." N Engl J Med 302 (1980): 1234-7

4. Ong EA, Canlas C, Smith W "Nitroglycerin-induced asystole ." Arch Intern Med 145 (1985): 954

5. Ewing RC, Janda SM, Henann NE "Ageusia associated with transdermal nitroglycerin." Clin Pharm 8 (1989): 146-7

6. Gagnon RL, Marsh ML, Smith RW, Shapiro HM "Intracranial hypertension caused by nitroglycerin." Anesthesiology 51 (1979): 86-7

7. Ahmad S "Nitroglycerin and intracranial hypertension ." Am Heart J 121 (1991): 1850-1

8. Alexander J, Kaplan K, Davison R, Blonsky ER, Gilbert J "Intravenous nitroglycerin-induced abducens nerve palsy." Am Heart J 106 (1983): 1159-60

9. Quigley PJ, Maurer BJ "Ventricular fibrillation during coronary angiography: association with potassium-containing glyceryl trinitrate." Am J Cardiol 56 (1985): 191

10. Hales CA, Westphal D "Hypoxemia following the administration of sublingual nitroglycerin." Am J Med 65 (1978): 911-8

11. Hoit B, Gregoratos G, Shabetai R "Paradoxical pulmonary vasoconstriction induced by nitroglycerin in idiopathic pulmonary hypertension." J Am Coll Cardiol 6 (1985): 490-2

12. Lancaster L, Fenster PE "Complete heart block after sublingual nitroglycerin." Chest 84 (1983): 111-2

13. Ong EA, Bass S "Nitroglycerin-induced bradycardia and hypotension in acute myocardial infarction." Chest 77 (1980): 244

14. Khosla S, Coutinho NB, Megellas MM, Mukherjee D, Somberg JC "Can nitroglycerin convert effort-induced angina in men into silent myocardial ischemia?" Am J Cardiol 76 (1995): 337-9

15. Buckley R, Roberts R "Symptomatic bradycardia following the administration of sublingual nitroglycerin." Am J Emerg Med 11 (1993): 253-5

16. Kopman EA, Weygandt GR, Bauer S, Ferguson TB "Arterial hypoxemia following the administration of sublingual nitroglycerin." Am Heart J 96 (1978): 444-7

17. Cunningham J "Hypotension following administration of sublingual nitroglycerin ." Heart Lung 8 (1979): 364

18. Hollander JE, Hoffman RS, Gennis P, Fairweather P, Disano MJ, Schumb DA, Feldman JA, Fish SS, Dyer S, Wax P, Whelan C, Sch "Nitroglycerin in the treatment of cocaine associated chest pain - clinical safety and efficacy." J Toxicol Clin Toxicol 32 (1994): 243-56

19. Berisso MZ, Cavallini A, Iannetti M "Sudden death during continuous Holter monitoring out of hospital after nitroglycerin consumption." Am J Cardiol 54 (1984): 677-9

20. Brandes W, Santiago T, Limacher M "Nitroglycerin-induced hypotension, bradycardia, and asystole: report of a case and review of the literature." Clin Cardiol 13 (1990): 741-4

21. Feldman RL, Pepine CJ, Conti CR "Unusual vasomotor coronary arterial responses after nitroglycerin." Am J Cardiol 42 (1978): 517-9

22. Wrenn K "The hazards of defibrillation through nitroglycerin patches." Ann Emerg Med 19 (1990): 1327-8

23. Lee SG, Jr "Nitroglycerin ointment therapy and leg edema ." Am Heart J 95 (1978): 273-4

24. von Arnim T, Autenrieth G, Bolte HD "Acute myocardial infarction during continuous electrocardiographic ST segment recording. Possible role of bradycardia and hypotension induced by glyceryl trinitrate." Br Heart J 51 (1984): 575-7

25. Curry RC, Jr "Coronary vasoconstriction following nitroglycerin ." Cathet Cardiovasc Diagn 6 (1980): 211-2

26. Gibson GR, Hunter JB, Raabe DS, Jr Manjoney DL, Ittleman FP "Methemoglobinemia produced by high-dose intravenous nitroglycerin." Ann Intern Med 96 (1982): 615-6

27. Ring T, Knudsen F, Kristensen SD, Larsen CE "Nitroglycerin prolongs the bleeding time in healthy males." Thromb Res 29 (1983): 553-9

28. Karlberg KE, Nowak J, Ahlner J, Sylven C "Evidence for tolerance to the platelet inhibitory effect of nitroglycerin." Am J Cardiol 73 (1994): 958-9

29. Robicsek F "Acute methemoglobinemia during cardiopulmonary bypass caused by intravenous nitroglycerin infusion." J Thorac Cardiovasc Surg 90 (1985): 931-4

30. Camarasa JG, Perez M "Nitroglycerine sensitivity." Contact Dermatitis 9 (1983): 320-1

31. Fischer RG, Tyler M "Severe contact dermatitis due to nitroglycerin patches." South Med J 78 (1985): 1523-4

32. Almeyda J, Levantine A "Cutaneous reactions to cardiovascular drugs." Br J Dermatol 88 (1973): 313-9

33. Prieto RD, Medina AA, Perez JMD "Contact dermatitis from nitroglycerin." Ann Allergy 72 (1994): 344-6

34. Sausker WF, Frederick FD "Allergic contact dermatitis secondary to topical nitroglycerin ." JAMA 239 (1978): 1743-4

35. Ryan FP "Erythroderma due to peritrate and glyceryl trinitrate." Br J Dermatol 87 (1972): 498-500

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