Nitrates medication list

A nitrates medication list is a point-of-care reference that sets out the main clinically used nitrates with their brand names, formulations, doses, and indications. Those nitrates are nitroglycerin for acute angina relief, plus isosorbide mononitrate and isosorbide dinitrate for angina prevention.

All three release nitric oxide, which relaxes vascular smooth muscle and lowers cardiac workload. Prescribers use the list to catch the interactions that matter most, especially PDE5 inhibitors and riociguat. It also helps them schedule doses around a nitrate-free interval that prevents tolerance.

This guide covers dosing, side effects, contraindications, and special populations for each drug. The PDF version is ready to print or adapt for your practice.

Key takeaways

Nitrates are vasodilators that work by releasing nitric oxide, causing smooth muscle relaxation and reducing cardiac workload in angina and heart failure.

Three nitrates cover most clinical use: nitroglycerin for acute relief, plus isosorbide mononitrate and isosorbide dinitrate for long-acting prevention.

Nitrates are absolutely contraindicated with PDE5 inhibitors (sildenafil, tadalafil, vardenafil) and riociguat, because the combination can cause severe, life-threatening hypotension.

Nitrate tolerance develops with continuous exposure, so long-acting regimens need a daily nitrate-free interval of 8-12 hours to keep working.

Patients using sublingual nitroglycerin should call emergency services if chest pain has not improved 5 minutes after the first dose.

What are nitrates? A clinical overview

Nitrates are a class of vasodilator medications that reduce cardiac oxygen demand and improve coronary blood flow by relaxing vascular smooth muscle. They release nitric oxide (NO), which activates guanylate cyclase and raises cyclic GMP, triggering smooth muscle relaxation.

Clinically, nitrates are used in four main settings:

• Acute angina relief. Short-acting nitroglycerin, given sublingually or as a spray, relieves symptoms within 1-3 minutes.
• Angina prophylaxis. Long-acting nitrates (isosorbide mononitrate, isosorbide dinitrate) reduce angina frequency in stable patients.
• Acute decompensated heart failure. IV nitroglycerin reduces preload and afterload, easing dyspnea and pulmonary congestion.
• Chronic heart failure. Isosorbide dinitrate is combined with hydralazine in a fixed-dose tablet (BiDil).

Patients with angina rarely take a nitrate alone. Most also take antiplatelet medications and other cardiovascular drugs, so review the whole medication list before adding one.

Clinically used nitrates: Reference table

The following table lists the main clinically used nitrates by generic name, brand names, formulation, and primary indication. For the wider set of heart drugs these patients often take, use the cardiovascular medication list.

A few less common agents sit outside this table. They include nitroglycerin ointment, buccal nitroglycerin, inhaled amyl nitrite, and nicorandil, a nitrate-like drug prescribed in the UK.

Short-acting nitrates: Examples and clinical use

Short-acting nitrates provide rapid vasodilation for acute symptom relief. Nitroglycerin remains the standard choice, with onset within 1-3 minutes when given sublingually or as a spray. Sublingual tablets dissolve under the tongue, while sprays offer faster absorption in some patients. The transdermal patch is a sustained-release form and is not used for acute relief.

For acute angina, prescribe sublingual nitroglycerin 0.3-0.6 mg as needed. If pain has not improved 5 minutes after the first dose, the patient should call emergency services. They may then repeat the dose every 5 minutes, up to 3 doses in total.

Nitrolingual spray delivers 0.4 mg per metered spray. The dose is 1-2 sprays (0.4-0.8 mg), following the same 5-minute rule.

Long-acting nitrates: Examples and clinical use

Isosorbide mononitrate and isosorbide dinitrate are used for chronic angina prevention. Isosorbide mononitrate is preferred for many patients because it bypasses first-pass hepatic metabolism, giving more predictable blood levels. Extended-release formulations (Imdur 30-240 mg daily) provide steady coverage through the day.

To prevent nitrate tolerance, plan a nitrate-free interval of 8-12 hours each day. Extended-release isosorbide mononitrate is taken once daily in the morning, usually 30-120 mg. Immediate-release isosorbide mononitrate is taken twice daily, for example 20 mg on waking and 20 mg about 7 hours later.

Nitrates drug classification: Onset and duration

Clinicians classify nitrates by pharmacokinetic profile to match patient needs and prevent tolerance.

Common side effects of nitrate medications

Most adverse effects stem from vasodilation and are often dose-related and self-limited.

• Headache. The most frequent complaint, affecting up to about half of patients. It usually improves with continued use or a lower dose.
• Flushing and facial redness. Common, caused by cutaneous vasodilation. Reassure the patient that it typically resolves within days.
• Hypotension. Most likely with IV or sublingual forms. Monitor blood pressure, especially in older or volume-depleted patients.
• Tachycardia. A reflex response to the drop in blood pressure, and usually transient.
• Dizziness or lightheadedness. Caused by blood pressure changes. Advise patients to sit or lie down during acute dosing.
• Burning sensation under the tongue. Common with sublingual nitroglycerin and not a cause for concern.
• Methemoglobinemia. Rare, and seen mainly with excessive doses or IV infusion. The risk is negligible with standard oral and sublingual dosing.

Contraindications and drug interactions with nitrates

Knowing the absolute and relative contraindications protects patients from serious harm.

Nitrate tolerance: Prevention and clinical management

Nitrate tolerance is a loss of drug efficacy that develops with continuous exposure to long-acting nitrates. The mechanism involves depletion of cofactors needed for nitric oxide generation and activation of oxidative-stress pathways that degrade NO.

To prevent tolerance, build a daily nitrate-free interval of 8-12 hours into the schedule, usually overnight. Each long-acting regimen gets there differently, as the schedule below shows.

• Immediate-release isosorbide mononitrate. Two doses about 7 hours apart, for example 20 mg on waking and 20 mg seven hours later, with no evening dose.
• Extended-release isosorbide mononitrate. One dose each morning.
• Nitroglycerin patch. Worn for 12-14 hours, then removed for 10-12 hours.

The break lets vascular enzymes regenerate the cofactors nitrates depend on, restoring drug sensitivity. Monitor patients for tolerance by asking about symptom recurrence after weeks of stable control. If tolerance develops, lengthen the nitrate-free interval or switch formulations temporarily before resuming.

Nitrates in special populations: Pregnancy, older adults, and renal impairment

Pregnancy: The FDA retired its pregnancy letter categories in 2015. The old Category C label for nitrates meant adequate human studies were lacking, and it did not indicate a proven teratogenic risk. Use nitrates only when angina cannot be controlled by other means, such as beta-blockers or calcium-channel blockers.

Older adults: Older patients are more sensitive to nitrate-induced hypotension and headache. Start with lower doses and titrate slowly. Monitor sitting and standing blood pressure, and assess fall risk in frail patients taking antihypertensives such as ACE inhibitors.

Renal impairment: Isosorbide mononitrate does not need dose adjustment in renal disease, because renal excretion is minimal. Isosorbide dinitrate and nitroglycerin are metabolized mainly by the liver, so use caution in severe liver disease.

The renal concern with IV nitroglycerin is propylene glycol, which some formulations contain. High-dose or prolonged infusions can cause propylene glycol toxicity, so monitor closely when kidney function is poor.

Best practices for nitrate prescribing and documentation

Before starting any nitrate, document baseline blood pressure, heart rate, and renal function. Screen patients explicitly for PDE5 inhibitor and riociguat use. Record the nitrate-free interval strategy in the patient record so the whole team understands the dosing intent.

Use digital forms to capture contraindication checks and adverse-effect monitoring at every visit. Weight loss and metabolic practices should ask the same questions at intake, because obesity raises coronary risk. Their weight loss practice software can hold that medication history next to the treatment plan.

Educate patients on correct sublingual nitroglycerin use. They should sit or lie down first, let the tablet dissolve under the tongue without swallowing it, and expect a mild burning sensation.

Tell patients to keep tablets tightly capped in the original glass bottle and to replace them by the label expiry date. Tablets moved to a plastic pill box or left uncapped lose potency sooner. Give written instructions on emergency care: If pain has not improved 5 minutes after the first dose, call emergency services before taking further doses.

How Pabau keeps nitrate safety checks in the patient record

In many practices, the PDE5 question is asked verbally and the nitrate-free schedule lives in a free-text note. When a covering prescriber sees the patient, neither answer is easy to find.

Pabau, the practice management platform we build, moves those checks onto intake forms that patients complete before the visit. Their answers about current medications, including PDE5 inhibitors and riociguat, land in the patient record next to the treatment history.

Pabau’s prescription management tools keep each nitrate order, dose, and schedule in that same record. Any prescriber can then confirm the dosing intent and the contraindication screen before writing the next prescription.

Keep every nitrate check in one record

Pabau’s digital forms and patient records capture medication history, PDE5 screening, and adverse effects before each visit. Book a demo to see the workflow.

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Conclusion

Nitrate prescribing tends to fail at three points. A PDE5 inhibitor or riociguat goes unnoticed, a regimen has no overnight break, or the patient is unsure when to call for help. Each one is preventable with a question asked at the right moment.

Build those three checks into the form you use at every visit, and the list does its job at the point of prescribing. The cost is a few extra questions per appointment, which is small next to treating nitrate-induced hypotension.

Download the template above, adapt it to your formulary, and keep it beside the prescribing screen. Book a demo to see how Pabau keeps medication screening and nitrate dosing notes together in one patient record.

Continue your research

Prescribing nitrates alongside blood thinners? Anticoagulant medication list sets out the anticoagulants most often co-prescribed with cardiac drugs.

Managing lipids in the same patients? Cholesterol medication list covers statins and other lipid-lowering therapy for patients with coronary disease.

Want a double-check list for risky drugs? High-alert medication list flags the medications that cause the most harm when given in error.

Dispensing extended-release tablets? Medication do-not-crush list shows which modified-release forms must be swallowed whole.

Advising angina patients on diet? Cardiac diet plan gives patients a heart-healthy eating plan to take home.

Frequently asked questions