Don’t Go Aching My Heart

SH is a 55 year old male who presents to your pharmacy with a new prescription for Nitrostat SL 0.4 mg.

Current medication list:

Crestor 10 mg PO QD

Losartan 50 mg PO QD

Metformin 500 mg PO BID

Aspirin 81 mg PO daily

Prozac 20 mg PO daily

Past Medical History: HTN, HLD, T2DM, MDD

Vitals and lab results from recent clinic visit:

HR: 78 BPM

RR: 16 BPM

Temp: 98.6 F

BP: 124/75 mmHg

Na: 142 mEq/L

K: 4.4 mEq/L

SCr: 0.8 mg/dL

TC: 172 mg/dL

HDL: 55 mg/dL

LDL: 98 mg/dL

TG: 140 mg /dL

When SH returns to pick up his new prescription, he tells you he’s concerned about his recurring chest pain and is confused about how to take his new medication. Which of the following is the most appropriate counseling to provide this patient about his new Nitrostat prescription? Select all that apply. 

A. Inform SH that Nitrostat tablets should never be taken prophylactically. They should only be administered at the onset of chest pain.

B. Let SH know he can either chew his Nitrostat tablets or let them dissolve under his tongue.

C. Advise SH that if he experiences headaches or mouth tingling with Nitrostat this is normal. 

D. Tell SH that he should administer a tablet at the onset of chest pain and an additional tablet every 5 minutes if pain persists. He may take a maximum of 3 tablets over 15 minutes. 

E. Encourage SH to store some of his Nitrostat tablets in his weekly pill planner for easy access.

Angina is chest pain caused by ischemia of the coronary arteries and can be classified as stable or unstable. Stable angina can be provoked by stress or exercise and is relieved by rest or nitroglycerin. Unstable angina is usually unpredictable, may persist despite rest, and should always be treated as an emergency. Chest pain can be unnerving for patients, so it’s important for pharmacists and other healthcare professionals to know how to treat and advise those with angina.

Nitrostat (nitroglycerin) is a nitrate that vasodilates the coronary arteries for the prophylaxis or relief of angina. Although Nitrostat is only available as a sublingual tablet, there are a variety of nitroglycerin dosage forms on the market including intravenous solutions, patches, and ointments. 

Answer A is incorrect. According to the package insert, Nitrostat may be taken at the onset of chest pain or as prophylaxis 5 to 10 minutes prior to strenuous or stressful activities that could provoke angina.

Answer B is incorrect. Nitrostat SL tablets should only be dissolved under the tongue or via the buccal pouch. They should not be chewed or swallowed whole.

Answer C is correct. Headaches and mouth tingling are common side effects of nitroglycerin and do not warrant discontinuation. If the patient is concerned about these reactions or their effects persist, the patient should contact their doctor.

Answer D is correct. Nitrostat tablets may be taken every 5 minutes with a maximum dose of 3 tablets within a 15 minute period. If the patient has taken 3 tablets with no relief, they should call 911 and seek prompt medical attention.

Answer E is incorrect. The package insert recommends keeping Nitrostat tablets in the original glass container to maintain their potency. The bottle should be kept tightly capped in a dry place at room temperature. Micardis, Truvada, and Pradaxa are examples of other medications that are prone to degradation and require special care to preserve their integrity. All of these medications should be kept in their original bottles/blister packs that are formulated to reduce their exposure to light, oxygen, and moisture and prevent degradation

Medications: Nitrostat (Nitroglycerin), Crestor (Rosuvastatin), Cozaar (Losartan), Glucophage (Metformin), Prozac (Fluoxetine), Aspirin

Competencies:

2.2 - Commercial availability; prescription or non-prescription status; brand, generic, or biosimilar names; physical descriptions; or how supplied

3.4 - Drug dosing or dosing adjustments; duration of therapy

3.5 - Drug route of administration, dosage forms, or delivery systems

3.7 - Adverse drug effects, toxicology, or overdose

5.6 - Packaging, storage, handling, or disposal

Nitrostat Package Insert: 

https://www.accessdata.fda.gov/drugsatfda_docs/label/2018/021134s010lbl.pdf