Alternate Name(s):
Nitro-Spray, Nitrolingual Pump Spray, Nitro-BID
Classification:
Antidote, Extravasation; Vasodilator
Original Date:
Dec 2021
Revised Date:
April 2022
Indications:
- Therapeutic alternative to nitroglycerin Topical 2% Ointment (discontinued product), to promote reperfusion for peripheral tissue ischemia
Administration:
- The drug may be sprayed directly onto the area (see case study), as a ribbon approximately 2 cm to the line of pallor of each affected digit. Note that this method may increase the risk of systemic absorption.
- Risk of systemic absorption increases as the dose increases, especially in premature babies (due to developing skin barrier).
Dosage:
- Each spray contains 0.4 mg of nitroglycerin
- Recommended dosage based on case reports ranges from 0.4-2.4 mg/kg/dose (1-6 sprays/kg/dose) , applied to affected area(s). If after 8 hours there is no improvement, the dose may be repeated at the site, and continued as needed Q 6-8h. Steady improvement should be noted within the first 24 hours of the appropriate dose, treatment usually continued until full resolution. Assess for hypotension before increasing dose.
- Risk of systemic absorption and hypotension increases as the dose increases.
- Duration of treatment is case-specific, and depends on patient response and on tolerability of side effects. Studies range from one dose - 1 month of treatment to resolution of symptoms
Side Effects:
Adverse effects are mostly dose-related, and due to systemic absorption of the drug.
- hypotension
- rebound hypertension
- tachycardia
- peripheral edema
- contact dermatitis
Parameters to Monitor:
- Monitor for improvement in pulses, colour and capillary refill.
- Heart rate, blood pressure, frequently to assess for potential adverse effects
- Methemoglobin level to monitor for toxicity
Compatibility:
N/A
Notes:
- Dosing using the spray is not as well established as with the ointment. Assess carefully for side effects
-
Some references using the discontinued ointment suggest the max dose should not bypass 7.5 mg/dose (which would be roughly 18 sprays per dose). Note, however, this is the usual adult dose for angina, and the lowest effective dose should be the goal.
References:
- Nitro-Bid 2% topical ointment monograph (Fougera Pharmaceuticals Inc.)
- Samiee-Zafarghandy S, van den Anker JN, Ben Fadel N. Topical nitroglycerin in neonates with tissue injury: A case report and review of the literature. Paediatr Child Health. 2014;19(1):9-12.
- Sushko K, Litalien C, Ferruccio L, et al. Topical nitroglycerin ointment as salvage therapy for peripheral tissue ischemia in newborns: a systematic review. CMAJ Open. 2021;9(1):E252-E260. Published 2021 Mar 17.
- Mosalli R. Successful use of nitroglycerin spray to treat a neonate with ischemic injury. Pediatr Int. 2021 Apr;63(4):486-487.