- Therapeutic alternative to nitroglycerin Topical 2% Ointment (discontinued product), to promote reperfusion for peripheral tissue ischemia
- 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).
- 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
Adverse effects are mostly dose-related, and due to systemic absorption of the drug.
- rebound hypertension
- peripheral edema
- contact dermatitis
- 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
- 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.
- 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.