Glyceryl Trinitrate 400mcg Spray
Glyceryl Trinitrate Spray 400 micrograms/metered dose, sublingual spray.
Glyceryl Trinitrate: 400 micrograms/metered dose
Excipients with known effect:
This product contains small amounts of ethanol (alcohol) less than 100mg per spray.
For the full list of excipients, see Section 6.1
Metered-dose oromucosal (sublingual) spray solution
Small aerosol canister.
Treatment of acute angina pectoris.
Prevention of inducible angina (e.g. physical effort, emotional stress, exposure to cold).
Route of administration
Before using Glyceryl Trinitrate Spray for the first time, the patient should check that the spray is working by pressing the pump button a few times until it produces a fine mist of liquid. The patient should practice aiming the spray onto a tissue or similar item so that they will be able to aim it correctly under the tongue when they need to use it. If the patient does not need to use Glyceryl Trinitrate Spray very often, the spray should be checked regularly to see that it still works properly.
Adults including the Elderly
At the onset of an attack: one or two metered doses (400 to 800 micrograms glyceryl trinitrate) to be sprayed under the tongue for the relief of anginal pain while the breath is held. No more than three doses are recommended at any one time.
For the prevention of inducible angina (e.g. physical effort, emotional stress, exposure to cold) one or two 400 microgram metered doses sprayed under the tongue within 2-3 minutes of the event starting.
Glyceryl Trinitrate Spray is not recommended for children.
During application, the patient should rest, ideally in the sitting position. The canister should be held vertically with the valve head uppermost and the spray orifice as close to the mouth as possible. The dose should be sprayed under the tongue and the mouth should be closed immediately after each dose. The spray should not be inhaled. Patients should be instructed to familiarise themselves with the position of the spray orifice, which can be identified by the finger rest on top of the valve, in order to facilitate orientation for the administration at night.
Hypersensitivity to the active substance or to any of the excipients listed in section 6.1.
Severe hypotension (systolic blood pressure lower than 90mm Hg).
Hypotensive shock, severe anemia, constrictive pericarditis, extreme bradycardia, Glucose-6-phosphate-Dehydrogenase-deficiency, cerebral hemorrhage, and brain trauma, aortic and/or mitral stenosis and angina caused by hypertrophic obstructive cardiomyopathy.
Circulatory collapse, cardiogenic shock, and toxic pulmonary edema.
Concomitant use with phosphodiesterase inhibitors such as Sildenafil, Tadalafil or Vardenafil.
Concomitant use with the soluble guanylate cyclase stimulator riociguat (see section 4.5).
Tolerance to this drug and cross-tolerance to other nitrates may occur.
Glyceryl Trinitrate Spray should be administered with particular caution in:
– pericardial tamponade
– low filling pressures (e.g. acute myocardial infarction, left ventricular failure)
– the tendency to dysregulation of orthostatic blood pressure
– diseases accompanied by an increase in intracranial pressure (so far further pressure increase has been observed solely in high doses of glyceryl trinitrate).
Alcohol should be avoided because of the hypotensive effect.
Medical controls of the intraocular pressure of glaucoma-patients are advisable.
Particular caution should also be exercised when using Glyceryl Trinitrate Spray in patients with volume depletion from diuretic therapy, severe hepatic or renal impairment and hypothyroidism.
Alcohol may potentiate the hypotensive effect.
Vasodilators, antihypertensives, ß-blockers, calcium antagonists, neuroleptics, tricyclic antidepressants, and diuretics can increase nitrate induced hypotension.
The hypotensive effects of nitrates are potentiated by the concurrent administration of phosphodiesterase inhibitors, such as Sildenafil, Tadalafil or Vardenafil.
The use of a soluble guanylate cyclase stimulator such as riociguat is contraindicated (see section 4.3) since concomitant use can cause hypotension.
The bioavailability of dihydroergotamine may be increased by concomitant use of Glyceryl Trinitrate Spray, which can result in vasoconstriction since dihydroergotamine can antagonize the effects of glyceryl trinitrate.
The concomitant administration of Glyceryl Trinitrate Spray and heparin can reduce the antithrombotic effect of heparin. Regular monitoring of coagulation parameters and adjustments of the heparin dose may be necessary.
In patients pretreated with organic nitrates, a higher dose of glyceryl trinitrate may be necessary to achieve the desired hemodynamic effect.
The safety of glyceryl trinitrate in human pregnancy, especially during the first trimester has not been established.
It is not known whether glyceryl trinitrate is excreted into human breast milk. Glyceryl Trinitrate Spray should only be used after weighing the benefit for the mother against possible risks for the child. Nursing should be discontinued during treatment with this product.
The ability to react may be diminished because of the side effects or interactions due to the nitrates. This effect is potentiated by alcohol consumption. Therefore, driving and/or using machines should be avoided during treatment with Glyceryl Trinitrate Spray.
The following adverse reactions have been reported:
|System Organ Class||Very Common
(≥1/100 to < 1/10)
(≥ 1,000 to < (1/100)
(≥1/10,000 to < 1,000)
|Nervous System Disorders||Headache||Vertigo
|Skin and Subcutaneous Tissue Disorders||Allergic Dermatitis*||Exfoliative dermatitis|
|Vascular Disorders||Facial Flushing||Orthostatic hypotension
|General Disorders and Administration Site Conditions||Asthenia||Application site discomfort including Burning Sensation And Stinging|
|Gastrointestinal Disorders||Nausea||Tongue blistering|
Angina pectoris aggravated
|Investigations||Blood pressure decreased|
*symptoms which are known in conjunction with hypersensitivity reactions
Use of Glyceryl Trinitrate Spray may give rise to transient hypoxemia and, in patients with coronary heart disease, ischemia as a result of a relative redistribution of the bloodstream, which is to hypoventilated alveolar areas.
Tolerance development and the occurrence of crossed tolerance of other nitro compounds have been found in chronic, continuous treatment using high doses. To avoid a decrease in efficacy or a loss of efficacy, high continuous doses should be avoided.
Reporting of suspected adverse reactions
Reporting suspected adverse reactions after authorization of the medicinal product is important. It allows continued monitoring of the benefit/risk balance of the medicinal product. Healthcare professionals are asked to report any suspected adverse reactions via the Yellow Card Scheme at www.mhra.gov.uk/yellowcard.
Signs and Symptoms
Flushing, severe headache, vertigo, tachycardia, a feeling of suffocation, hypotension, fainting and rarely cyanosis and methemoglobinemia may occur. In a few patients, there may be a reaction comparable to shock with nausea, vomiting, weakness, sweating, and syncope.
Recovery often occurs without special treatment. Hypotension may be corrected by elevation of the legs to promote venous return.
Methaemoglobinaemia should be treated by intravenous methylthioninium chloride and/or toluidine blue. Symptomatic treatment should be given for respiratory and circulatory defects in more serious cases.