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ANGINEX
DRUG INTERACTION:
Nitrates include - Erythrityl tetranitrate, Isosorbide dinitrate, Isosorbide mononitrate, nitroglycerin, pentraerythritrol, tetranitrate, glyceryl trinitrate
Refer - Isorbide mononitrate.
Alcohol
severe hypotension and cardiovascular collapse occur.
Aspirin
Increased nitrate serum concentrations and actions occur
Calcium Chl blkrs
Marked orthostatic hypotension occur. Dosage adjustment of either agent necessary
Dihydroergatamine
Increased bioavailability of dihydroergotamine with resultant increase
in mean standing systolic blood pressure, or functional antagonism
between these agents, decreasing the antianginal effects.

CONTRA-INDICATIONS:
Acute MI when shock is present. Marked anaemia, Cerebral haemorrhage, Hypotension.

Special precautions:
Glaucoma, elderly, hypothyroidism, malnutrition.
Tolerance- to vascular and antianginal effects of nitrates may develop.
Glaucoma- intraocular pressure may be increased, therfore caution isequired in administering to patients with glaucoma.
Excessive dosage- may produce severe headache. Lowering the dosage and using analgesics will help control the headaches, which diminish or disappear as therapy continues.
Volume depletion/hypotension- severe hypotension (particularly upright posture ) may occur witrh even small doses of isosorbide mononitrate.
Excercise caution in patients who may be volume depleted or hypotensive for any reason. Withdrawl- in terminating of angina gradually reduce the dosage to prevent withdrawal reactions.
Drug abuse and dependence- amyl nitrate is abused for sexual stimulation. The effect of inhaltion is almost instaneous causing lightheadeness, dizziness, and euphoria.
Drug/Lab test interactons- nitrates may interfere with the Zlatkis-Zak color reaction causing a false report of decreased serum cholesterol.

Warnings:
MI- data supporting the use of nitrates during the early days of the acute phase of MI are insufficient to establish safety. In acute MI, use nitrates only under close clinical observation and with hemodynamic monitoring.
Arching- a cardioverter/defribrillator should be discharged through a paddle electrode that overlies a transdermal nitroglycerin system.
Postural hypotension- may occur even in small doses.Transcient episodes of dizziness, weakness, syncope or other cerebral ischemia diue to postural hypotension may develop following administration, particularly if the patient is standing or immobile.
Use measures which facilitate venous return (eg. head low posture, deep breathing, movements of the extremities) to hasten recovery. Angina- mitrates may aggravate angina caused by hypertrophic cardiomyopathy.
Nitroglycerin IV- the vailable preparations differ in concentration or voulme per vial or ampul. When switching from product to the another, pay attention to the dilution, dosage and administration instructions.
Hepatic or renal disease, severe- use with caution.
Hypotension- avoid excessive prolonged hypotension because of possible deleterious effects on the brain, heart, liver, and kidney from poor perfusion and the atendent risk of ischemia
Alcohol intoxification- has developed in patients on high dose IV nitroglycerin, Consider this complication when administering high doses for prolonged periods
Sublingal nitroglycerin- absorption is dependent on salivary secretion.
Dry mouth (including drug-indiced dry mouth) decreases absorption.
Transdermal nitroglycerin- is not for immediate relief of anginal attacks.
Pregnancy- use only when clearly needed and when potential benefits outweigh potential hazards.
Lactation- excercise caution when administering to nursing woman.
Children- safety and efficacy for use in children have not been established.

DOSAGES/OVERDOSAGE:
Indications: Angina pectoris.
Dosage: 20mg twice daily,with 2 doses given 7 hours apart. Suggested regimen is to give first dose on awakening and seconf dose 7 hours apart.
Overdosage - Symptoms Treatment Toxic effects may result from inhalatiion of the drug:
- Induce emesis or perform gastric lavage followed as dust,by ingestion or excessive absorption through the by charcoal administration, however, nitrates are intact skin or mucous membranes. rapidly and comletely absorbed Prolonged contact will produce skin eruptions.
- Keep patient recumbent in shock position and Signs and symptoms result primariliy from comfortably warm or temporarily terminate the vasodilation and hemoglobinemia. infusion until the patients condition stabilizes. Manifestations include hypotension, tachycardia,
- Gastric lavage may be of use if the medication has flushing, perspirng skin (later becoming cold and only recently swallowed. cyanotic ) headache, vertigo, palpitations, visual
- Passive movement of extremities may aid venous disturbances, diaphoresis, diziness, syncope, return. nausea, vomiting,(possibly with colic and bloody
- Administer oxygen and artificial ventilation if diarrhea) anorexia, intial hyperpnea, dyspnea, and necessary . slow breathing, slow pulse, (dicrotic and intermittent )
- Monitor methoglobin levels as indicated heart block, increased intracranial pressure with cerebral
- Treat severe hypotension and reflex tachcardia by symptoms of confusion, moderate fever, and paralysis. elevating the legs and administering IV fluids. Tissue hypoxia, due to methoglobinemia can lead to
- Since the duration of the hemodynamic effects cyanosis, metabolic acidosis, coma,convulsions and death following IV nitroglycerin administration is quite due to cardiovascular collapse. short additional corrective measures are usually not required
- Consider an IV- alpha adrenergic agonist (eg. phenylephrine,methgoxamine)
- Treat methoglobinemia
- Ephinephrine is ineffective in reversing the severe hypotensive events associated with overdosage, ephinephrine and related compounds are contraindicated in overdosage

Missed dose
For patients using the ointment form of this medicine
- If you miss a dose of this medicine, apply it as soon as possible, unless the next scheduled dose is within 2 hours.
- Then go back to your regular dosing schedule.
- Do not increase the amount used
For patients using transdermal (stick-on-patch) system
- If you miss a dose this medicine appply it as soon as possible.
- Then go back to your regular dosing schedule.PREGNANCY AND LACTATION:
Pregnancy
Use only when clearly needed and when potential benefits outweigh potential hazards.
Lactation
Excercise caution when administering to nursing woman.
Children - Safety and efficacy for use in children have not been established.

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