From the Guidelines
I strongly recommend confiscating the Nitrostat 0.4 mg tablets found in the patient's possession and conducting a thorough medication reconciliation. Since the patient denies having the medication and claims to have lost his previous supply during a hospital visit for chest pain, it's essential to verify his medical history to determine if he has a legitimate need for nitroglycerin. A cardiology consultation should be arranged to evaluate his cardiac status and assess whether he requires nitroglycerin for angina management, as recommended by the American College of Cardiology Foundation/American Heart Association Task Force on Practice Guidelines 1. If clinically indicated, a new prescription can be issued with proper documentation and monitoring. In the prison setting, nitroglycerin should be administered under direct supervision to prevent misuse or diversion, as emphasized in the guidelines for the management of patients with unstable angina/non-ST-elevation myocardial infarction 2. This approach is necessary because unauthorized possession of prescription medications in correctional facilities violates policy and poses safety risks. Additionally, nitroglycerin requires proper storage and handling as it degrades with exposure to light, air, and moisture, potentially becoming ineffective for treating acute anginal episodes if improperly maintained, as noted in the guidelines for the management of patients with unstable angina/non-ST-elevation myocardial infarction 3.
Some key points to consider in this case include:
- The importance of verifying the patient's medical history to determine if he has a legitimate need for nitroglycerin
- The need for a cardiology consultation to evaluate the patient's cardiac status and assess whether he requires nitroglycerin for angina management
- The requirement for proper documentation and monitoring if a new prescription is issued
- The need for direct supervision in the prison setting to prevent misuse or diversion
- The importance of proper storage and handling of nitroglycerin to maintain its effectiveness.
It is also worth noting that the patient's denial of having the medication and claim of having lost his previous supply during a hospital visit for chest pain should be investigated further to determine the circumstances surrounding the possession of the Nitrostat 0.4 mg tablets, as recommended by the guidelines for the management of patients with unstable angina/non-ST-elevation myocardial infarction 4.
Overall, the management of this patient's case should be guided by the principles of ensuring patient safety, preventing misuse or diversion of prescription medications, and providing evidence-based care for the management of angina, as recommended by the American College of Cardiology Foundation/American Heart Association Task Force on Practice Guidelines 5, 6, 7.
From the FDA Drug Label
One tablet should be dissolved under the tongue or in the buccal pouch at the first sign of an acute anginal attack. The dose may be repeated approximately every 5 minutes until relief is obtained. If the pain persists after a total of 3 tablets in a 15-minute period, or if the pain is different than is typically experienced, prompt medical attention is recommended.
The patient should have a valid prescription for Nitrostat 0.4 mg tabs to use them for acute anginal attacks.
- Key points:
- The patient denies having any tabs and reports that he lost them.
- There is no information in the provided drug labels that directly supports the patient's claim of losing the medication.
- The patient should be evaluated by a medical professional to determine the best course of action regarding his chest pain and the possession of Nitrostat 0.4 mg tabs without a valid prescription 8.
From the Research
Patient Profile
- The patient is a 76-year-old male
- He was found in possession of Nitrostat 0.4 mg tabs with no old or current active prescription
- The patient denies having any tabs and reports that he lost them during his last hospital visit for chest pain
Relevant Medical Information
- Nitroglycerin and long-acting nitrates are effective antianginal agents, reliable, safe, and easy to use 9
- Ideal patient characteristics for nitrate therapy include predictably favourable response of chest pain to sublingual nitroglycerin and symptoms of congestive heart failure 9
- Stable angina is associated with an average annual risk of 3% to 4% for myocardial infarction or death 10
- Diagnostic tests and medical therapies for stable angina have evolved over the last decade, with a better understanding of the optimal use of coronary revascularization 10
Treatment Options
- Antianginal medications, such as β-blockers, nitrates, or calcium channel blockers, should be initiated to improve angina symptoms 10
- Beta-blockers and calcium channel blockers are recommended as first line therapies for the management of effort-induced angina 11
- Nitrates, such as Nitrostat, can be used to manage angina, but careful consideration should be given to the potential for nitrate tolerance or attenuation 9
Management Plan
- The patient's denial of possessing the Nitrostat tabs and reported loss during the last hospital visit should be investigated further
- A thorough medical evaluation, including diagnostic tests, should be conducted to determine the best course of treatment for the patient's chest pain and potential stable angina 10, 12
- The patient's treatment plan should prioritize optimizing lifestyle factors and preventive medications, such as lipid-lowering and antiplatelet agents, to reduce the risk for cardiovascular events and death 10