What are the contraindications for Nitroglycerin (NM)?

From the Guidelines

Nitroglycerin is contraindicated in patients with recent use of phosphodiesterase-5 inhibitors, hypotension, and other specific conditions due to the risk of severe hypotension and other adverse effects. The contraindications for nitroglycerin (NM) include:

• Hypersensitivity to nitrates
• Concurrent use of phosphodiesterase-5 inhibitors (such as sildenafil, tadalafil, or vardenafil) within the past 24-48 hours due to risk of severe hypotension, as noted in 1
• Concurrent use of riociguat
• Hypotension (systolic blood pressure below 90 mmHg)
• Severe anemia
• Closed-angle glaucoma
• Increased intracranial pressure
• Cerebral hemorrhage
• Right ventricular infarction, as these patients are preload dependent and nitroglycerin reduces venous return Relative contraindications include:
• Hypertrophic obstructive cardiomyopathy
• Severe aortic stenosis
• Constrictive pericarditis, as nitroglycerin can worsen cardiac output in these conditions by reducing preload Caution should be exercised in patients with volume depletion or those taking other vasodilators, as stated in 1. The mechanism behind these contraindications relates to nitroglycerin's vasodilatory effects, which can cause excessive hypotension in vulnerable patients or dangerous interactions with medications that affect similar pathways. According to 1, nitroglycerin should not be administered to patients with hypotension or to those who received a phosphodiesterase inhibitor. Additionally, 1 highlights the importance of monitoring for potential adverse effects, particularly profound hypotension, in patients receiving nitroglycerin.

From the FDA Drug Label

Nitroglycerin sublingual tablets are contraindicated in patients who are allergic to it. Sublingual nitroglycerin therapy is contraindicated in patients with early myocardial infarction, severe anemia, increased intracranial pressure, and those with a known hypersensitivity to nitroglycerin. Administration of nitroglycerin sublingual tablets are contraindicated in patients who are using a phosphodiesterase-5 (PDE-5) inhibitor (e.g., sildenafil citrate, tadalafil, vardenafil hydrochloride) since these compounds have been shown to potentiate the hypotensive effects of organic nitrates. Do not use nitroglycerin sublingual tablets in patients who are taking the soluble guanylate cyclase stimulator riociguat. Concomitant use can cause hypotension.

The contraindications for Nitroglycerin (NM) are:

• Allergy to nitroglycerin
• Early myocardial infarction
• Severe anemia
• Increased intracranial pressure
• Known hypersensitivity to nitroglycerin
• Use of phosphodiesterase-5 (PDE-5) inhibitors (e.g., sildenafil citrate, tadalafil, vardenafil hydrochloride)
• Use of soluble guanylate cyclase stimulator riociguat 2

From the Research

Contraindications for Nitroglycerin (NM)

• The use of nitroglycerin is contraindicated in patients receiving organic nitrates, such as phosphodiesterase 5 (PDE5) inhibitors, due to the synergistic decrease in blood pressure 3.
• Patients with certain medical conditions, such as hypotension or bradycardia, may be at risk for worsening of these conditions with nitroglycerin administration 4, 5.
• Nitroglycerin should be used with caution in patients taking alpha-blockers, as it may cause orthostatic hypotension 3.
• Concomitant use of nitroglycerin with other vasodilators or blood pressure-lowering medications may increase the risk of hypotension 3, 6.

Special Considerations

• Patients with acute myocardial infarction should be carefully monitored during nitroglycerin administration, as it may cause hypotension, bradycardia, or asystole 7, 4, 5.
• The use of intravenous nitroglycerin in patients with acute myocardial infarction may be beneficial in reducing infarct size and improving hemodynamics, but it requires careful monitoring 7, 6.