How to Apply Topical Nitroglycerin Ointment for Raynaud's Phenomenon
Apply nitroglycerin ointment 2% using the dose-measuring applicator supplied with the tube: measure 0.5 to 1 inch (7.5-15 mg) of ointment onto the applicator, place it ointment-side down on the affected finger or hand, spread lightly without rubbing, and secure with tape or plastic wrap. 1
Application Technique
Step-by-Step Method
Measure the dose by placing the applicator on a flat surface (printed side down) and squeezing 0.5 to 1 inch of ointment from the tube onto the applicator 1
Apply directly to affected digits: Place the applicator ointment-side down on the skin of the affected finger, hand, or other area experiencing Raynaud's symptoms 1
Spread lightly without rubbing: Use the applicator to spread the ointment over the skin surface—do not massage or rub into the skin, as this may alter absorption 1
Cover the application site: Tape the applicator in place or cover completely with plastic kitchen wrap to prevent staining of clothing and ensure consistent absorption 1
Apply immediately before or within 5 minutes of the beginning of a Raynaud's episode for optimal effect 2
Dosing Regimen
Frequency and Timing
Maximum 4 applications daily as needed for Raynaud's episodes 2
For scheduled dosing (if using prophylactically rather than as-needed): Start with 0.5 inch (7.5 mg) twice daily, with one dose applied in the morning and another 6 hours later 1
Include a nitrate-free interval of 10-12 hours daily to prevent tolerance development—this is critical as continuous exposure eliminates all efficacy within 24 hours 1
Dose Titration
The dose can be doubled (to 1 inch) and even doubled again (to 2 inches) in patients who tolerate the medication but fail to respond adequately 1
Coverage area should be approximately 3.5 inches by 2.25 inches, though a larger area may be used if needed 1
Clinical Context and Evidence
Efficacy Data
Nitroglycerin ointment (MQX-503 formulation) demonstrated a 14.3% improvement in Raynaud's Condition Score compared to 1.3% with placebo (p=0.04) in a randomized controlled trial of 219 patients 2
Laboratory studies showed 66-69% of subjects achieved baseline blood flow with nitroglycerin gel versus 45.8% with placebo (p=0.01-0.002) 3
Meta-analysis of approximately 200 patients with secondary Raynaud's phenomenon showed topical nitrates improved clinical symptoms and blood flow 4
Critical Safety Considerations
Contraindications and Precautions
Absolutely contraindicated with concurrent PDE5 inhibitor use (sildenafil, tadalafil, vardenafil)—this combination can cause severe hypotension and is explicitly prohibited by ACC/AHA guidelines 4, 5
Avoid in patients with systolic blood pressure <90 mmHg or >30 mmHg below baseline 4
Do not use in patients with marked bradycardia or tachycardia 4
Common Side Effects
Headache is the most common limiting adverse effect and may prevent continued use 4
Faintness, flushing, and dizziness may occur, especially when arising from lying position—if these symptoms occur, discontinue therapy and notify physician 1
The novel MQX-503 formulation demonstrated a side effect profile similar to placebo, suggesting improved tolerability compared to traditional formulations 2
Storage and Handling
Keep tube tightly closed when not in use 1
Store at 20-25°C (68-77°F) 1
Foilpac single-dose packages should be discarded immediately after use 1
Take care to prevent clothing stains by ensuring complete coverage with plastic wrap 1
Position in Treatment Algorithm
Topical nitroglycerin serves as an alternative or adjunctive therapy when calcium channel blockers (first-line) are insufficient or not tolerated 4, 5
It is particularly useful for as-needed application during acute Raynaud's episodes rather than scheduled prophylaxis 2, 6
If topical nitrates fail or cause intolerable headaches, escalate to PDE5 inhibitors (second-line) or intravenous prostacyclin analogues (third-line for severe/refractory cases) 5