Prophylactic treatment of attacks of angina pectoris, as monotherapy or in combination with other anti-anginal agents.

 

Prophylactic treatment of phlebitis and extravasation secondary to venous cannulation for intravenous fluid and drug administration when the duration of treatment is expected to last for 2 days or longer.

For dermal administration

 

Adults:

 

Angina:  Treatment should be initiated with one Nitroderm^® TTS 5 patch daily.  If a higher dosage is required a Nitroderm^® TTS 10 patch may be substituted.  The dosage may be increased to a maximum of two Nitroderm^® TTS 10 patches daily in resistant cases.  Nitroderm^® TTS may be given either continuously, or intermittently with a patch off period of 8-12 hours, usually at night, during each 24 hour period.  Development of tolerance or attenuation of therapeutic effect commonly occurs with prolonged or frequent administration of all long-acting nitrates.  Recent evidence suggests that intermittent therapy with Nitroderm^® TTS may reduce the incidence of tolerance.

 

Prior to the use of intermittent therapy, the clinical benefits to the patients should be weighed against the risks of angina in the patch-free interval.  In patients considered to be at risk, concomitant anti-anginal therapy should be implemented (see “Precautions”).

 

It is recommended that the patch is applied to the lateral chest wall.  The replacement patch should be applied to a new area of skin.  Allow several days to elapse before applying a fresh patch to the same area of skin.  If acute attacks of angina pectoris occur, rapidly acting nitrates may be required.

 

Phlebitis and extravasation:  One Nitroderm^® TTS 5 patch is to be applied distal to the site of intravenous cannulation at the time of venepuncture.  The patch should be removed after 3-4 days and a new replacement patch applied to a different area of skin.  Treatment with Nitroderm^® TTS should be discontinued once intravenous therapy has stopped.

 

Use in the elderly

 

No specific information on use in the elderly is available; however no evidence exists to suggest that an alteration in dosage is required.

 

Use in children

 

There is insufficient knowledge of the effects of Nitroderm^® TTS in children and therefore recommendations for its use cannot be made.

• Known hypersensitivity to nitroglycerin, and related organic nitrates or any excipient. • Acute circulatory failure associated with marked hypotension (shock). • Conditions associated with elevated intracranial pressure. • Myocardial insufficiency due to obstruction, as in aortic or mitral stenosis or constrictive pericarditis. • Concomitant use of Nitroderm® TTS and phosphodiesterase type 5 (PDE5) inhibitors such as sildenafil (Viagra®) is contraindicated, because PDE5 inhibitors may amplify the vasodilatory effects of Nitroderm® TTS resulting in severe hypotension. • Severe hypotension (systolic blood pressure less than 90 mmHg). • Severe hypovolemia.

Warnings

As with other nitrate preparations, when transferring the patient on long-term therapy to another form of medication, nitroglycerin should be gradually withdrawn and overlapping treatment started.

 

The Nitroderm^® TTS patch contains an aluminium layer.  Therefore the patch must be removed before applying magnetic or electrical fields to the body during procedures such as MRI (Magnetic Resonance Imaging), cardioversion, DC defibrillation or diathermy treatment.

 

In cases of recent myocardial infarction or acute heart failure, treatment with Nitroderm^® TTS should be carried out cautiously under strict medical surveillance and/or haemodynamic monitoring.

 

Removal of the patch should be considered as part of the management of patients who develop significant hypotension.

 

Precautions

 

Hypoxaemia

Caution should be exercised in patients with arterial hypoxaemia (including G6PD deficiency induced forms) due to severe anaemia because, in such patients the biotransformation of nitroglycerin is reduced.  Similarly, caution is called for in patients with hypoxaemia and a ventilation/perfusion imbalance due to lung disease or ischaemic heart failure.  In patients with alveolar hypoventilation a vasoconstriction occurs within the lung to shift perfusion from areas of alveolar hypoxia to better ventilated regions of the lung (Euler–Liljestrand mechanism).  Patients with angina pectoris, myocardial infarction, or cerebral ischaemia frequently suffer from abnormalities of the small airways (especially alveolar hypoxia).  Under these circumstances vasoconstriction occurs within the lung to shift perfusion from areas of alveolar hypoxia to better ventilated regions of the lung. As a potent vasodilator, nitroglycerin could reverse this protective vasoconstriction and thus result in increased perfusion of poorly ventilated areas, worsening of the ventilation/perfusion imbalance, and a further decrease in the arterial partial pressure of oxygen.

 

Hypertrophic cardiomyopathy

Nitrate therapy may aggravate the angina caused by hypertrophic cardiomyopathy.

 

Increased angina

The possibility of increased frequency of angina during patch-off periods should be considered.  In such cases, the use of concomitant anti-anginal therapy is desirable.

 

Tolerance to sublingual nitroglycerin

If tolerance to nitroglycerin patches develops, the effects of sublingual nitroglycerin on exercise tolerance may be partially diminished.

 

Use of Nitroderm^® TTS in the prevention of phlebitis

The infusion site should be examined regularly. If phlebitis develops, it should be treated accordingly.

Concomitant administration of Nitroderm^® TTS and other vasodilators e.g PDE5 inhibitors such as sildenafil potentiates the blood pressure lowering effects of Nitroderm^® TTS.

 

Concomitant treatment with calcium antagonists, ACE inhibitors, beta-blockers, diuretics, antihypertensives, tricyclic antidepressants and major tranquillisers may potentiate the blood pressure-lowering effect of Nitroderm^® TTS, as may alcohol.

 

Concurrent administration of Nitroderm^® TTS with dihydroergotamine may increase the bioavailability of dihydroergotamine. This warrants special attention in patients with coronary artery disease, because dihydroergotamine antagonises the effect of nitroglycerin and may lead to coronary vasoconstriction.

 

The non-steroidal anti-inflammatory drugs except acetyl salicylic acid may diminish the therapeutic response of Nitroderm^® TTS.

 

Concurrent administration of Nitroderm^® TTS with amifostine and acetyl salicylic acid may potentiate the blood pressure lowering effects of Nitroderm^® TTS.

Women of child-bearing potential

There is no data supporting any special recommendations in women of child-bearing potential.

 

Pregnancy

Like any drug, Nitroderm^® TTS should be employed with caution during pregnancy, especially in the first 3 months.

 

Lactation

There is limited information on the excretion of the active substance in human or animal breast milk. A risk to the suckling child cannot be excluded.

 

A decision must be made whether to discontinue breast-feeding or to discontinue/abstain from Nitroderm^® TTS therapy taking into account the benefit of breast feeding for the child and the benefit of therapy for the woman.

 

Fertility

There is no data available on the effect of Nitroderm^® TTS on fertility in humans.

Nitroderm^® TTS, especially at the start of treatment or dose adjustments, may impair the reactions or might rarely cause orthostatic hypotension and dizziness (as well as exceptionally syncope after overdosing). Patients experiencing these effects should refrain from driving or using machines.

Adverse drug reactions are ranked in descending order of frequency, as follows: Very common (≥ 1/10); common (≥ 1/100, <1/10); uncommon (≥1/1000, <1/100); rare (≥ 1/10,000, <1/1000); very rare (<1/10,000), including isolated reports. Within each frequency grouping, adverse reactions are ranked in order of decreasing seriousness.

 

Table 1

 

Nervous System Disorders:
Common:	Headache
Very rare:	Dizziness
Cardiac Disorders:
Rare:	Tachycardia
Vascular Disorders:
Rare:	Orthostatic hypotension, flushing
Gastrointestinal Disorders:
Very Common:	Nausea,  vomiting
Skin and subcutaneous tissue disorders:
Uncommon:	Contact dermatitis
General disorders and administration site conditions:
Uncommon:	Application site erythema,  pruritus,  burning,  irritation.
Investigations:
Rare:	Heart rate increase

 

Like other nitrate preparations, Nitroderm^® TTS commonly causes dose-dependent headaches due to cerebral vasodilatation. These often regress after a few days despite the maintenance of therapy. If headaches persist during intermittent therapy, they should be treated with mild analgesics. Unresponsive headaches are an indication for reducing the dosage of nitroglycerin or discontinuing treatment.

 

A slight reflex-induced increase in heart rate can be avoided by resorting, if necessary, to combined treatment with a beta-blocker.

 

Upon removal of the patch, any slight reddening of the skin will usually disappear within a few hours. The application site should be changed regularly to prevent local irritation.

 

The following adverse drug reactions have been derived from post-marketing experience with Nitroderm^® TTS via spontaneous case reports and literature cases. Because these reactions are reported voluntarily from a population of uncertain size, it is not possible to reliably estimate their frequency which is therefore categorized as not known.

-            Cardiac disorders:  palpitation.

-      Skin and subcutaneous tissue disorders: rash generalized.

 

            Reporting of suspected adverse reactions

Reporting adverse reactions after authorisation of the medicinal product is important.  It allows continued monitoring of the benefit/risk balance of the medicinal product. 

 

To report any side effect(s):

·         Saudi Arabia

 

-          Saudi Food and Drug Authority National Pharmacovigilance Center (NPC):

 

o Fax: +966112057662

o Call NPC at +966-11-2038222, Exts: 2317-2356-2340.

o Toll free phone: 8002490000

o SFDA call center: 19999

o E-mail: npc.drug@sfda.gov.sa

o Website: https://ade.sfda.gov.sa

 

-          Patient Safety Department Novartis Consulting AG - Saudi Arabia:

 

o Toll Free Number: 8001240078

o Phone: +966112658100

o Fax: +966112658107

o Email: adverse.events@novartis.com

 

•    Other GCC States:

-  Please contact the relevant competent authority.

Signs

High doses of nitroglycerin may lead to severe hypotension and reflex tachycardia or to collapse and syncope. Methaemoglobinaemia has also been reported following accidental overdosage.

 

Management

The nitrate effect of Nitroderm^® TTS can be rapidly terminated simply by removing the system(s).

 

Hypotension or collapse can be treated by elevation or, if necessary, compression bandaging of the patient’s legs.

ATC code: C01DA02

 

Nitroglycerin relaxes smooth muscle.  It acts chiefly on systemic veins and large coronary arteries, with more predominant effects on the former.  In angina pectoris the fundamental mechanism of action of nitroglycerin is based on an increase in venous capacitance leading to a decreased return of blood to the heart.  Owing to this, preload and hence filling volume diminishes, resulting in a decreased myocardial oxygen requirement at rest and especially during exercise.

 

In the coronary arterial circulation nitroglycerin dilates extramural conductance and small resistance vessels.  It appears to cause redistribution of coronary blood flow to the ischaemic subendocardium by selectively dilating large epicardial vessels and also relaxes vasospasm.

 

Nitroglycerin dilates the arteriolar vascular bed, as a result of which afterload and left ventricular systolic wall tension decrease, leading to a reduction in myocardial oxygen consumption.

Following a single application, plasma concentrations of nitroglycerin reach a plateau within 2 hours, which is maintained throughout the day until patch removal.  The height of this plateau is directly proportional to the size of the system’s drug-releasing area.

 

The same plasma levels are attained regardless of whether the system is applied to the skin of the upper arm, pelvis or chest.  Upon removal of Nitroderm^® TTS the plasma level falls rapidly.  After repeated application of Nitroderm^® TTS no cumulation occurs.

Mutagenicity

Standard mutagenicity tests provided contradictory results in vitro. Cell culture and in vivo studies revealed no evidence of mutagenic activity of nitroglycerin, and therefore its use is considered devoid of genotoxic potential at exposures relevant to man.

 

Carcinogenicity

Dietary studies in rodents led to the conclusion that nitroglycerin has no carcinogenic effects relevant for the therapeutic dose range in man.

 

Reproduction toxicity

Animal teratology studies have not been conducted with nitroglycerin transdermal systems. Conventional reproduction studies involving the oral, intravenous, intraperitoneal and dermal (as ointment) administration routes of nitroglycerin have been performed in rats and rabbits. Nitroglycerin showed no teratogenic potential in these animals.

Lactose, silicone oil, silica dioxide, ethylene-vinyl acetate copolymer, silicone-based adhesive (medical adhesive CH15).

None.

36 months.

Store below 30ºC.

Individual patches in a sealed pouch (made of paper/PE/AL/surlyn*).  10 or 30 sealed patches in each cardboard container.

 

*  Aluminium 12µm ± 10%, polyethylene 16G/m² ± 20%, surlyn 20G/m² ± 15%.

None stated.