1.  Prophylaxis and treatment of angina pectoris.

2.  As an adjunctive treatment in the management of severe acute or chronic congestive cardiac failure. 

Posology

Adults

•       Angina: 30-120mg daily in divided doses according to individual requirements. Dosage should be gradually increased to minimize the possibility of nitrate headache and/or tolerance.

•       Congestive cardiac failure: In severe congestive cardiac failure doses of 40-160mg, daily in divided doses may be employed depending on individual requirements.  The optimum dosage is best determined by continuous hemodynamic monitoring.  The use of isosorbide dinitrate tablets in severe congestive cardiac failure should be regarded as an adjunctive therapy to more conventional treatment (e.g. cardiac glycosides, diuretics).

The maximum daily dose should not exceed 240mg in divided doses.

Elderly

• Dosage may be reduced in the elderly especially where there is impairment of renal or hepatic function. 

Pediatric population

            •             The safety and efficacy of isosorbide dinitrate has yet to be established in children.

Method of Administration

For oral administration

Use with caution in patients with closed-angle glaucoma (increased intra-ocular pressure).

These tablets should be used with caution in patients who are suffering from hypothyroidism, hypothermia, malnutrition, severe liver disease or renal disease.

Symptoms of circulatory collapse may arise after the first dose, particularly in patients with labile circulation.

This product may give rise to symptoms of postural hypotension and syncope in some patients.

These tablets should be used with particular caution and under medical supervision in the following:

•                 Low filling pressures e.g. in acute myocardial infarction, impaired left ventricular function (left ventricular failure).

•                 Reducing systolic blood-pressure below 90 mmHg must be avoided patients with aortic/mitral valve stenosis.

Hypertrophic obstructive cardiomyopathy (HOCM), constrictive pericarditis, cardiac tamponade, low cardiac filling pressures, aortic/mitral valve stenosis, and diseases associated with raised intracranial pressure.

Treatment with these tablets must not be interrupted or stopped to take phosphodiestearase inhibitor products due to the increased risk of inducing an attack of angina pectoris.

If these tablets are not taken as indicated, tolerance to the medication could develop.

Hypoxemia

Caution should be exercised in patients with hypoxemia and ventilation/perfusion imbalance due to lung disease or ischemic heart failure. As a potent vasodilator, ISDN could 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.

During treatment with ISDN alcohol should be avoided as it may potentiate the hypotensive and vasodilating effect of ISDN (see section 4.5).

Excipients

This medicine contains lactose. Patients with rare hereditary problems of galactose intolerance, total lactase deficiency or glucose-galactose malabsorption should not take this medicine.

Concurrent intake of drugs with blood pressure lowering properties e.g. beta-blockers, calcium antagonists, vasodilators, ACE-inhibitors, monoamine oxidase inhibitors etc. and/or alcohol may potentiate the hypotensive effect of the tablets. Symptoms of circulatory collapse can arise in patients already taking ACE inhibitors.

The concurrent intake of ISDN with ACE-inhibitors or arterial vasodilators could be a desirable interaction unless the antihypertensive effects are excessive in which case consider reducing the dose of one or both drugs.

The hypotensive effect of nitrates is potentiated by concurrent administration of phosphodiesterase inhibitors (e.g. sildenafil). This might also occur with neuroleptics and tricyclic antidepressants.

Reports suggest that when administered concomitantly, nitrates may increase the blood level of dihydroergotamine and its hypertensive effect.

Saproterin (Tetrahydrobioterine, BH4) is a cofactor for nitric oxide sythetase. Caution is recommended during concomitant use of saproterin-containing medicine with all agents that cause vasodilation by affecting nitric oxide (NO) metabolism or action, including classical NO donors (e.g. glyceryl trinitrate (GTN), isosorbide dinitrate (ISDN), isosorbide mononitrate (ISMN) and others).

The use of isosorbide dinitrate with riociguat, a soluble guanylate cyclase stimulator, is contraindicated (see section 4.3) since concomitant use can cause hypotension.

Pregnancy and breast-feeding

This product should not be used during pregnancy or lactation unless considered essential by the physician.

Fertility

There is no data available on the effect of ISDN on fertility in humans.

Headaches, tiredness and dizziness may occur. These may affect the ability to drive and operate machinery. Patients should not drive or operate machinery if their ability is impaired.

Undesirable effects frequencies are defined as: very common (≥ 1/10), common (≥ 1/100 to < 1/10), uncommon (≥ 1/1,000 to < 1/100), rare (≥ 1/10,000 to < 1/1,000), very rare (< 1/10,000), not known (cannot be estimated from the available data)

Severe hypotensive responses have been reported for organic nitrates and include nausea, vomiting, restlessness, pallor and excessive perspiration.

During treatment with these tablets, temporary hypoxemia may occur due to a relative redistribution of the blood flow in hypoventilated alveolar areas. Particularly in patients with coronary artery disease this may lead to myocardial hypoxia.

To report any side effect(s):

• Saudi Arabia:

·   Other GCC States:

-    Please contact the relevant competent authority.

Symptoms

•                 Fall blood pressure ≤ 90mm Hg, paleness, sweating, weak pulse, tachycardia, lightheadedness on standing, headache, weakness, dizziness, nausea and vomiting.

•                 During isosorbide mononitrate biotransformation nitrite ions are released, which may include methemoglobinemia and cyanosis with subsequent tachypnoea, anxiety, loss of consciousness and cardiac arrest. It cannot be excluded that an overdose of isosorbide dinitrate may cause this adverse reaction.

•                 In very high doses the intracranial pressure may be increased. This might lead to cerebral symptoms.

Management

•  Stop intake of the drug.

•  General procedures in the event of nitrate-related hypotension:

-  Patient should be kept horizontal with the head lowered and legs raised

-  Supply oxygen

-  Expand plasma volume

-  For specific shock treatment admit patient to intensive care unit.

• Specific Procedures:

-  Raising the blood pressure if the blood pressure is very low

-  Treatment of methaeglobinaemia (reduction therapy of choice with vitamin C, methylene blue, or toluidine-blue; administer oxygen (if necessary); initiate artificial ventilation; haemodialysis (if necessary)).

• Resuscitation measures:

- In case of signs of respiratory and circulatory arrest, initiate resuscitation measures immediately.

Pharmacotherapeutic group: Vasodilators used in cardiac diseases. organic nitrates, ATC code: C01D A08

Pharmacodynamics

Isosorbide dinitrate causes a relaxation of vascular smooth muscle thereby inducing a vasodilation.

Both peripheral arteries and veins are relaxed by isosorbide dinitrate. The latter effect promotes venous pooling of blood and decreases venous return to the heart, thereby reducing ventricular end-diastolic pressure and volume (preload).

The action on arterial, and at higher dosages arteriolar vessels, reduce the systemic vascular resistance (afterload). This in turn reduces the cardiac work.

The effect on both preload and afterload lead subsequently to a reduced oxygen consumption of the heart.

Furthermore, isosorbide dinitrate causes redistribution of blood flow to the subendocardial regions of the heart when the coronary circulation is partially occluded by arteriosclerotic lesions. This last effect is likely to be due to a selective dilation of large coronary vessels. Nitrate-induced dilation of collateral arteries can improve the perfusion of poststenotic myocardium. Nitrates also dilate eccentric stenoses as they can counteract possible constricting factors acting on the residual arch of compliant smooth muscle at the site of the coronary narrowing. Furthermore, coronary spasms can be relaxed by nitrates.

Nitrates were shown to improve resting and exercise hemodynamics in patients suffering from congestive heart failure. In this beneficial effect several mechanisms including an improvement of valvular regurgitation (due to the lessening of ventricular dilation) and the reduction of myocardial oxygen demand are involved.

By decreasing the oxygen demand and increasing the oxygen supply, the area of myocardial damage is reduced. Therefore, isosorbide dinitrate may be useful in selected patients who suffered a myocardial infarction.

Effects on other organ systems include relaxation of the bronchial muscle, the muscles of the gastrointestinal, the biliary and the urinary tract. Relaxation of the uterine smooth muscles is reported as well.

Mechanism of action

Like all organic nitrates, isosorbide dinitrate acts as a donor of nitric oxide (NO). NO causes a relaxation of vascular smooth muscle via the stimulation of guanylyl cyclase and the subsequent increase of intracellular cyclic guanosine monophosphate (cGMP) concentration. A cGMP-dependent protein kinase is thus stimulated, with resultant alteration of the phosphorylation of various proteins in the smooth muscle cell. This eventually leads to the dephosphorylation of the light chain of myosin and the lowering of contractility.

After administration of one tablet of ISDN 20mg at least two peak concentrations of ISDN occurred in the plasma. The initial peak (mean 1.9 ng/ml, range 1.0 to 3.4 ng/ml) occurred during 0.5 to 2 hours and then the mean plasma concentrations declined to 1.3 ng/ml at 3 hours. The concentration then increased again to reach a major peak level (mean 6.2 ng/ml range 1.6 to 12.3 ng/ml) during 4 to 6 hours after dosing. Plasma concentrations of ISDN have been measured after administration of increasing doses in the range 20 to 100 mg as ISDN 20mg tablets. Means of peak concentrations of 4.2 ng/ml, 13.1 ng/ml, 20.7 ng/ml, 36.8 ng/ml and 34.9 ng/ml were measured after doses of 20mg, 40mg, 60mg, 80mg and 100mg respectively.

Gastrointestinal absorption is slower than absorption through the oral mucosa. The first pass effect is higher when given orally. 

Isosorbide dinitrate is metabolised to isosorbide 2-mononitrate with a half-life of 2.01 h (±0.4 h) to 2.5 h and isosorbide 5-mononitrate with a half-life of 4.6 h (±0.8 h). Both metabolites are pharmacologically active.

The relative bioavailability of ISDN in comparison to the non-sustained-release tablet amounts to more than 80% after oral use.

There are no preclinical data of relevance to the prescriber which are additional to that already included in other sections of the SPC.

Lactose Monohydrate

Microcrystalline Cellulose

Sodium Starch Glycolate Type A

Povidone

FD&C Blue No. 1 Aluminum Lake

D&C Yellow No. 10 Aluminum Lake

Sodium Starch Glycolate Type A

Magnesium Stearate

 None known.

Store below 25°C.

Protect from light. Dispense in a light resistant, tight container

-                 Isosorbide Dinitrate Tablets 10 mg are White to off white colored, round shaped, biconvex, uncoated tablets debossed with “1149” on one side and breakline on other side. The tablet should be free of all physical defects.

-                 Isosorbide Dinitrate Tablets 20 mg are Light green to green colored, spotted, round shaped, biconvex, uncoated tablets debossed with “1150” on one side and breakline on other side. The tablet should be free of all physical defects.

-                 Isosorbide Dinitrate Tablets 30 mg Light blue to blue colored, spotted, round shaped, biconvex, uncoated tablets debossed with “1151” on one side and breakline on other side. The tablet should be free of all physical defects.

-                 Isosorbide Dinitrate Tablets 40 mg Light green to green colored, spotted, round, biconvex, uncoated tablets, debossed with “1152” on one side and break line on other side. The tablet should be free of all physical defects.

HDPE Pack of 100’s tablets.

Not applicable.