Invasive monitoring of central fluid volume is advised in renal failure and congestive heart failure patients. The liver contains organic nitrate reductase, which removes the nitrate group in a stepwise manner and ultimately inactivates the drug. For example, if you are taking standard tablets twice a day, they may tell you to take 1 dose in the morning at 8am and the second dose in the afternoon at 2pm (leaving a gap of 6 hours between your first and . @media (max-width: 1171px) { .sidead300 { margin-left: -20px; } } (See Tolerance and Dependence under Cautions.). [7], Isosorbide helps alleviate the symptoms of angina byincreasing the myocardial blood flow and decreasing the myocardial oxygen demand. If you notice that your baby is not feeding as well as usual, or seems unusually sleepy, or if you have any other concerns about your baby, talk to your health visitor, midwife or doctor. But Its maximal effect is seen in venous capacitance vessels. Controlled medication release is achieved using the Durules principle of insoluble matrix embedding.Data from randomised double-blind trials show that IMD 60mg once daily (the most widely studied dosage) has significant antianginal and anti-ischaemic effects compared . Some people may be able to stop taking it after certain types of heart surgery. Isosorbide mononitrate comes as standard tablets and slow-release (modified release) tablets and capsules. Sublingual isosorbide dinitrate and nitroglycerin are the two compounds used to treat acute angina. May cause a burning or tingling sensation when administered sublingually. http://creativecommons.org/licenses/by-nc-nd/4.0/. Nitroglycerin is the fastest-working medicine to relieve chest pain, but make sure to sit down before taking it. Bortolotti M, Coccia G, Brunelli F, Sarti P, Mazza M, Bagnato F, Barbara L. Isosorbide dinitrate or nifedipine: which is preferable in the medical therapy of achalasia? PI & CMI Trade Names and Active Ingredients containing. Pharmacokinetics of isosorbide mononitrate. Roman S, Kahrilas PJ. Elantan long (EL) is the only long-acting isosorbide mononitrate formulation based on a controlled membrane principle. Etter EF, Eto M, Wardle RL, Brautigan DL, Murphy RA. Angina adalah rasa nyeri atau tidak nyaman di dada karena kurangnya aliran darah ke jantung. Extended-release oral nitrate preparations should not be used in patients with functional or organic GI hypermotility or malabsorption syndrome. You can report any suspected side effect using the Yellow Card safety scheme. In contrast, isosorbide mononitrate, an active metabolite of isosorbide dinitrate, does not undergo the first-pass effect, and its bioavailability is 100 percent after oral administration. It can make your blood pressure too low and you may feel dizzy, lightheaded or sleepy. Isosorbide dinitrate is used to prevent chest pain ( angina) in patients with a certain heart condition ( coronary artery disease ). Initially, isosorbide dinitrate 20 mg and hydralazine hydrochloride 37.5 mg (1 tablet of BiDil) 3 times daily. Conventional measures in the management of angina pectoris are aimed at reducing the frequency, duration, and severity of attacks, and include coronary risk reduction (e.g., discontinuance of smoking, weight control, antilipemic strategies), rest, avoidance of precipitating circumstances (e.g., eating heavy meals, getting emotionally upset, performing strenuous exercise, exposure to cold air) and, if possible, treatment of the underlying cause. Target: 40 mg 3 times/day. In the latter case, glyceryl trinitrate is preferable. FDA Approved Indications for Isosorbide Dinitrate, Non-FDA Approved Indications for Isosorbide Dinitrate, FDA Approved Indications for Isosorbide Mononitrate, Isosorbide is a nitrate that exerts its pharmacologic effect by releasing nitric oxide (NO), an endothelium-derived relaxing factor (EDRF).NO is endogenously produced in the endothelium to dilate the blood vessels. Furthermore, there can be some severe effects as well, which include low blood pressure when exposed to PDE5 inhibitors, e.g. They are used to prevent angina symptoms (chest pain), they do not work to treat a current angina attack. Isosorbide mononitrate and dinitrate will not stop your contraception working, including emergency contraception. What is the difference or advantage of using isosorbide dinitrate over isosorbide mononitrate? The principal pharmacological action of isosorbide mononitrate is relaxation of vascular smooth [2] It can be used both to treat and to prevent heart-related chest pain; however, it is generally less preferred than beta blockers or calcium channel blockers. Due to the high prevalence of cardiovascular disease among the general population, effective management of anginal pain and heart failure with significant interprofessional communication plays a crucial role in reducing mortality and readmission rates with long-term benefits of improved exercise tolerance and quality of life. Weused pulse pressure as the in vivo haemodynamicindex, andshowedthat the ED50s (doses to reduce pulse pressure by 50%) were 10.2, 18.1, 43.2 and48.6mgkg-1, forL-isoidide mono-nitrate, isosorbide-2-mononitrate, isomannide mono-nitrate and5-ISMN,respectively (only a 5 . Both isosorbide mononitrate and isosorbide dinitrate are broken down into nitrates in the body. Relieves chest pain. It's important that you keep taking your medicine to keep you well. With a mind rooted firmly to basic principals of chemistry and passion for ever evolving field of industrial chemistry, she is keenly interested to be a true companion for those who seek knowledge in the subject of chemistry. To reduce your risk of problems like these, it may help to: Page last reviewed: 1 July 2021 Because of this decrease in the heart's workload, myocardial oxygen demand becomes reduced. !W#Lgy Adult 30-120 mg daily in divided doses. Isosorbide mononitrate and dinitrate usually starts to work within 1 hour. The patent was approved, leading to the production of BiDil, a single-pill equivalent to the generic H-ISDN. ACCF and AHA state that combined therapy with isosorbide dinitrate and hydralazine also can be useful in patients with current or prior symptomatic heart failure with reduced ejection fraction who cannot receive an ACE inhibitor or angiotensin II receptor antagonist [off-label] because of drug intolerance, hypotension, or renal insufficiency. The development of tolerance is a significant concern during long-term isosorbide therapy. Figure 01: The Chemical Structure of Isosorbide Mononitrate. This book is distributed under the terms of the Creative Commons Attribution-NonCommercial-NoDerivatives 4.0 International (CC BY-NC-ND 4.0) 2 0 obj It is in the nitrate class of drugs. However, monitoring is recommended in: Close monitoring of blood pressure and heart rate in the above patients is recommended to avoid severe hypotension and bradycardia. Lincoln TM, Komalavilas P, Cornwell TL. No specific dosage recommendations for renal impairment. Isosorbide mononitrate (ISMN) is widely used for the prophylaxis of angina pectoris. Importance of warning all patients taking either selective PDE inhibitors or organic nitrates or nitrites of the potentially severe and life-threatening hemodynamic consequences of taking the drugs within close proximity (e.g., within 24 hours of sildenafil; possibly more prolonged periods of risk with longer-acting PDE inhibitors) of taking a nitrate- or nitrite-containing preparation. Tell your doctor that you're taking isosorbide mononitrate or dinitrate if you're going to be put to sleep (using general anaesthesia), or you're having any kind of major operation. [11] It decreases systemic vascular resistance (afterload) by dilating the peripheral arterioles. Like all medicines, isosorbide mononitrate and dinitrate can cause side effects, although not everybody gets them. Dr. Rick Koch answered. Talk to your doctor if you want to stop taking isosorbide mononitrate or dinitrate. The challenges of isosorbide therapy are drug interactions, adverse effects, and the development of tolerance during chronic isosorbide therapy. Tell your doctor or pharmacist if you're taking any other medicines, including herbal medicines, vitamins or supplements. . Talk to your doctor if you're not sure it's safe for you to exercise. Isosorbide mononitrate and isosorbide dinitrate are important medications for some heart diseases. These are not all the side effects of isosorbide mononitrate and isosorbide dinitrate. stream Hypertensive crisis: short-term reduction of blood pressure. Isosorbide mononitrate and isosorbide dinitrate are important medications for some heart diseases. It has high . Imdur (isosorbide mononitrate) Extended Release and Isordil (isosorbide dinitrate) are vasodilators indicated for the prevention of angina pectoris due to coronary artery disease.. Side effects of Imdur and Isordil that are similar include headache and dizziness.. Side effects of Isordil that are different from Imdur include weakness and skin changes such as redness, tingling, or warmth. Cardiology 24 years experience. Patients who fail to respond to nitroglycerin lingual or sublingual: 2.55 mg of isosorbide dinitrate. %PDF-1.4 Isosorbide mononitrate: Approximately 45%. Sisenwine SF, Ruelius HW. Abshagen UW. Isosorbide mononitrate (ISMN) is the active metabolite of ISDN and is primarily used in the management of chronic stable angina. (dinitrate conventional tablets) two to three times daily. Initially, (e.g., Imdur): 30 mg (as a single 30-mg tablet or as of a 60-mg tablet) or 60 mg (as a single 60-mg tablet) once daily. Isosorbide mononitrate and dinitrate are not used to treat sudden angina attacks. You can take either tablets or capsules with or without food. Administer sublingually, intrabuccally, or orally. Boden WE, Finn AV, Patel D, Peacock WF, Thadani U, Zimmerman FH. Manufacturers of selective PDE inhibitors (e.g., sildenafil, tadalafil, vardenafil) state that the drugs are contraindicated in patients receiving organic nitrates or nitrites in any form (e.g., orally, sublingually, transmucosally, parenterally), given regularly or intermittently, or nitric oxide donors since severe, potentially fatal hypotensive episodes can occur. Porje initiated the research on isosorbide in Stockholm, and the drug was marketed in Sweden in 1946. Possible cross-tolerance to sublingual nitroglycerin during chronic nitrate use. Isosorbide. Nitrates as an integral part of optimal medical therapy and cardiac rehabilitation for stable angina: review of current concepts and therapeutics. ChildrenUse and dose must be determined by your doctor. Apart from limiting alcohol, you can eat and drink normally while you are taking isosorbide mononitrate or dinitrate. Titrate dosages to levels similar to those recommended for the fixed-combination preparation and administer both drugs at least 3 times daily. [2] Treatment of chronic angina pectoris due to coronary artery disease. Along with non-selective beta-blockers (NSBB), it can be used as secondary prophylaxis in preventing recurrent variceal hemorrhage. [12], The two forms of isosorbide (isosorbide mononitrate and isosorbide dinitrate) vary extensively in their pharmacokinetic properties. Isosorbide mononitrate and dinitrate can be taken by most adults aged 18 years and above. Isosorbide mononitrate helps to prevent angina chest pain from developing. They may be able to change your dose or prescribe a different medicine instead. In the V-HeFT I and II trials, isosorbide dinitrate was dosed 20 mg four times a day for 2 weeks, then 40 mg four times a day; In the A-HeFT trial, isosorbide dinitrate was initially dosed 20 mg three times a day, then increased to 40 mg three times a day if tolerated; May take without regard to food Prescription only. The key difference between isosorbide mononitrate and isosorbide dinitrate is that isosorbide mononitrate is primarily used in the management of chronic stable angina, whereas isosorbide dinitrate is recommended for heart failure. Development of a Combination Product. ISDN has an extensive first pass metabolism in the liver, produces two major metabolites . Slow-release tablets and capsules release the medicine gradually into your body. How can lifestyle changes help the health of my heart? Long-term isosorbide therapy with appropriate drug-free intervals can improve the patient's exercise capacity and exercise hemodynamics in patients with chronic congestive heart failure. Avoid long-acting dosage forms in the early management of acute MI or heart failure since the effects are difficult to terminate rapidly should excessive hypotension or tachycardia occur. Is there any food or drink I need to avoid? Laufen H, Aumann M, Leitold M. Oral absorption and disposition of isosorbide dinitrate and isosorbide mononitrates in man. They differ from each other according to their applications and properties. We comply with the HONcode standard for trustworthy health information. Vasodilator Therapy: Nitrates and Nicorandil. This activity describes the indications, action, and contraindications for isosorbide as a valuable agent in treating angina pectoris due to coronary artery disease, heart failure with reduced ejection fraction, and achalasia. Clinicians unfamiliar with their patients drug history, especially those involved in emergency care (e.g., for presumed myocardial infarction or ischemia), should take a careful history so that concomitant use of organic nitrates or nitrites with selective PDE inhibitors can be avoided. The manufacturer of the fixed combination of isosorbide dinitrate and hydralazine hydrochloride states that dosage should be selected with caution because of age-related decreases in hepatic, renal, and/or cardiac function and concomitant disease and drug therapy. Below is a conversion table to enable using this preparation in place of standard release isosorbide mononitrate and modified release (M/R) preparations which are not going to be kept. This is called a "nitrate low" period and is needed to make sure your medicine works properly. The organic nitrates are vasodilators, active on both arteries and veins. Adults: Usual adult dose is one isosorbide mononitrate XL 60 mg tablet per day (taken in the morning).If necessary, the dosage may be increased to 120 mg once daily (i.e. This medicine is not suitable for some people. Isosorbide mononitrate slow-release tablets or capsules: Isosorbide dinitrate slow-release tablets: Isosorbide dinitrate immediate release tablets: Taking too much isosorbide mononitrate or dinitrate may cause your blood pressure to fall too low, making you feel sick, faint and dizzy. For oral dosage form (tablets): Adults20 milligrams (mg) two times a day. After several days, dosage may be increased to 120 mg (given as single 120-mg tablet or two 60-mg tablets) once daily. The easiest way to lookup drug information, identify pills, check interactions and set up your own personal medication records. Conventional tablets: Approximately 100%. 4, 7 Isosorbide mononitrate is an active metabolite of isosorbide dinitrate. What is Isosorbide Mononitrate Maximum 120 mg daily administered concomitantly with hydralazine hydrochloride (maximum 300 mg daily). Isosorbide is used to manage anginal pain due to coronary artery disease, and it has approval for use in heart failure. [10]The MLCK, along with the unphosphorylated myosin light chain, causes the myosin head to detach from the actin component of the smooth muscle, resulting in smooth muscle relaxation and causing vasodilation. 1. Other medicines used to prevent angina attacks are: If you cannot take either of these medicines, you may be given another medicine such as ivabradine, nicorandil or ranolazine. In rare cases, it's possible to have a serious allergic reaction (anaphylaxis) to isosorbide mononitrate and isosorbide dinitrate. If you take other medicines that lower blood pressure with isosorbide mononitrate and dinitrate, it can sometimes lower your blood pressure too much. Severe hypotension, particularly in upright position, can occur even with low doses. Off-label: Use is not currently included in the labeling approved by the US Food and Drug Administration. Terms of Use and Privacy Policy: Legal. May decrease dosage to as little as of the fixed-combination tablet 3 times daily in patients who experience intolerable effects, but attempt to titrate dosage up once adverse effects subside. Adjust dosage of isosorbide dinitrate and isosorbide mononitrate carefully according to the patient's requirements and response; use the smallest effective dosage. This increases the blood supply to your heart, which gets more oxygen to your heart muscles and this reduces chest pain. <> Manufacturers state that selective phosphodiesterase (PDE) inhibitors (e.g., sildenafil, tadalafil, vardenafil) are contraindicated in patients receiving nitrates. Chronic isosorbide use without drug-free intervals may cause poor symptom control and endothelial dysfunction due to the release of excessive free radicals.[26]. Drug class: Nitrates and Nitrites Your doctor may increase your dose as needed. Patients with right ventricular infarction are preload sensitive. Isosorbide mononitrate and dinitrate can make some people feel dizzy, sleepy or faint. Tell your doctor if this happens to you. CAS number: 87-33-2. Conversion table Original isosorbide prescription: Convert to: 10 mg twice a day at 8am and 4pm 20 mg twice a day at 8am and 4pm 30% of the dose is available for immediate release and the remaining 70% is gradually released over time. For example, if you are taking standard tablets twice a day, they may tell you to take 1 dose in the morning at 8am and the second dose in the afternoon at 2pm (leaving a gap of 6 hours between your first and second dose). Isosorbide undergoes bioactivation in the endoplasmic reticulum through the cytochrome P450 enzymes to release NO[7], which activates the enzyme soluble guanylyl cyclase in the vascular smooth muscles, thereby increasing the levels of intracellular cGMP and the associated protein kinases such as cGMP- dependent protein kinases(cGK-I). The metabolism of this drug occurs in the liver, and the elimination half-life is about 5 hours. Initially, isosorbide dinitrate conventional tablets (e.g., Isordil Titradose) 520 mg administered 23 times daily, followed by maintenance dosage of 1040 mg administered 23 times daily (some patients may require higher dosages). In patients with hypertrophic cardiomyopathy, isosorbide decreases the preload and, hence, the left ventricular volume, worseningleft ventricular outflow tract obstruction.[11]. There can be some side effects of using this medication, which include headache, low blood pressure, blurry vision, and skin flushing. One manufacturer of isosorbide mononitrate states that dosage should be selected with caution, usually initiating therapy at the low end of the range, although age, renal, hepatic, and cardiovascular dysfunction do not appear to have a significant effect on drug clearance. There is no clear evidence that isosorbide mononitrate or dinitrate affects fertility in men or women. If you are trying to get pregnant, talk to your doctor. This is because it can lower your blood pressure too much when combined with some anaesthetics. Z L0y+"Z=A]*=_/Kw&FEa"O,KqKl]s-:G{. This might make you feel dizzy or faint. Isosorbide dinitrate (Isordil) is good for a specific type of chest pain (called angina), but it can cause headaches after you take it. May increase dosage to 120 mg (as a single 120-mg tablet or as two 60-mg tablets) once daily after several days; 240-mg dosages rarely needed. This medicine is particularly used in heart failure due to the ability of systolic dysfunction in combination with hydralazine. If your doctor and health visitor say your baby is healthy, you may be able to take it while you're breastfeeding. Isosorbide dinitrate and isosorbide mononitrate: Organic nitrates; vasodilating agents. Nitrate dependence is possible (documented in daily industrial exposures); withdrawal manifestations (e.g., ischemic symptoms, MI, sudden death) can occur. Therecommended drug-free intervals for preventing the development of tolerance for oral sustained-release isosorbide dinitrate are as follows[27]: The patients should understand the possibility of developing anginal episodes during the drug-free interval. According to pharmacokinetic data, the bioavailability of this drug is about 25% on average, and its metabolism occurs in the liver. Combination of isosorbide dinitrate and hydralazine in blacks with heart failure. Isosorbide mononitrate differs from isosorbide dinitrate according to the number of nitro groups per molecule. Isosorbide Mononitrate vs Isosorbide Dinitratein Tabular Form Isosorbide-5-mononitrate is completely bioavailable after oral doses and is not subjected to pre-systemic elimination processes.Isosorbide-5-mononitrate is eliminated from the plasma with half-life of about 5.1 hours. Combination of isosorbide dinitrate and hydralazine recommended by ACCF and AHA for self-identified black patients with NYHA class III or IV heart failure and reduced ejection fraction who are receiving optimal therapy with ACE inhibitors and -blockers, unless contraindicated. Postural hypotension may occur and may cause dizziness, weakness, and other signs of cerebral ischemia. Isosorbide is a medication used to treat and prevent angina pectoris in patients with coronary heart disease. Next review due: 1 July 2024, Isosorbide mononitrate and isosorbide dinitrate. Isosorbide mononitrate or dinitrate is not likely to affect your sex life. Isosorbide dinitrate conventional tablets, peak: 60 minutes. Prophylactic management in situations likely to provoke angina attacks in patients who fail to respond to sublingual nitroglycerin: 2.55 mg of isosorbide dinitrate should be placed under the tongue approximately 15 minutes prior to engaging in such activities. The activity of isosorbide dinitrate may depend on the production of active metabolites, the most important . ISDN has a short half-life and is primarily effective clinically by metabolism to the active metabolite isosorbide-5-mononitrate, which has an average half-life of 5 hours. Paradoxical bradycardia and angina exacerbation may accompany hypotension. You can help reduce your risk of problems like these by: If you have stable angina (the most common type), you'll be given medicine to take when you have an angina attack. Available for Android and iOS devices. 1 0 obj Isosorbide dinitrate is effective by mouth for the prophylaxis and treatment of angina; although the effect is slower in onset, it may persist for several hours. Lethal dose LD50 of isosorbide has not been a topic of sufficient research in the human population. Isosorbide mononitrate is available under the following different brand names: Imdur, Monoket, and ISMO. Swallow the tablets or capsules whole with a drink of water. The predominant venodilation results in decreased venous return to the heart by reducing the left ventricular end-diastolic volume, left ventricular end-diastolic pressure(preload), and the ventricular wall tension,therebyindirectly facilitating subendocardial blood flow. The patient should be sitting immediately after sublingual or intrabuccal administration. Standard-release nitrate preparations: use an asymmetric dosing interval to maintain a daily nitrate-free time of 10-14 hours to minimize development of nitrate tolerance. It usually happens because your arteries have become hardened and narrowed. Prolonged use of oral nitrates has been associated with the development of tolerance to the hemodynamic and antianginal effects and possibly with cross-tolerance to sublingual nitrates. Review the appropriate monitoring necessary with isosorbide. Isosorbide use requires caution in the following conditions: Generally, isosorbide does not need any monitoring. Adjust dosage of isosorbide dinitrate and isosorbide mononitrate carefully according to the patients requirements and response; use the smallest effective dosage. The methemoglobinemia associated with isosorbide toxicity is manageable by supportive care and cessation of isosorbide. If you take isosorbide mononitrate or dinitrate 2 or 3 times a day, your doctor or pharmacist will explain how to space out your doses. Imdur is a vasodilator and Ranexa is an anti-anginal medication. However, do not take medicines for erection problems if you are taking isosorbide mononitrate or dinitrate. Careful clinical or hemodynamic monitoring for possible hypotension or tachycardia if used in acute MI or heart failure. However, nitrate tolerance develops rapidly with persistent exposure and these agents are given in a way that allows for an 8 to 12 hour nitrate free period to restore efficacy. May titrate dosage to a maximum tolerated dosage not to exceed 2 tablets (a total of 40 mg of isosorbide dinitrate and 75 mg of hydralazine hydrochloride) 3 times daily. How does isosorbide mononitrate and dinitrate work? It comes as a mouth spray or tablets that dissolve under your tongue. Plasma concentrations and urinary excretion of isosorbide dinitrate and its metabolites in the dog. VA class: CV250 Warn all patients taking either selective PDE inhibitors or organic nitrates or nitrites of the potential consequences of taking the drugs within close proximity (e.g., within 24 hours of sildenafil; possibly more prolonged periods of risk with longer-acting PDE inhibitors) of taking a nitrate- or nitrite-containing preparation. There is no information about whether isosorbide mononitrate or dinitrate passes into breast milk, but the amounts are likely to be small. Isosorbide mononitrate, sold under many brand names, is a medication used for heart-related chest pain ( angina ), heart failure and esophageal spasms. Isosorbide dinitrate is contraindicated in patients with shock or marked low blood pressure. 1. Side effects of Imdur and Ranexa that are similar include headache and dizziness. In addition to vascular smooth muscle, nitrates and nitrites relax bronchial, biliary (including the gallbladder, biliary ducts, and sphincter of Oddi), GI (including the esophagus), ureteral, and uterine smooth muscle; nitrates relax all smooth muscle irrespective of autonomic innervation and are functional antagonists of norepinephrine, acetylcholine, and histamine. Angina is chest pain that happens when not enough blood gets to the muscles of the heart. Readily absorbed from the GI tract; does not undergo first-pass hepatic metabolism. [11]It directly increases the myocardial blood flow by dilating the large and medium-sized coronary arteries at higher doses. Isosorbide dinitrate is good for chest pain, but you have to be able to stick to your dosing schedule or it won't work as well. Isosorbide Mononitrate: Uses, Dosage & Side Effects. Drugs.com. Miano C, Garcia-Tsao G. Clinical pharmacology of portal hypertension. <>/XObject<>/ProcSet[/PDF/Text/ImageB/ImageC/ImageI] >>/MediaBox[ 0 0 595.32 841.92] /Contents 4 0 R/Group<>/Tabs/S/StructParents 0>> Not known whether geriatric patients respond differently than younger patients. Employ intermittent dosing of nitrates (e.g., use of a nitrate-free interval of 1012 hours daily) to minimize or prevent the development of tolerance to the hemodynamic and antianginal effects of the drugs. In angina, isosorbide mononitrate and dinitrate works by widening blood vessels (veins and arteries). If you have darker skin your gums or the skin around your eyes may turn blue or grey these are signs of low oxygen levels in your body, your heart starts beating much faster or slower than usual, you get chest pain that is different or worse than your usual angina pain, you get severe pain in your eye, headache, blurred vision or you suddenly go blind in one eye these could be signs of acute angle closure glaucoma, you get a skin rash that may include itchy, red, swollen, blistered or peeling skin, your mouth, face, lips, tongue or throat start swelling, medicines for erection problems including, calcium channel blockers to relax the arteries, increasing blood supply to the heart muscle, build up your activity level gradually and take regular breaks, keep your GTN tablets or spray with you in case you need them, use your tablets or spray before starting exercise, if you need to. Administer extended-release tablets with adequate amounts of fluid (e.g., 120 mL) on arising in the morning. Do not use extended-release isosorbide dinitrate preparations or any isosorbide mononitrate preparation to abort an acute anginal episode or for acute relief of angina or in the prophylactic management in situations likely to provoke angina attacks; onset is not sufficiently rapid.
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