First Week Response: Please see below posts 1 and 2 please answer separately each response with 3 citations/references ( totals of 6 )
Nitroglycerine is a medication usually administered to relieve chest pain and angina in cardiac patients. This medication can also be prescribed as needed by a patient’s primary care provider. For acute angina or chest pain, the most common form of administration is sublingual which a tablet is placed under the tongue (Hollier, 2019). This administration route is the best practice for immediate administration of the drug. Sublingual administration relieves chest pain quicker than the alternate route orally (Kim et al., 2021). The dosing for adults is decided by the patient’s primary care provider and can range from 0.3mg to 0.8mg (Divakaran & Loscalzo, 2017). For sublingual use when symptomatic a patient can place one tablet sublingually every 3 to 5 minutes for a maximum of three tablets (Hollier, 2019).
Nitroglycerine is available in different forms and can be prescribed based on the patient’s presenting symptoms. Some common forms of the drug include sublingual tablets, sublingual spray, oral forms, topical patches, and oral tablets (Hollier, 2019). One common way nitroglycerine is prescribed is as needed by the patient when experiencing angina at home sublingual. This is a very common form and is absorbed by the body in 1 to 3 minutes and has a bioavailability of around 30% (Divakaran & Loscalzo, 2017). This is a more preferred method as opposed to oral which has a lower bioavailability to the first pass effect. The first pass effect is the reduction of the concentration of the medicine administered due to certain organs in the body such as the liver (Rosenthal & Lehne, 2021).
Nitroglycerine is used to treat Angina in cardiac patients and can be used to lower blood pressure. Primary care providers are responsible for the prescribing and management of care while the patient is taking the medication. Sublingual is the preferred method at home but for instant results, IV administration can also be given in an acute setting (Rosethal & Lehne, 2021). The medication effectiveness of the medication depends highly on the route administered. The oral administration greatly reduces the effectiveness of the medication due to the first pass effect in the body. To avoid the first pass effect the medication is often administered sublingually and dissolvable tablets are given to the patient under their tongue.
Hollier, A. (2021). Clinical guidelines in primary care. Advanced Practice Education Associates.
Divakaran, S., & Loscalzo, J. (2017). The Role of Nitroglycerin and Other Nitrogen Oxides in
Cardiovascular Therapeutics. Journal of the American College of Cardiology, 70(19), 2393–2410. https://doi.org/10.1016/j.jacc.2017.09.1064
Kim KH, Kerndt CC, Adnan G, et al. Nitroglycerin. [Updated 2021 Nov 4]. In: StatPearls
[Internet]. Treasure Island (FL): StatPearls Publishing; 2022 Jan-. Available from: https://www.ncbi.nlm.nih.gov/books/NBK482382/
Rosenthal, L. D., Burchum, J. R., & Lehne, R. A. (2021). Lehne’s pharmacotherapeutics for advanced practice nurses and physician assistants. Elsevier.
Many factors should be considered when prescribing medications to patients as each of these elements can elicit different responses to medication. Patient response to drugs is influenced by various factors. Safe and effective drug treatment is not only a function of the physical and chemical properties of drugs but also a function of how the human body responds to the administration of medication (Sakai, 2008). Absorption, distribution, metabolism, and excretion are four processes that define pharmacokinetics (Doogue & Polasek, 2013). Each of these processes has an effect on the bioavailability of the drug and different routes of administration can affect the bioavailability of the drug.
Nitroglycerine and Bioavailability
For example, nitroglycerine is available in a number of preparations for delivery via several routes: oral tablets, sublingual tablets, buccal tablets, sublingual spray, transdermal ointment, and transdermal patch, as well as intravenous formulations (Divakaran et al., 2017). Nitroglycerine is usually not administered orally because it has a very high first-pass effect and undergoes extensive metabolism in the stomach prior to being absorbed in the bloodstream.
In contrast, when nitroglycerine is administered through the sublingual or buccal routes, the drug is rapidly absorbed into the bloodstream and its peak plasma level is reached within minutes. (Narang & Sharma, 2010). The sublingual and buccal route allows for more prolonged effects lasting for a few hours thus, the longer the drug is available in the body, the more of it can be absorbed.
Additionally, nitroglycerine sublingual sprays are available in a metered-dose spraying pump, which administers the drug in the form of spray droplets which ultimately increase the absorption and hence the bioavailability of nitroglycerine (Narang & Sharma, 2010). Intravenous administration of nitroglycerine results in its breakdown by vascular endothelium. Over time, the enzymes become depleted through continuous exposure to the reaction, and a state of tolerance develops, which prevents further reactions. Thus, this route of administration is not appropriate since it has a low bioavailability.
Drugs that are rapidly cleared from the body via the liver will have a diminished effect after oral administration because some of the drugs are eliminated before it reaches the bloodstream. However, administering the drug via different routes of administration can prevent this from happening. It is essential for advanced practice nurses to be aware of each of these processes as each patient may not achieve the desired effect of the drug.
In summary, it is essential for the advanced practice nurse to understand the pharmacokinetics of medications as part of the management of patient care. Sakai (2008) reports the interactions between a drug and the human body are incredibly complex. Having a thorough knowledge of medication profiles will not only ensure the safety and efficacy of drug interactions and will contribute to positive patient outcomes.
Divakaran S, Loscalzo J, et al. The Role of Nitroglycerin and Other Nitrogen Oxides in Cardiovascular Therapeutics. J Am Coll Cardiol. 2017 Nov, 70 (19) 2393–2410.
Doogue, M. P., & Polasek, T. M. (2013). The ABCD of clinical
pharmacokinetics. Therapeutic Advances Drug Safety, 5–7.
Sakai, J. B. (2008). Pharmacokinetics: The absorption, distribution, and excretion of
drugs. In Practical pharmacology for the pharmacy technician (pp. 27-40).
Philadelphia, PA: Jones & Bartlett Learning.
Narang, N., & Sharma, J. (2010, December 8). Sublingual mucosa as a route for systemic drug delivery. SUBLINGUAL MUCOSA AS A ROUTE FOR SYSTEMIC DRUG DELIVERY. Retrieved June 1, 2022, from https://innovareacademics.in/journal/ijpps/Vol3Suppl2/1092.pdf