Isosorbide dinitrate
ISORDIL
Pronunciation: eye-soe-SOR-bide dye-NYE-trayt
“Ice sorbet Is (an) ordeal”
two nitrates to contrast with isosorbide and isosorbide mononitrate
What it isNitric oxide donor; angina, and with hydralazine in heart failure.
Why this oneHydralazine combination has mortality benefit in Black patients with HFrEF, and it is usable when renal function forbids an ACE inhibitor.
What limits itExtensive first-pass metabolism means three-times-daily dosing and a mandatory nitrate-free interval. Fatal hypotension with PDE5 inhibitors.
Pearls
- Titrate with hydralazine every 2–4 weeks; headache and dizziness common.
- Hydralazine adds tachycardia, peripheral neuritis and lupus-like syndrome.
FDA-approved for
- angina pectoris
Principal riskFatal hypotension with PDE5 inhibitors
Classes and tags
Clinical profile
Legacy pregnancy categoryC
Defining liabilityGenerally tolerated at therapeutic doses; clinically important risks are agent-specific and increase with interactions or organ impairment.
FDA label
Read the full label on DailyMed ↗
NO BOXED WARNINGS
| FDA dosing | Population | Start | Target | Max |
|---|---|---|---|---|
| Prevention of angina pectoris | Adult | 5-20 mg BID-TID | 10-40 mg BID-TID |
Renal Undefined
Hepatic Undefined
No regimen provides more than ~12 hours of continuous anti-anginal effect per day.
Instructions
- Provide a daily nitrate-free interval of at least 14 hours to minimize tolerance
- Use the minimum dose that produces the desired effect
Available strengths
- tab 5, 10, 20, 30, 40 mg
Contraindications
- Concurrent PDE5 inhibitors (sildenafil, tadalafil, vardenafil) — severe hypotension/syncope
- Concurrent riociguat (soluble guanylate cyclase stimulator) — hypotension
Cautions
- Severe/recurrent headache
- Symptomatic hypotension, lightheadedness, syncope
- Tolerance with continuous (no interval) dosing
- Rare methemoglobinemia
Adverse reactions
- Headache (most common)
- Lightheadedness
- Hypotension
- Syncope, crescendo angina, rebound hypertension (uncommon)
- Methemoglobinemia (extremely rare)
Pregnancy Category C; use only if potential benefit justifies fetal risk.
Lactation Undefined
Cost
Generic entry1986
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Self-check
- Which partner provides a mortality benefit with isosorbide dinitrate in Black patients with HFrEF?
Hydralazine. - Which co-medications can cause fatal hypotension with isosorbide dinitrate?
PDE5 inhibitors.