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Angina - stable - Management
What dose and formulation of nitrate should I prescribe?
- Standard-release nitrate preparations: use an asymmetric dosing interval to minimize nitrate tolerance.
- For mononitrate preparations, this can be achieved with twice-daily dosing, for example at 8 a.m. and 3 p.m., or 2 p.m. and 10 p.m.
- For dinitrate preparations, dosing may be more complicated because dinitrate requires more frequent administration than mononitrate.
- Modified-release nitrate preparations: use a once-daily dose to maintain a nitrate-low period and thus minimize tolerance.
- Modified-release preparations are significantly more expensive than standard-release preparations, but they may be useful for people who find it difficult to comply with an asymmetric dosing regimen.
Basis for recommendation
These recommendations are consistent with guidelines from the European Society of Cardiology and the Scottish Intercollegiate Guidelines Network [Fox et al, 2006a; SIGN, 2007], and the British National Formulary [BNF 57, 2009].
- Nitrate tolerance quickly develops if nitrates are given continuously over 24 hours, and their anti-anginal effects are then reduced. Tolerance can be minimized or avoided by means of a daily nitrate-free or nitrate-low period. However, this has been associated with rebound myocardial ischaemia and adverse effects on performance during the nitrate-free period [Liu et al, 2005].
- Compliance to treatment has been shown to improve in people who have switched from multiple-daily to once-daily dose regimens [SIGN, 2007].
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