Passive elevation of the patient's legs to reduce the venous pooling of blood. 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. Nitrostat (Nitroglycerin) Relieves chest pain. Isosorbide-5-mononitrate must not be used in cases of: hypersensitivity to isosorbide-5-mononitrate (the active substance), other nitrate compounds or to any of the excipients acute circulatory failure (shock, circulatory collapse) cardiogenic shock, unless a sufficiently high left-ventricular end-diastolic pressure is Nitrates as an integral part of optimal medical therapy and cardiac rehabilitation for stable angina: review of current concepts and therapeutics. % Chronic isosorbide use without drug-free intervals may cause poor symptom control and endothelial dysfunction due to the release of excessive free radicals.[26]. 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. Isosorbide dinitrate: Also probably metabolized at extrahepatic sites. x][7~_cNv2}LN ` 8ql'O_}U%zwZ]U{_U]V?/*S~[~|^bn[zHsxuy][^,;}.oO^mweU^.Wn>{l .6=(r#n*xW7| J{{or`}|4^r Extended-release tablets: Approximately 7780%. Christiansen I, Iversen HK, Olesen J. Headache characteristics during the development of tolerance to nitrates: pathophysiological implications. 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. Lethal dose LD50 of isosorbide has not been a topic of sufficient research in the human population. Some people need to take 2 or more medicines. 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. Isosorbide use requires caution in the following conditions: Generally, isosorbide does not need any monitoring. In patients with hypertrophic cardiomyopathy, isosorbide decreases the preload and, hence, the left ventricular volume, worseningleft ventricular outflow tract obstruction.[11]. Isosorbide is used to manage anginal pain due to coronary artery disease, and it has approval for use in heart failure. Take the first dose in the morning right after you . The Role of Nitroglycerin and Other Nitrogen Oxides in Cardiovascular Therapeutics. Because of their hemodynamic profile, particularly beneficial in patients with left ventricular systolic dysfunction or heart failure. [7], Isosorbide helps alleviate the symptoms of angina byincreasing the myocardial blood flow and decreasing the myocardial oxygen demand. Isosorbide mononitrate and isosorbide dinitrate are important medications for some heart diseases. In angina, isosorbide mononitrate and dinitrate works by widening blood vessels (veins and arteries). Taylor AL, Ziesche S, Yancy C, Carson P, D'Agostino R, Ferdinand K, Taylor M, Adams K, Sabolinski M, Worcel M, Cohn JN., African-American Heart Failure Trial Investigators. Talk to your doctor if you're taking a combined hormonal contraceptive. 2. (dinitrate conventional tablets) two to three times daily. x\[o~`kYH]r M 0-:/n77nnN,v.V"mYf/2[7bf?x>}>\wG }Nx'XT^FVw_fo ~;Hfz^@mlgz]3GD6'lKi~6A-,Bw Lt"i'1Y}=7Og b-yb@Y=lY(v -l`'c#EqxXhb MANO{65j5H$~$2J-;oHDI~ IY~wr_x Importance of informing patients of other important precautionary information. Maximum daily dosage of Dilatrate-SR: 160 mg (4 capsules). [8][9], The decreased intracellular calcium inhibits the myosin light chain kinase(MLCK). They differ from each other according to their applications and properties. It is an anti-anginal agent that works by relaxing the smooth muscles of both arteries and veins, but but predominantly veins to reduce cardiac preload. You do not need to avoid playing sports due to taking isosorbide mononitrate or dinitrate. Isosorbide mononitrate is available under the following different brand names: Imdur, Monoket, and ISMO. Some people may be able to stop taking it after certain types of heart surgery. This increases the blood supply to your heart, which gets more oxygen to your heart muscles and this reduces chest pain. 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 Tablets may be taken with or without food, and should be swallowed whole and not chewed. Long-acting isosorbide mononitrate 2-3 times anginal isosorbide mononitrate first-pass liver 100% bioavailability. They are similar medicines that work in the same way, but the doses are different so you'll need to take the type that you're prescribed. Isosorbide mononitrate dose 10 mg twice daily to 120 mg daily in divided doses. ;6YXZp2k>!'Z)IfFW`VG@Y!b /r980t ~pE Divakaran S, Loscalzo J. 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. If you are trying to get pregnant, talk to your doctor. Isosorbide mononitrate or dinitrate is not likely to affect your sex life. Selective PDE inhibitors can potentiate the hypotensive effects of organic nitrates and nitrites, possibly resulting in potentially life-threatening hypotension and/or hemodynamic compromise. Invasive monitoring of central fluid volume is advised in renal failure and congestive heart failure patients. However, if you have angina, oral contraceptives such as the combined pill are not recommended because they increase the risk of heart attack and stroke. Advise patients to take nitrates as directed, particularly since tolerance can occur. Sublingual isosorbide dinitrate and nitroglycerin are the two compounds used to treat acute angina. The three forms of organic nitrates are described separately . They differ from each other according to their applications and . 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. Or 5 to 20 mg (mononitrate conventional tablets) b.i.d. Isosorbide mononitrate and dinitrate comes as tablets, or capsules. Let your provider know if they are excessive. In: StatPearls [Internet]. Isosorbide mononitrate and dinitrate usually starts to work within 1 hour. The effect of food on the bioavailability of isosorbide dinitrate when administered in fixed combination with hydralazine hydrochloride is not known. After oral administration, isosorbide dinitrate undergoes an extensive first-pass effect in the liver, reducing the oral bioavailability to 20 percent. Isosorbide dinitrate-hydralazine combination therapy in African Americans with heart failure. 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. @media (max-width: 1171px) { .sidead300 { margin-left: -20px; } } Maximum 120 mg daily administered concomitantly with hydralazine hydrochloride (maximum 300 mg daily). Usually you will take isosorbide mononitrate and dinitrate for a long time, possibly for the rest of your life. AdultsAt first, 30 or 60 milligrams (mg) once a day. Your doctor may advise you to stop taking isosorbide mononitrate or dinitrate before surgery. Conventional tablets (e.g., Monoket): Tight, light-resistant containers at 1530C. Take the dose in the morning right after you wake up. Access free multiple choice questions on this topic. Rapid titration (over 35 days) may be possible; however, slower titration may be needed due to adverse effects. Thadani U, Whitsett T. Relationship of pharmacokinetic and pharmacodynamic properties of the organic nitrates. This is called a "nitrate low" period and is needed to make sure your medicine works properly. Multiple health care professionals such as cardiologists, general practitioners, nurses, pharmacists, home care workers, and dieticians can work together to overcome these challenges of isosorbide therapy. The elimination half-life of isosorbide dinitrate is 1 hour, while the elimination half-life of isosorbide mononitrate is 5 to 6 hours. . Thadani U, Rodgers T. Side effects of using nitrates to treat angina. Talk to your doctor or pharmacist if these side effects bother you or last more than a few days: Serious side effects after taking isosorbide mononitrate and dinitrate are rare. Isosorbide dinitrate and isosorbide mononitrate are mainly excreted in the urine. Tight, light-resistant containers at room temperature (25C); do not expose to extremes in temperature. ISDN works directly on the vascular smooth muscle in an identical manner to the natural endothelium derived relaxing factor, nitric oxide. No specific dosage recommendations for renal impairment. Importance of clinicians unfamiliar with their patients drug history, especially those involved in emergency care (e.g., for presumed myocardial infarction or ischemia), to take a careful history so that concomitant use with selective PDE inhibitors can be avoided. [13] Hence the sublingual route, which avoids the first-pass effect, is preferred to achieve the therapeutic levels rapidly. After introducing isosorbide, its popularity temporarily decreased as Needleman and his colleagues questioned its efficacy as it underwent extensive biotransformation in the liver. Elantan long (EL) is the only long-acting isosorbide mononitrate formulation based on a controlled membrane principle. Fung HL. This book is distributed under the terms of the Creative Commons Attribution-NonCommercial-NoDerivatives 4.0 International (CC BY-NC-ND 4.0) Manufacturers state that selective phosphodiesterase (PDE) inhibitors (e.g., sildenafil, tadalafil, vardenafil) are contraindicated in patients receiving nitrates. The most common side effects are headaches and feeling dizzy, weak or tired. Target: 40 mg 3 times/day. Product and Consumer Medicine Information. 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. Transient flushing may occur with the nitrates, and inhalation of amyl nitrite commonly causes cutaneous flushing of the head, neck, and clavicular area. After therapeutic doses, cardiac output may increase transiently and then decrease. Figure 01: The Chemical Structure of Isosorbide Mononitrate. Benefits in acute MI and heart failure not established. The patent was approved, leading to the production of BiDil, a single-pill equivalent to the generic H-ISDN. Isosorbide mononitrate and dinitrate are not used to treat sudden angina attacks. 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. Do not exceed daily Dilatrate-SR dosages of 160 mg (4 capsules). Learn how we can help. Peripheral venous resistance is decreased via a selective action on venous capacitance vessels and results in venous pooling of blood and decreased venous return to the heart. Chemical name: d-Glucitol-1,4:3,6-dianhydrodinitrate StatPearls Publishing, Treasure Island (FL). Their those has to be increased sufficiently to be given in oral form in maintenance therapy as these are rapidly degraded by liver with very low . 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.. Isosorbide mononitrate and isosorbide dinitrate are important medications for some heart diseases. The isosorbide mononitrate extended-release tablet is an oral extended-release formulation of ISMN, the major active metabolite of isosorbide dinitrate; most of the clinical activity of the dinitrate is attributable to the mononitrate. Serious adverse reactions to the organic nitrates and nitrites are uncommon and their adverse effects mainly involve the CNS and cardiovascular system. The elimination half-life of isosorbide dinitrate is about 1 hour, and the excretion occurs through the kidney. 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. Intermediate: Release is Isosorbide Dinitrate while mono nitrate is extended.Immediate release is nitro stat. Pharmacokinetics and pharmacodynamics of isosorbide dinitrate. Several contraindications exist for the use of isosorbide. It is as safe as other forms of exercise with similar levels of effort. Isosorbide dinitrate or mononitrate can be used alone or in combination as either second-line or third-line therapy in patients previously treated with a -blocker. <> After several days, dosage may be increased to 120 mg (given as single 120-mg tablet or two 60-mg tablets) once daily. Vasodilatory effect on arteriolar resistance is not as great as the action on the venous side; as a result of this combined action, both venous filling pressure (preload) and, to a lesser extent, arterial impedance (afterload) are reduced. Isosorbide mononitrate and dinitrate will not stop your contraception working, including emergency contraception. Parker JD, Parker JO. Inal ME, Egz AM. The major drawback of their therapeutic use is the rapid development of tolerance. Laufen H, Aumann M, Leitold M. Oral absorption and disposition of isosorbide dinitrate and isosorbide mononitrates in man. Treatment of congestive heart failure. Nitrates in the management of acute coronary syndrome. The effects of isosorbide dinitrate on methemoglobin reductase enzyme activity and antioxidant states. Talk to your pharmacist if you need a painkiller stronger than paracetamol. Visit Yellow Card for further information, non-steroidal anti-inflammatory medicines (NSAIDs), no more than 14 units of alcohol each week, HealthUnlocked: isosorbide dinitrate forum, HealthUnlocked: isosorbide mononitrate forum, About isosorbide mononitrate and isosorbide dinitrate, Who can and cannot take isosorbide mononitrate and isosorbide dinitrate, How and when to take isosorbide mononitrate and isosorbide dinitrate, How to cope with side effects of isosorbide mononitrate and isosorbide dinitrate, Common questions about isosorbide mononitrate and isosorbide dinitrate. 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. Your doctor may tell you to leave a gap of 4 to 12 hours a day (usually when you are sleeping) where you do not take the tablets or capsules. The easiest way to lookup drug information, identify pills, check interactions and set up your own personal medication records. 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. They are used to prevent angina symptoms (chest pain), they do not work to treat a current angina attack. 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. <>stream We can use this medication to both treat and prevent heart-related chest pain. [11]It directly increases the myocardial blood flow by dilating the large and medium-sized coronary arteries at higher doses. 1 0 obj 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. The principal pharmacological action of ISMN and all organic nitrates in general is relaxation of vascular . There can be some side effects of using this medication, which include headache, low blood pressure, blurry vision, and skin flushing. e5;O"]rQR8ku:mw/CYux:s8ofW`KMb`! The possibility of developing orthostatic hypotension in elderly patients, The possibility of developing severe hypotension when combined with Phosphodiesterase(PDE) inhibitors in male patients, The development of tolerance during chronic isosorbide therapy and drug-free intervals, The possibility of developing anginal pain during drug-free intervals. The symptoms of isosorbide overdose may arise from its vasodilating property causing profound systemic hypotension, heart block with bradycardia, syncope, nausea, vomiting, increased intracranial tension (probably along with persistent throbbing headache, fever, confusion), diaphoresis, dizziness, and palpitations. (See Selective Phosphodiesterase (PDE) Inhibitors under Cautions.). Isosorbide mononitrate and dinitrate are types of heart medicine called nitrates. [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. Isosorbide mononitrate. Prevention or treatment of angina pectoris resulting from coronary artery disease - however, it is not recommended for use once the anginal episode has started because the onset of action is not sufficiently rapid enough to abort an acute anginal event. Blood returning from the body in the veins must be pumped by . Isosorbide mononitrate: Generally, food delays the rate but not the extent of absorption (less than 10%) of conventional or extended-release tablets. It is not suitable to take to treat an angina attack - you should always carry with you a short-acting nitrate, such as glyceryl trinitrate (GTN), for if you get angina pain. They may need to change your dose. It is in the nitrate class of drugs. Data sources include IBM Watson Micromedex (updated 5 Feb 2023), Cerner Multum (updated 22 Feb 2023), ASHP (updated 12 Feb 2023) and others. mononitrate, isomannide mononitrate, isosorbide-2-mononitrate, and 5-ISMN. [2] It is taken by mouth. Trade Name. By decreasing myocardial oxygen consumption, nitrates and nitrites alter the imbalance of myocardial oxygen supply and consumption which is thought to cause angina pectoris. Isosorbide mononitrate and dinitrate belong to a group of medicines called nitrates. Subscribe to Drugs.com newsletters for the latest medication news, new drug approvals, alerts and updates. Answers. These include: Some people with angina worry that having sex will trigger an angina attack, but the risk of this happening is low. Gelfond M, Rozen P, Gilat T. Isosorbide dinitrate and nifedipine treatment of achalasia: a clinical, manometric and radionuclide evaluation. ACCF and AHA recommend initial dosage of 2030 mg 3 or 4 times daily; give concomitantly with hydralazine hydrochloride 2550 mg 3 or 4 times daily. Like all medicines, isosorbide mononitrate and dinitrate can cause side effects, although not everybody gets them. 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. In addition, each tablet contains the . '~|4+TYG_X7b0-umj-&0=5Gf37{h73?}vQ8V:/-%c:y S`(0hIk i[j_ {?Mkpr | C+{wC7Rl q3fc(@L0h{a2V,9 y:et/!i!-U*cu6<63l^}W>8V26U;s:u;x=_pTm}FI6hR{AH &VH=0Xa Q@?gB kCRt)tmlx &>AwVqF+|UGFhGEV=AVofypRu"8F=bj [18] They are as follows: PDE inhibitors such as tadalafil and sildenafil work by inhibiting the phosphodiesterase (PDE) enzyme, which is involved in breaking down the cGMP. sildenafil. Imdur (isosorbide mononitrate) Extended Release and Ranexa (ranolazine) are indicated for the prevention of angina pectoris. Imdur is a vasodilator and Ranexa is an anti-anginal medication. Berlin R. Historical aspects of nitrate therapy. Particularly small stature, maintenance: Increased to at least 10 mg twice daily by the second or third day. 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. [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. This material is provided for educational purposes only and is not intended for medical advice, diagnosis or treatment. Isosorbide dinitrate used in fixed combination with hydralazine (BiDil) as adjunct to standard therapy for the treatment of heart failure in self-identified black patients to improve survival, decrease rate of hospitalization for worsened heart failure, and improve patient-reported functional status. Although many clinicians do not gradually reduce the dosage when discontinuance of oral nitrates is planned, it appears prudent that dosage be gradually reduced (e.g., over a period of about 12 weeks) to avoid withdrawal manifestations. Tolerance to the vascular and antianginal effects of individual nitrates and cross-tolerance among the drugs may occur with repeated, prolonged use. Isosorbide. Usual initial dosage of conventional tablets (e.g., Monoket): 20 mg twice daily, with the 2 doses administered 7 hours apart. No specific dosage recommendations for hepatic impairment. To reduce your risk of problems like these, it may help to: Page last reviewed: 1 July 2021 Tight, light-resistant containers at 25C; may be exposed to 1530C. Along with non-selective beta-blockers (NSBB), it can be used as secondary prophylaxis in preventing recurrent variceal hemorrhage. Known hypersensitivity to isosorbide or any ingredient in the respective formulation. These may make your angina or heart failure worse. 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. Complete avoidance may not be possible, provided sufficient time elapses between use of the drugs. This helps your heart to work properly and reduces chest pain. Adjust dosage of isosorbide dinitrate and isosorbide mononitrate carefully according to the patient's requirements and response; use the smallest effective dosage. <>/XObject<>/ProcSet[/PDF/Text/ImageB/ImageC/ImageI] >>/MediaBox[ 0 0 595.32 841.92] /Contents 4 0 R/Group<>/Tabs/S/StructParents 0>> 2 0 obj Talk to your doctor if you're not sure it's safe for you to exercise. Available for Android and iOS devices. When the transdermal route is used, the patch should be left in place for 12 hours. If this happens, sit or lie down and put your feet up. Isosorbide dinitrate in fixed combination with hydralazine hydrochloride: About 2 hours. In heart failure, isosorbide mononitrate and dinitrate relaxes the blood vessels, making it easier for your heart to pump blood around your body. Daiber A, Mnzel T. Organic Nitrate Therapy, Nitrate Tolerance, and Nitrate-Induced Endothelial Dysfunction: Emphasis on Redox Biology and Oxidative Stress. Conventional oral tablets: 25% unchanged drug; about half that following sublingual administration (4050%). However, do not take medicines for erection problems if you are taking isosorbide mononitrate or dinitrate. Furthermore, there can be some severe effects as well, which include low blood pressure when exposed to PDE5 inhibitors, e.g. 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. Isosorbide mononitrate has one nirate group and isosorbide dinatrate has 2 nitro groups. Excipients in commercially available drug preparations may have clinically important effects in some individuals; consult specific product labeling for details. Importance of warning all patients receiving organic nitrates or nitrites about the potential interaction between the drugs and selective PDE inhibitors, even if they currently are not receiving the drugs, since there is substantial potential for patients to receive the drugs from another clinician, from a friend, with little or no clinical intervention (e.g., via the Internet), or illicitly. Although a . 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 most common side effects of isosorbide dinitrate include headache, lightheadedness when standing, and blurred vision. ISDN allows you to exercise for up to eight hours. For oral dosage form (tablets): Adults20 milligrams (mg) two times a day. If your heart needs to work harder, during exercise for example, it needs increased blood flow to get more oxygen. What isIsosorbide Dinitrate Isosorbide mononitrate helps to prevent angina chest pain from developing. Both isosorbide mononitrate and isosorbide dinitrate are broken down into nitrates in the body. Isosorbide dinitrate, sublingual - 2.5 to 10 mg (duration of action - 10 to 60 minutes), Isosorbide dinitrate, oral - 10 to 40 mg 3 times a day (duration of action - 4 to 6 hours), Isosorbide dinitrate, spray - 1.25 mg per dose, Isosorbide dinitrate, oral sustained-release capsules/tablets - 40 mg,14 hours apart (duration of action:12 to 14 hours), Isosorbide mononitrate, oral - 20 mg twice daily, 7 hours apart (duration of action - 6 to 10 hours), Isosorbide mononitrate, oral sustained-release tablets - 30 to 120 mg daily, A fixed-dose combination of isosorbide dinitrate (20 mg) and hydralazine hydrochloride (37.5 mg) has received approval for use in treating heart failure in African-Americans, Orthostatic hypotension (0.1 to 10 percent), Concomitant use of isosorbide with PDE inhibitors such as sildenafil and tadalafil, Concomitant use of isosorbide with riociguat, a soluble guanylate cyclase stimulator used for the treatment of pulmonary arterial hypertension and chronic thromboembolic pulmonary hypertension, Elderly patients with autonomic dysfunction due to a high risk of orthostatic hypotension, Patients on diuretics will be volume depleted and can develop severe hypotension, Patients who are taking other vasodilators due to the risk of severe hypotension, Patients who have low blood pressure and low heart rate, Patients who are on chronic diuretic therapy, Elderly patients with underlying autonomic dysfunction, Patients with right ventricular infarction who are preload sensitive, Volume-depleted patients, e.g.,from chronic diarrhea and vomiting, Patients who are taking other types of vasodilators, 12-hour drug-free interval with 40 mg dose, 18-hour drug-free interval with 80 mg dose, 24-hour drug-free interval with 120 mg dose. The approximate onset and duration of action of various dosage forms of isosorbide dinitrate (ISDN) and isosorbide mononitrate (ISMN) are as follows: Onset and duration of action following intrabuccal administration are probably similar to those after sublingual administration of isosorbide dinitrate.

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