Imdur: Long-Acting Nitrate Therapy for Angina Prevention
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Synonyms | |||
Imdur (isosorbide mononitrate) is an extended-release nitrate medication indicated for the prevention of angina pectoris (chest pain) due to coronary artery disease. It belongs to a class of vasodilators that work primarily by relaxing venous smooth muscle, reducing preload and myocardial oxygen demand. This medication is not intended for the acute relief of angina attacks but serves as a foundational prophylactic therapy to decrease the frequency and severity of anginal episodes, improve exercise tolerance, and enhance overall quality of life in eligible patients. Its once-daily dosing regimen supports adherence and provides sustained hemodynamic effects.
Features
- Active ingredient: Isosorbide mononitrate
- Pharmacologic class: Organic nitrate vasodilator
- Formulation: Extended-release tablets (30 mg, 60 mg, 120 mg)
- Mechanism: Venodilation with reduced preload and afterload
- Dosing frequency: Once daily
- Bioavailability: Nearly 100%
- Half-life: Approximately 5 hours (mononitrate metabolite)
Benefits
- Reduces frequency of angina episodes through sustained vasodilation
- Decreases myocardial oxygen demand by lowering preload and afterload
- Improves exercise tolerance and functional capacity in chronic stable angina
- Supports adherence with convenient once-daily dosing
- May delay onset of angina during physical exertion
- Provides hemodynamic effects for up to 12 hours post-dose
Common use
Imdur is primarily prescribed for the prophylactic management of chronic stable angina pectoris in patients with documented coronary artery disease. It is typically used as monotherapy or in combination with other antianginal agents such as beta-blockers or calcium channel blockers when additional symptom control is required. The medication is not indicated for use in acute coronary syndromes, variant (Prinzmetal’s) angina, or heart failure unless specifically directed by a cardiologist. Clinical use requires careful patient selection and ongoing cardiovascular assessment.
Dosage and direction
The recommended starting dose for most patients is 30 mg or 60 mg once daily, taken in the morning upon awakening. Dosage may be titrated upward at 3-day intervals to a maximum of 240 mg daily based on therapeutic response and tolerability. Tablets should be swallowed whole with a glass of water and not crushed, chewed, or divided. Administration with food may minimize potential headache. To prevent tolerance development, a daily nitrate-free interval of 10-14 hours is recommended, typically achieved through once-daily morning dosing. Dose adjustments are necessary in hepatic impairment.
Precautions
Patients should be advised that Imdur may cause dizziness or lightheadedness, particularly upon standing abruptly. Alcohol consumption may potentiate these effects. Headache is common initially and often diminishes with continued therapy; acetaminophen may provide symptomatic relief. Abrupt discontinuation may precipitate rebound angina. Periodic blood pressure monitoring is recommended, especially during dose titration. Use with caution in patients with hypovolemia, hypotension, or hypertrophic cardiomyopathy. Tablet shell may appear in stool—this is normal and does not indicate lack of absorption.
Contraindications
Imdur is contraindicated in patients with known hypersensitivity to organic nitrates. Concurrent use with phosphodiesterase-5 inhibitors (sildenafil, tadalafil, vardenafil) is absolutely contraindicated due to risk of profound hypotension. Additional contraindications include severe anemia, increased intracranial pressure, and circulatory failure associated with marked hypotension. Should not be used in patients with cardiogenic shock or right ventricular infarction. Not recommended for use during acute myocardial infarction complicated by congestive heart failure.
Possible side effects
- Common (>10%): Headache (may be severe initially), dizziness, lightheadedness
- Less common (1-10%): Nausea, vomiting, flushing, orthostatic hypotension
- Rare (<1%): Syncope, tachycardia, paradoxical angina, dermatitis
- Cardiovascular: Hypotension, reflex tachycardia, palpitations
- Neurological: Weakness, restlessness
- Dermatological: Rash, pruritus
- Gastrointestinal: Abdominal pain, dry mouth
Drug interaction
Concomitant use with phosphodiesterase-5 inhibitors may cause severe hypotension and is contraindicated. Antihypertensive agents, beta-blockers, calcium channel blockers, and diuretics may potentiate hypotensive effects. Alcohol, vasodilators, and tricyclic antidepressants may enhance orthostatic hypotension. Concurrent use with riociguat may result in additive hypotensive effects. Aspirin may increase nitrate serum concentrations. Hepatic enzyme inducers may reduce efficacy. Ergot alkaloids may antagonize vasodilatory effects.
Missed dose
If a dose is missed, it should be taken as soon as remembered unless it is nearly time for the next scheduled dose. Do not double the dose to make up for a missed administration. If multiple doses are missed, contact healthcare provider before resuming therapy as dose adjustment may be necessary. Maintain the prescribed nitrate-free interval to prevent tolerance development.
Overdose
Nitrate overdose manifests primarily as vasodilation with severe hypotension, syncope, flushing, dizziness, headache, tachycardia, and nausea. Methemoglobinemia may occur with massive overdose. Management includes supine position with legs elevated, fluid resuscitation, and supportive care. Intravenous fluids and alpha-adrenergic agonists may be used for hypotension. Methylene blue is indicated for methemoglobinemia exceeding 30%. Hemodialysis is not effective due to extensive tissue distribution.
Storage
Store at room temperature (15-30°C/59-86°F) in original container with lid tightly closed. Protect from moisture, light, and excessive heat. Keep out of reach of children and pets. Do not transfer to other containers. Discard any medication that is discolored or shows signs of deterioration. Do not flush medications down toilet—dispose of unused medication through proper medication take-back programs.
Disclaimer
This information is provided for educational purposes only and does not constitute medical advice. Individual patient needs may vary. Always consult with a qualified healthcare professional before starting, changing, or discontinuing any medication. Not all possible uses, interactions, or adverse effects are included. Healthcare providers should reference the full prescribing information before making treatment decisions.
Reviews
Clinical studies demonstrate Imdur significantly reduces angina frequency and nitroglycerin use compared to placebo. In randomized controlled trials, approximately 70% of patients showed improved exercise tolerance. Patient satisfaction surveys indicate high adherence rates due to once-daily dosing. Some reports note initial headache as a limiting factor, though this typically diminishes with continued use. Long-term studies confirm maintained efficacy without development of tolerance when proper dosing schedule is followed. Real-world evidence supports its role as a cornerstone in chronic angina management.