Isosorbide dinitrate - How It Works

CLINICAL PHARMACOLOGY The principal pharmacological action of isosorbide dinitrate is relaxation of vascular smooth muscle and consequent dilatation of peripheral arteries and veins, especially the latter.

Dilatation of the veins promotes peripheral pooling of blood and decreases venous return to the heart, thereby reducing left ventricular end-diastolic pressure and pulmonary capillary wedge pressure (preload).

Arteriolar relaxation reduces systemic vascular resistance, systolic arterial pressure, and mean arterial pressure (afterload).

Dilatation of the coronary arteries also occurs.

The relative importance of preload reduction, afterload reduction, and coronary dilatation remains undefined.

Dosing regimens for most chronically used drugs are designed to provide plasma concentrations that are continuously greater than a minimally effective concentration.

This strategy is inappropriate for organic nitrates.

Several well-controlled clinical trials have used exercise testing to assess the anti-anginal efficacy of continuously-delivered nitrates.

In the large majority of these trials, active agents were no more effective than placebo after 24 hours (or less) of continuous therapy.

Attempts to overcome nitrate tolerance by dose escalation, even to doses far in excess of those used acutely, have consistently failed.

Only after nitrates have been absent from the body for several hours has their anti-anginal efficacy been restored.

Pharmacokinetics Absorption of isosorbide dinitrate after oral dosing is nearly complete, but bioavailability is highly variable (10% to 90%), with extensive first-pass metabolism in the liver.

Serum levels reach their maxima about an hour after ingestion.

The average bioavailability of isosorbide dinitrate is about 25%; most studies have observed progressive increases in bioavailability during chronic therapy.

Once absorbed, the volume of distribution of isosorbide dinitrate is 2 to 4 L/kg, and this volume is cleared at the rate of 2 to 4 L/min, so isosorbide dinitrate's half-life in serum is about an hour.

Since the clearance exceeds hepatic blood flow, considerable extra hepatic metabolism must also occur.

Clearance is affected primarily by denitration to the 2-mononitrate (15 to 25%) and the 5-mononitrate (75 to 85%).

Both metabolites have biological activity, especially the 5-mononitrate.

With an overall half-life of about 5 hours, the 5-mononitrate is cleared from the serum by denitration to isosorbide, glucuronidation to the 5-mononitrate glucuronide, and denitration/hydration to sorbitol.

The 2-mononitrate has been less well studied, but it appears to participate in the same metabolic pathways, with a half-life of about 2 hours.