Angina: medications and paying cash

Overview

Angina, also called angina pectoris, is chest pain or discomfort that occurs when part of the heart muscle does not get enough oxygen-rich blood, and it is a common symptom of coronary heart disease. It can feel like pain, pressure, tightness, squeezing, heaviness or burning, usually starting behind the breastbone and growing more intense over a few minutes, and it can come with shortness of breath, extreme tiredness, light-headedness, nausea, indigestion, sweating or weakness. Women more often feel the pain in the arms, neck, back and jaw, and more often have symptoms other than chest pain, which can delay treatment. Stable angina, the most common type, follows a pattern, often brought on by exertion, and is relieved by rest or nitroglycerin. Unstable angina does not follow a pattern and is a medical emergency, because it can progress to a heart attack. Vasospastic angina (also called Prinzmetal or variant angina) is caused by a spasm of a heart artery and usually comes at rest, between midnight and early morning; microvascular angina involves the heart’s tiny arteries, and medicine may not relieve it. Chest pain that does not go away with rest or medicine is a reason to call 911.

Nitroglycerin under the tongue (Nitrostat) is the medicine for an attack, and it can also be taken 5 to 10 minutes before an activity that usually brings one on. The label says to take one tablet at the first sign of an attack, sitting down, then one more every 5 minutes until relief, with no more than three tablets in 15 minutes; MedlinePlus advises calling 911 if the pain is not better 5 minutes after the first dose, unless the prescriber has given other instructions, such as trying three doses 5 minutes apart first. The tablets dissolve under the tongue or between cheek and gum and are not chewed, crushed or swallowed. To prevent attacks, isosorbide mononitrate is taken every day: the immediate-release tablets twice a day, the first on waking and the second 7 hours later, and the extended-release tablets once a day on arising, swallowed whole with half a glass of fluid, never chewed or crushed. It works too slowly to stop an attack in progress. Excessive use of nitrates can lead to tolerance, in which they work less well, so the schedule on the prescription is followed. Both medicines can cause headaches and a sharp drop in blood pressure on standing, and their labels say not to take them with erectile dysfunction medicines such as sildenafil, tadalafil or vardenafil, or with riociguat, because the combination can lower blood pressure dangerously.

Beta blockers slow the heart and lower its workload. Metoprolol succinate extended-release (Toprol-XL) is approved for long-term treatment of angina, starting at 100 mg once a day and raised weekly; its scored tablets can be divided but not crushed or chewed. Propranolol tablets and nadolol (Corgard, starting at 40 mg once a day) are also approved for angina. Stopping any of them suddenly can make angina much worse and has led to heart attacks, so the dose is lowered gradually under the prescriber’s guidance, and beta blockers can make vasospastic angina worse. Calcium channel blockers relax the heart and blood vessels: amlodipine (Norvasc) is approved for chronic stable and vasospastic angina, diltiazem and verapamil are approved for chronic stable angina and angina from artery spasm in the forms described below, and nifedipine is approved for vasospastic and chronic stable angina in some forms. Combining a beta blocker with diltiazem or verapamil can cause a very slow heartbeat or heart block. Ranolazine extended-release (Ranexa) is approved for chronic angina, starting at 500 mg twice a day with a maximum of 1000 mg twice a day; it is swallowed whole, is not used for a sudden attack, prolongs the QT interval on the ECG, and is not taken by people with liver cirrhosis or with strong CYP3A inhibitors such as ketoconazole and clarithromycin or inducers such as rifampin and St. John’s wort. Diltiazem, verapamil and grapefruit products limit its dose to 500 mg twice a day. Treatment can also include aspirin or another antiplatelet medicine to keep clots from forming, a statin to slow coronary heart disease, procedures such as angioplasty with a stent or bypass surgery, and quitting smoking, heart-healthy eating, physical activity and rest breaks when exertion brings on pain.

Choosing between the options when you pay cash

Nitroglycerin sublingual tablets and isosorbide mononitrate extended-release tablets are both sold as generics rated equivalent to the brands, and the Imdur brand has been discontinued, so these are filled as generics. Nitroglycerin tablets keep their strength only in the original glass bottle, tightly capped after each use, so the bottle the pharmacy dispenses is part of the product. Isosorbide mononitrate comes as immediate-release tablets taken twice a day and extended-release tablets taken once a day; they are different products with different schedules, so a quote applies only to the form and strength on the prescription.

Form matters most for the calcium channel blockers. Diltiazem immediate-release tablets and Cardizem CD are approved for chronic stable angina and angina due to artery spasm, while Cardizem LA is approved to improve exercise tolerance in chronic stable angina. Immediate-release verapamil covers vasospastic, unstable and chronic stable angina, but the extended-release Calan SR label lists only high blood pressure. Nifedipine extended-release (Procardia XL) is approved for angina and high blood pressure, but Adalat CC is approved only for high blood pressure, and nifedipine capsules are approved for angina and not for high blood pressure. Metoprolol succinate extended-release (Toprol-XL) is labeled for angina, while the current Lopressor (metoprolol tartrate) brand label lists only treatment after a heart attack, so check which metoprolol is written. None of these can be swapped for another form at the counter without the prescriber, so ask for a quote on exactly the product written.

Medicines at a glance

How the medicines in this group are supplied and usually taken. Each guide has the full details.

• Nitroglycerin
  Sublingual tablets (Nitrostat and generics), Sublingual spray (Nitrolingual Pumpspray, NitroMist and generics), Transdermal patch (Nitro-Dur, Minitran and generics)
  Generic: Yes · Every 12 hours
• Isosorbide Mononitrate
  Immediate-release tablets, Extended-release tablets
  Generic: Yes · Twice a day
• Amlodipine
  Tablets (Norvasc and generic), Oral suspension (Katerzia), Oral solution (Norliqva)
  Generic: Yes · Once a day
• Diltiazem
  Tablets (Cardizem and generic), Extended-release capsules (Cardizem CD, Cartia XT, Tiazac, Dilt-XR and generics), Extended-release tablets (Cardizem LA, Matzim LA and generics)
  Generic: Yes · Three or four times a day
• Verapamil
  Immediate-release tablets, Extended-release tablets, Extended-release capsules (Verelan and generic)
  Generic: Yes · Three or four times a day
• Nifedipine
  Extended-release tablets (Procardia XL and generics), Immediate-release capsules (generic)
  Generic: Yes · Once a day
• Metoprolol
  Tablets, tartrate (Lopressor and generics), Oral solution, tartrate (Lopressor), Extended-release tablets, succinate (Toprol-XL and generics)
  Generic: Yes · Twice a day, or once a day extended-release
• Propranolol
  Tablets, Oral solution, Extended-release capsules (Inderal LA and generics, InnoPran XL, Inderal XL)
  Generic: Yes · Two to four times a day
• Nadolol
  Tablets
  Generic: Yes · Once a day
• Ranolazine
  Extended-release tablets
  Generic: Yes · Twice a day
• Atenolol
  Tablets (Tenormin and generics)
  Generic: Yes · Once or twice a day
• Felodipine
  Extended-release tablets
  Generic: Yes · Once a day

Medications

Which of these is right for a given person is a decision for the prescriber. The guides explain what each drug is, how it is supplied, and why its cash price varies between pharmacies. No page on this site shows a price; prices come from pharmacies responding to your actual prescription.

Questions worth asking

• How many nitroglycerin doses should I take during an attack before I call 911, and where should I keep the bottle?
• Which of my angina medicines is for an attack and which is for prevention, and what is my daily schedule for each?
• Is the extended-release form on my prescription approved for angina, or only for high blood pressure?
• Which of my medicines must never be stopped suddenly, and what should I do if I run out before a refill?
• Can I take an erectile dysfunction medicine, grapefruit, or any over-the-counter or herbal product with my angina medicines?

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