As a hospital pharmacist, you will get questions about how to optimize therapy for angina when the maximum tolerated dose of a beta-blocker isn't enough. Follow these steps...
Use a calcium channel blocker (CCB). SWITCH from a beta-blocker to verapamil (Isopten, initial 80 mg TID to QID; max 480 mg/day, divided) or diltiazem (Altiazem, initial 120 to 180 mg QD; max 360 mg QD and can titrate to effect over seven to 14 days), if a beta-blocker isn't tolerated. Or ADD a dihydropyridine CCB like amlodipine (Norvasc, initial 5 mg once daily [2.5 mg QD for impaired hepatic function); max 10 mg QD]) to a beta-blocker if needed to control angina or blood pressure but watch for peripheral edema.
Add a long-acting nitrate. Choose one based on ease of use and cost, they all have similar efficacy for angina. Use isosorbide MONOnitrate EXTENDED-release (Imdur) 30 mg PO once daily in the morning for most patients. This gives a 12-hour nitrate-free interval to limit tolerance. Remember that 60 mg and 120 mg tablets may be cut in half. Consider a patch (Nitroderm, etc) as a low-cost topical option, as long as the patient can remember to remove the patch after 12 hours.
Save ranolazine (Ranexa, NOT available in Egypt). Consider it for the rare patient who can't tolerate other angina medications that lower blood pressure or heart rate. And be aware of special caveats with ranolazine. It's NOT more effective than other angina medications and using it as an add-on only reduces attacks by less than one/week. Plus, it can cause QT prolongation and has many drug interactions. See our note, "Avoid QT-prolonging medications in HIGH-risk patients".
Ensure patients have a rapid-acting nitrate (Nitrolingual Spray, Nitrostat, etc). During acute attack, one to two sprays on or under the tongue OR one tablet under tongue. Remind them to call 123 (Egypt) or 911 (United States) for an acute attack if they don't get relief within 5 minutes after the FIRST dose and continue to use it every 5 minutes for 2 more doses if needed. Prior to first use, prime with five sprays. Re-prime if not used for more than six weeks (one spray) or more than three months (five sprays). Get our notes, "Management of stable coronary artery disease (Stable Angina)" and "Use ABCDs to optimize medications for stable coronary artery disease" for more details.
REFERENCES
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Rayner-Hartley E, Sedlak T. Ranolazine: A Contemporary Review. J Am Heart Assoc. 2016 Mar 15;5(3):e003196. Available at: https://www.ahajournals.org/doi/10.1161/JAHA.116.003196
Fihn SD, Gardin JM, Abrams J, Berra K, Blankenship JC, Dallas AP, Douglas PS, Foody JM, Gerber TC, Hinderliter AL, King SB 3rd, Kligfield PD, Krumholz HM, Kwong RY, Lim MJ, Linderbaum JA, Mack MJ, Munger MA, Prager RL, Sabik JF, Shaw LJ, Sikkema JD, Smith CR Jr, Smith SC Jr, Spertus JA, Williams SV; American College of Cardiology Foundation; American Heart Association Task Force on Practice Guidelines; American College of Physicians; American Association for Thoracic Surgery; Preventive Cardiovascular Nurses Association; Society for Cardiovascular Angiography and Interventions; Society of Thoracic Surgeons. 2012 ACCF/AHA/ACP/AATS/PCNA/SCAI/STS Guideline for the diagnosis and management of patients with stable ischemic heart disease: a report of the American College of Cardiology Foundation/American Heart Association Task Force on Practice Guidelines, and the American College of Physicians, American Association for Thoracic Surgery, Preventive Cardiovascular Nurses Association, Society for Cardiovascular Angiography and Interventions, and Society of Thoracic Surgeons. J Am Coll Cardiol. 2012 Dec 18;60(24):e44-e164. Available at: https://www.sciencedirect.com/science/article/pii/S0735109712027027?via%3Dihub