Nitroglycerin Spray and Alteplase, Recombinant: Interaction Details
AI-assisted, pharmacist-reviewed · Source data updated Aug 8, 2026 · Sources: FDA labeling, DDInter 2.0, cited literature
Nitroglycerin Spray
Alteplase, Recombinant
How we grade severity & evidence
Severity levels
- Contraindicated: These should generally not be used together.
- Major: Potentially serious — often needs a change or close monitoring.
- Moderate: Can be significant — usually manageable with monitoring.
- Minor: Usually limited clinical impact.
Evidence grades
- Established: Well documented — supported by controlled studies or strong clinical data.
- Probable: Good supporting evidence, though not definitively proven.
- Suspected: Some evidence suggests this interaction, but it is not well established.
- Possible: Limited or conflicting evidence; the interaction may occur.
- Theoretical: Predicted from the drugs' pharmacology; not yet confirmed in people.
Ratings come from the documented interaction literature and are reviewed by a pharmacist. They describe the documented risk of the combination, not what will necessarily happen to you — your dose, timing, and health picture all matter.
What happens
Less coronary artery reperfusion, longer time to reperfusion, and more coronary artery reocclusion
Interaction Deep Dive
By increasing hepatic blood flow, nitroglycerin infusions may increase the clearance of alteplase, resulting in decreased alteplase plasma concentrations1. Reduced alteplase plasma concentrations may be associated with reocclusion of the coronary arteries.
Why it happens (mechanism)
Enhanced hepatic blood flow resulting in increased catabolism of alteplase
Literature reports
1 report — tap to read
a) Sixty patients with acute myocardial infarction (AMI) were randomized to two groups. Group A (33 patients) received alteplase 100 mg IV infusion over 3 hours; group B (27 patients) received the same alteplase dose plus nitroglycerin 100 mcg/min for eight hours. ECG evidence of reperfusion was 76% compared with 56% and reperfusion time was 19.6 minutes compared with 37.8 minutes for group A and group B, respectively. ECG evidence of reocclusion was 24% in group A and 53% in group B 1. However, the results of this study were questioned on the basis of statistical methods 2. An earlier study by some of the same researchers produced similar results in AMI patients who received nitroglycerin plus alteplase 3. In addition, two animal studies showed results similar to those obtained in humans 45.
Common questions
Can I take Nitroglycerin Spray and Alteplase, Recombinant together?
Less coronary artery reperfusion, longer time to reperfusion, and more coronary artery reocclusion Always confirm with your pharmacist or prescriber before making any change.
How serious is the Nitroglycerin Spray and Alteplase, Recombinant interaction?
It is rated major. Potentially serious — often needs a change or close monitoring.
How quickly could this interaction happen?
The documented onset is "rapid". Effects can appear quickly, often within about 24 hours of combining the drugs.
How strong is the evidence for this interaction?
The evidence is graded "probable". Good supporting evidence, though not definitively proven.
Questions for your pharmacist
- Does my dose of Nitroglycerin Spray or Alteplase, Recombinant need adjusting while I take them together?
- What symptoms should prompt me to call you or my prescriber right away?
- Does the timing of my doses matter for this combination?
- Is there a safer alternative to one of these medications for me?
References (5)
- Romeo F, Rosano G, Martuscelli E, et al: Concurrent nitroglycerin administration reduces the efficacy of recombinant tissue-type plasminogen activator in patients with acute anterior wall myocardial infarction. Am Heart J 1995; 130:692-697. DOI
- Massel D: Concomitant nitroglycerine and rTPA (letter). Am Heart J 1997; 133:713-714.
- Nicolini FA, Ferrini D, Ottani F, et al: Concurrent nitroglycerin therapy impairs tissue-type plasminogen activator-induced thrombolysis in patients with acute mycocardial infarction. Am J Cardiol 1994; 74:662-666.
- Nicolini F, Nichols W, Saldeen T, et al: Pathological basis of failure of concurrent glyceryl trinitrate therapy to improve efficacy of tissue type plasminogen activator in coronary thromosis. Cardiovasc Res 1991; 25:284-289.
- Mehta J, Nicolini F, Nichols W, et al: Concurrent nitroglycerin administration decreases thrombolytic potential of tissue-type plasminogen activator.RL JL. J Am Coll Cardiol 1991; 17:805-811. PubMed
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