Isosorbide Mononitrate Dosing Guidelines for Heart Failure Management

Dosing Recommendations

The American College of Cardiology recommends a fixed-dose combination of isosorbide dinitrate and hydralazine, starting with 20 mg isosorbide dinitrate/37.5 mg hydralazine three times daily, with a target dose of 40 mg isosorbide dinitrate/75 mg hydralazine three times daily, for patients with heart failure with reduced ejection fraction (HFrEF) 1, 2
For separate prescriptions, the American College of Cardiology suggests starting with 20-30 mg isosorbide dinitrate 3-4 times daily, with a target dose of up to 120 mg total daily in divided doses, for patients with HFrEF 1, 2, 3

The mean dose achieved in clinical trials for heart failure treatment was approximately 90 mg isosorbide dinitrate daily when used in fixed-dose combination with hydralazine, according to the American College of Cardiology 1, 2
The combination of hydralazine and isosorbide dinitrate has shown a 43% relative risk reduction in mortality in patients with HFrEF, with a number needed to treat (NNT) of 25 to prevent one death over 10 months, as reported in Circulation 4, 3

The American Heart Association, as reported in Circulation, advises that phosphodiesterase inhibitors (e.g., sildenafil, tadalafil) should not be used concurrently with isosorbide mononitrate due to the risk of profound hypotension 5

The American College of Cardiology, as reported in Circulation, recommends monitoring blood pressure and heart rate, especially during dose titration, and watching for signs of hypotension, particularly in elderly patients or those on multiple antihypertensive medications 5