Utility and optimal dose of nicorandil for physiological assessment of the femoropopliteal artery

BACKGROUND

Nicorandil is widely used as a vasodilator for the physiological assessment of coronary arteries because of its usefulness and safety; however, there are no data on its use in peripheral arteries.

AIMS

To identify the utility of nicorandil and its appropriate dose for the physiological assessment on the femoropopliteal artery.

METHODS

We retrospectively enrolled patients from three institutes in which physiological assessment was carried out with various doses of nicorandil before treatment. Twenty-four femoropopliteal artery stenotic lesions from 22 patients were included. The nicorandil doses used were 2, 4, and 6 mg. Twenty-two lesions were also assessed using 30 mg of papaverine. The pressure gradient (PG) and peripheral fractional flow reserve (pFFR) were calculated based on the mean and systolic pressure levels. We examined the correlation of each parameter with the peak systolic velocity ratio (PSVR) based on the duplex ultrasound images using Spearman's rank correlation coefficient. Systemic blood pressure was assessed for safety.

RESULTS

The correlations were higher for mean pressure-based parameters than for systolic pressure-based parameters. As the nicorandil dose increased, the correlations among PG, pFFR, and PSVR also increased (mean pressure-based PG: 2 mg, r = 0.360; 4 mg, r = 0.498; 6 mg, r = 0.694, mean pressure-based pFFR: 2 mg, r = -0.479; 4 mg, r = -0.469; 6 mg, r = -0.641). The blood pressure after the administration of 6 mg of nicorandil was low, and the median systemic mean pressure was 65 mmHg.

CONCLUSION

A 4 mg dose of nicorandil is effective and safe for the mean pressure-based physiological assessment of lesions in the femoropopliteal artery.

Effects of nicorandil on QT prolongation and myocardial damage caused by citalopram in rats

Citalopram is a selective serotonin re-uptake inhibitor (SSRI) antidepressant; it exhibits the greatest cardiotoxic effect among SSRIs. Citalopram can cause drug-induced long QT syndrome (LQTS) and ventricular arrhythmias. We investigated the protective effect of nicorandil, a selective mitochondrial KATP (mito-KATP) channel opener, on LQTS and myocardial damage caused by citalopram in male rats. In a preliminary study, we determined that the minimum citalopram dose that prolonged the QT interval was 102 mg/kg injected intraperitoneally. For the main study, rats were divided randomly into five experimental groups: untreated control, normal saline + citalopram, nicorandil + citalopram, 5-hydroxydecanoate (5-HD) + citalopram, 5-HD + nicorandil + citalopram. Biochemical and histologic data from blood and heart tissue samples from six untreated control rats were evaluated. Electrocardiographic parameters including QRS duration, QT interval, corrected QT interval (QTc) and heart rate (HR) were assessed, and biochemical parameters including malondialdehyde, reduced glutathione, glutathione peroxidase, superoxide dismutase were measured. We also performed histomorphologic and immunohistochemical examination of heart tissue. Citalopram prolonged QT-QTc intervals significantly and increased significantly the histomorphologic score and proportion of apoptotic cells, but produced no differences in the oxidant and antioxidant parameters. Nicorandil did not prevent citalopram induced QT-QTc interval prolongation and produced no significant changes in oxidant and antioxidant parameters; however, it did reduce histologic damage and apoptosis caused by citalopram.

Refractory cardiac arrest caused by type I Kounis syndrome treated with adrenaline and nicorandil: A case report

RATIONALE

Kounis syndrome is a rare but life-threatening anaphylactic reaction that can lead to acute coronary syndrome and cardiac arrest, and requires prompt diagnosis. Adrenaline, which is used to treat anaphylaxis, may cause coronary vasoconstriction and worsen ischemia, whereas coronary vasodilators may dilate systemic vessels and exacerbate hypotension. Delayed diagnosis of Kounis syndrome and inadequate therapeutic intervention may thus lead to a poor outcome.

PATIENT CONCERNS

A 59-year-old man was treated for sepsis due to a liver abscess. Following administration of daptomycin, the patient developed severe anaphylactic shock leading to refractory cardiac arrest. Because conventional cardiopulmonary resuscitation was ineffective, extracorporeal cardiopulmonary resuscitation was considered as an alternative approach.

DIAGNOSES

On bedside monitoring during cardiopulmonary resuscitation, unexpected ST-segment elevation was found on lead II electrocardiogram. Accordingly, the patient was clinically diagnosed with Kounis syndrome.

INTERVENTIONS

Nicorandil (6 mg/h), a coronary vasodilator with minimal blood pressure effects, was administered along with high doses of vasopressors, including adrenaline 0.2 µg/kg/min.

OUTCOMES

After the initiation of nicorandil administration, the patient achieved return of spontaneous circulation and did not require extracorporeal cardiopulmonary resuscitation. Based on the elevated serum tryptase level, normal creatine kinase-MB range, and lack of stenosis on coronary angiography, the patient was definitively diagnosed with type I (coronary vasospasm) Kounis syndrome. He was subsequently transferred to the referring hospital without neurological sequelae.

LESSONS

If anaphylaxis leads to refractory shock and cardiac arrest, ischemic changes on the electrocardiogram should be investigated to identify underlying Kounis syndrome. In addition to adrenaline, coronary dilators are the definitive treatment. Nicorandil may be a useful treatment option because of its minimal effect on blood pressure.

Cardioprotective and Antianginal Efficacy of Nicorandil: A Comprehensive Review

ABSTRACT

Angina pectoris remains a significant burden despite advances in medical therapy and coronary revascularization. Many patients (up to 30%) with angina have normal coronary arteries, with coronary microvascular disease and/or coronary artery vasospasm being major drivers of the myocardial demand-supply mismatch. Even among patients revascularized for symptomatic epicardial coronary stenosis, recurrent angina remains highly prevalent. Medical therapy for angina currently centers around 2 disparate goals, viz secondary prevention of hard clinical outcomes and symptom control. Vasodilators, such as nitrates, have been first-line antianginal agents for decades, along with beta-blockers and calcium channel blockers. However, efficacy in symptoms control is heterogenous, depending on underlying mechanism(s) of angina in an individual patient, often necessitating multiple agents. Nicorandil (NCO) is an antianginal agent first discovered in the late 1970s with a uniquely dual mechanism of action. Like a typical nitrate, it mediates medium-large vessel vasodilation through nitric oxide. In addition, NCO has adenosine triphosphate (ATP)-dependent potassium channel agonist activity (K ATP ), mediating microvascular dilatation. Hence, it has proven effective in both coronary artery vasospasm and coronary microvascular disease, typically challenging patient populations. Moreover, emerging evidence suggests that cardiomyocyte protection against ischemia through ischemic preconditioning may be mediated through K ATP agonism. Finally, there is now fairly firm evidence in favor of NCO in terms of hard event reduction among patients with stable coronary artery disease, following myocardial infarction, and perhaps even among patients with congestive heart failure. This review aims to summarize the mechanism of action of NCO, its efficacy as an antianginal, and current evidence behind its impact on hard outcomes. Finally, we review other cardiac and emerging noncardiac indications for NCO use.

Combination of Nicorandil and Beta-Adrenergic Receptor Blockers in Patients with Coronary Artery Disease: A Real-World Observational Study

BACKGROUND

The effect of combined nicorandil and beta-adrenergic receptor blockers (BBs) compared with that of BBs alone on long-term clinical outcomes in patients with coronary artery disease (CAD) remains undetermined.

METHODS

A multicenter retrospective cohort study was performed. Adult patients who had been hospitalized for CAD and treated for angina with a combination of nicorandil and BBs or BBs alone were included. The effect of different treatments on the cumulative incidence of major adverse cardiovascular event (MACE) and their components within a follow-up duration of 2.5 years were analyzed using Kaplan-Meier survival curves. An inverse probability of treatment weighting (IPTW) method was used to adjust for the possible effect of confounding factors.

RESULTS

A total of 137,714 patients were screened, of whom 16,912 individuals (mean age: 61.5 years, men: 67.1%) were successfully enrolled. Among the enrolled participants, 4669 received the combined treatment of nicorandil and BBs, while 12,243 received BBs alone. After IPTW, the results demonstrated that the combined treatment was associated with a significantly reduced incidence of MACE (hazard ratio [HR] 0.79, 95% conidence interval [CI] 0.72-0.87) and stroke (HR 0.48, 95% CI 0.42-0.54) but not of MI (HR 1.03, 95% CI 0.92-1.15) or all-cause mortality (HR 0.93, 95% CI 0.64-1.37). Sensitivity analyses revealed similar results.

CONCLUSIONS

A combined antiangina treatment of nicorandil and BBs may be more effective than treatment of BBs alone in reducing the long-term incidence of MACE in patients with CAD.

Nicorandil and ranolazine overdose management

A man in his 60s was admitted to the emergency department with chest pain following an intentional overdose of nicorandil and ranolazine. He was known to have an extensive cardiac history and had taken his prescribed medication with suicidal ideation. On presentation, he was hypotensive with a blood pressure of 70/50 mm Hg despite fluid resuscitation. He was commenced on vasopressor support and transferred to the intensive care unit. Despite an adequate blood pressure on vasopressors, he suffered a ventricular fibrillation cardiac arrest. Return of spontaneous circulation with a Glasgow Coma Score of 15 was achieved following cardiopulmonary resuscitation and three direct current shocks. Following subsequent continuous overnight significant vasopressor dependence, a dose of glucagon was given, and within 2 hours, his vasopressor requirement ceased, maintaining an unsupported normal blood pressure. He remained stable and was subsequently discharged to the coronary care unit for monitoring.

[Ulcers in vulva and perineum induced by an anti-anginal drug]

Nicorandil is a type of nicotinamide ester used for the treatment of angina and ischaemic heart disease. A 67-year-old woman was referred to a pelvic floor unit with possible vulvar cancer. She had a painful 2 × 1.5 cm punched-out ulcer. A biopsy showed inflammation, but no evidence of malignancy, infection or dysplasia. She had angina which had been controlled with nicorandil for the past six years. After nearly two years of treatment and examinations nicorandil-induced ulceration was suspected and in liaison with cardiologist, the nicorandil treatment was discontinued. Within a few months, the pain settled, and her ulcers healed.

Clinical Implications of Nicorandil Combined with Trimetazidine in Patients with Coronary Heart Disease: A Real-World Observational Study

INTRODUCTION

Coronary heart disease (CHD) remains the leading cause of mortality in China. The treatment strategies, especially for patients with ischemic angina pectoris, are still far from satisfactory. Hence, this study was carried out to evaluate the long-term potential of nicorandil in Chinese patients with CHD.

METHODS

Adult patients with CHD were reviewed retrospectively from three hospitals in Central China to obtain relevant data. The primary outcome was the rate of major adverse cardiovascular events (MACE) which is the composite outcome of stroke, myocardial infarction (MI), and mortality at 3 years while the secondary outcomes included rates of MACE, stroke, MI, and mortality at 1 and 2 years. The rates of MACE were estimated using Kaplan-Meir survival curves and compared by log-rank test. The association between various treatment regimens and hazards of MACE was estimated using Cox proportional hazards model. All analyses were carried out using SAS 9.4.

RESULTS

A total of 5504, 1674, and 3923 patients treated with the nicorandil-trimetazidine combination, nicorandil, and trimetazidine were included in the study, respectively. At 3-year follow-up, the rate of MACE [hazard ratio (HR) 0.85; 95% CI 0.74-0.97; P = 0.017] and stroke (HR 0.58, 95% CI 0.48-0.71; P < 0.0001) was lower in the combination group compared to trimetazidine group. Similarly, the rate of stroke was significantly lower (HR 0.69; 95% CI 0.52-0.93; P = 0.0146) at 3 years in the nicorandil group compared to the trimetazidine group. The rate of stroke (HR 0.65; 95% CI 0.52-0.83; P = 0.0004) was significantly lower among the combination group compared with the trimetazidine group at 1-year follow-up. Similarly, the rate of stroke was significantly lower at 1 year (HR 0.70; 95% CI 0.50-0.97; P = 0.03) but not at 2 years (HR 0.70; 95% CI 0.52-0.94; P = 0.0177), while the rate of other outcomes, though lower in the nicorandil group than the trimetazidine group, was not statistically significant at 1 and 2 years respectively.

CONCLUSION

Nicorandil in combination with trimetazidine can be considered as an effective and potential treatment strategy in reducing the rate of MACE in patients with CHD in the Chinese population.

Nicorandil Decreases Renal Injury in Patients With Coronary Heart Disease Complicated With Type I Cardiorenal Syndrome

ABSTRACT

Cardiorenal syndrome (CRS) is a group of disorders in which heart or kidney dysfunction worsens each other. This study aimed to explore the improvement effect of nicorandil on cardiorenal injury in patients with type I CRS. Patients with coronary heart disease complicated with type I CRS were enrolled. Based on the conventional treatment, the patients were prospectively randomized into a conventional treatment group and a nicorandil group, which was treated with 24 mg/d nicorandil intravenously for 1 week. Fasting peripheral venous blood serum and urine were collected before and at the end of treatment. An automatic biochemical analyzer and enzyme linked immunosorbent assay were used to detect B-type brain natriuretic peptide (BNP), serum creatinine (Scr) and cystatin C (Cys-C), renal injury index-kidney injury molecule-1 (KIM-1), neutrophil gelatinase-associated lipocalin (NGAL), and interleukin-18 (IL-18) levels. The left ventricular ejection fraction was measured by echocardiography. All measurements were not significantly different between the nicorandil and conventional treatment groups before treatment (all P > 0.05), and BNP, Scr, Cys-C, NGAL, KIM-1, and IL-18 were decreased in the 2 groups at the end of treatment (all P < 0.05). Compared with the conventional treatment group, BNP, Scr, Cys-C, NGAL, KIM-1, and IL-18 were more significantly decreased in the nicorandil group (all P < 0.05) and left ventricular ejection fraction was more significantly increased (P < 0.05). Therefore, nicorandil could significantly improve the cardiac and renal function of patients with type I CRS. This may prove to be a new therapeutic tool for improving the prognosis and rehabilitation of type I CRS.

The effectiveness and safety of nicorandil in the treatment of patients with microvascular angina: A protocol for systematic review and meta-analysis

BACKGROUND

Microvascular angina has become a clinical and frequent cardiovascular disease in recent years, which is complicated and there is no clear treatment. Today, Western medicine still deals with microvascular angina with standardized treatment based on the stable angina. Firstly, it is to control the risk factors of atherosclerosis, and the second is to reduce the oxygen consumption of the patient's heart muscle. In the previous randomized controlled clinical trials, it has shown that nicorandil can improve the symptoms of angina for the treatment of microvascular angina, but there is a lack of high-quality randomized controlled trials on the clinical effectiveness and safety of nicorandil in the treatment of microvascular angina, and the lack of evaluation of its effectiveness and safety. Therefore, this paper aims to understand whether nicorandil can further improve the prognosis of patients with microvascular angina and the safety of the drug through the method of systematic evaluation.

METHODS

Retrieval of relevant network electronic databases by computer: SinoMed, CNKI, WanFang Data, VIP, PubMed, EMbase and The Cochrane Library, the retrieval time is from the establishment of each database to December 2017, to collect randomized controlled studies of nicorandil in the treatment of microvascular angina. At the same time, it is supplemented by manual search of the included literature references, as far as possible to increase the included literature imformation. Two researchers independently browse the topics and abstracts, and select, find, read the full text of the relevant literature, and screen the literature according to the criteria for inclusion and exclusion established in advance, then extract the data, and cross-check, and resolve the differences through multi-person discussion. Data analysis of collected information is performed by using RevMan 5.3 software.

RESULTS

The data of the included literature are statistically analyzed by meta-analysis, and the key outcome indicators are used to determine whether nicorandil can further improve the prognosis of patients with microvascular angina and the safety of the drug.

CONCLUSION

Through the method of evidence-based medicine, this study finds the existing problems and defects in the current research, which will provide high-quality evidence-based medical evidence for nicorandil's treatment of microvascular angina, and it help the clinical treatment and further research.

OSF REGISTRATION NUMBER

DOI 10.17605/OSF.IO/DSQG9.

Intracoronary administration of nicorandil-induced cardiac arrest during primary percutaneous coronary intervention: A case report

RATIONALE

Primary percutaneous coronary intervention (PPCI) is the most effective therapy for patients with an acute ST-segment elevation myocardial infarction (STEMI). However, up to half of STEMI patients suffer from coronary microvascular dysfunction, presenting as the slow flow or no-reflow phenomenon.

PATIENTS CONCERNS

A 78-year-old man was admitted to the chest pain center with sudden chest pain and tightness for about an hour.

DIAGNOSES

Electrocardiography demonstrated ST-segment elevation in leads II, III, aVF, and third-degree atrioventricular block. Coronary angiography showed acute total occlusion in the distal right coronary artery (RCA).

INTERVENTIONS

PPCI was performed on the patient. After thrombus aspiration, a stent was placed in the distal RCA. As coronary angiography showed TIMI grade 2 flow in RCA, 6 mg nicorandil was intracoronary administrated in twice. Immediately, cardiac arrest occurred and cardiopulmonary resuscitation (CPR) was performed.

OUTCOMES

The patient survived and had a good outcome during follow-up for >6 months.

LESSONS

Up to now, there has been no case report of cardiac arrest caused by nicorandil. Although intracoronary nicorandil is one of the most commonly used methods to improve coronary flow, much more attention should be paid to side effects of nicorandil.

Nicorandil-induced ulcerations: a 10-year observational study of all cases spontaneously reported to the French pharmacovigilance network

Nicorandil-induced ulcers remain often poorly recognised, with a late diagnosis and an inadequate management. We aimed to provide a clinical overview of the 148 spontaneously reported cases of nicorandil-induced ulcers to the French pharmacovigilance network between 2005 and 2014 and to complete this picture with worldwide published cases over the same period. Spontaneously reported nicorandil-induced ulcers were mainly mucosal (oral and anal) with a previous trauma in 23·0% of patients, revealed by a severe complication in 12·8% of cases. The mean cumulative dose of nicorandil was higher in serious cases. The median delay between the start of nicorandil use and the onset of the ulcer was 23·4 months, and after the ulcer was diagnosed, the median time to incriminate nicorandil was still 3·3 months, being shorter for mucosal ulcerations than for cutaneous ulcerations (5·2 versus 14·0 months, P = 0·001). The anatomic distribution in the 199 published cases differed slightly, but delays were similar. The hypothesis of mechanism becomes more precise, leaving no doubt about the necessity to discontinue the treatment. Practitioners need to be aware that nicorandil-induced ulcers can occur in many locations, possibly multiple and complicated, and should be simply managed by discontinuing treatment with no further reintroduction of nicorandil.

The clinical effect of nicorandil on perioperative myocardial protection in patients undergoing elective PCI: A Systematic Review and Meta-Analysis

Many scholars have studied the effect of nicorandil on perioperative myocardial protection in patients undergoing elective percutaneous coronary intervention (PCI), but results are inconsistent. Therefore, we performed this meta-analysis. Finally, 16 articles, including 1616 patients, were included into this meta-analysis. Meta-analysis results showed that: (1) Nicorandil can reduce the level of CK-MB after PCI, including at 6 hours, 12 hours, 18 hours and 24 hours. (2) Nicorandil can reduce the level of TnT after PCI, including at 6 hours, 12 hours, 18 hours and 24 hours. (3) Nicorandil can reduce the incidence of adverse reactions after PCI. (4) Nicorandil cannot reduce the level of MVP after PCI, including at 12 hours and 24 hours. (5) Subgroup analysis showed that nicorandil can reduce CK-MB and TnT level at 24 hours after PCI for Chinese's population (P < 0.05), but can not reduce CK-MB and TnT level at 24 hours after PCI for non Chinese's population (P > 0.05). Our meta-analysis indicate that nicorandil can reduce myocardial injury and reduce the incidence of adverse reaction caused by PCI for Chinese's population, but is not obvious for non Chinese's population. However, this conclusion still needs to be confirmed in the future.

[Comparative Assessment of Antianginal Efficacy and Safety of Nicorandil at the Background of Therapy With -Adrenoblockers in Ischemic Heart Disease Patients With Stable Angina]

AIM

to demonstrate impact of addition of nicorandil to standard treatment in patients with stable ischemic heart disease (IHD) on clinical manifestations of the disease and safety of conducted therapy.

MATERIAL AND METHODS

We included in this double-blind placebo controlled study with parallel groups 120 patients with verified IHD and stable effort angina. During the entire study all patients received metoprolol (100 mg/day). Patients of main group were given nicorandil (10 mg twice a day for 2 weeks and 20 mg twice a day thereafter); patients of control group were given placebo. Study duration was 6 weeks.

RESULTS

Addition of nicorandil was associated with significant reduction of number of anginal attacks both compared with control period and addition of placebo. Consumption of short acting nitrates significantly decreased on both nicorandil doses compared with control period. Adverse events were registered in 10 of 61 and 7 of 59 patients (16.4 and 11.9%) taking nicorandil and placebo, respectively (n.s.). Three patients withdrew from the study because of headache.

CONCLUSION

Addition of nicorandil to standard therapy in patients with chronic IHD and stable effort angina promoted significant reduction of number of angina attacks. Good tolerability of nicorandil was also demonstrated.

Nicorandil, Gastrointestinal Adverse Drug Reactions and Ulcerations: A Systematic Review

INTRODUCTION

Nicorandil is a popular anti-anginal drug in Europe and Japan. Apart from some common adverse drug reactions (ADR), its safety is satisfactory. Several reports have suggested a link between nicorandil, gastrointestinal (GI) ulceration and fistulas. The review aims to critically appraise, synthesize and present the available evidence of all known GI ADR per anatomical location.

METHODS

The study complied with the PRISMA statement. Literature and pharmacovigilance databases were used to provide rate and/or calculate parameters (median age, median dose, history of symptoms, length of therapy and healing time after withdrawal of the drug). Differences in distribution of quantitative variables were analyzed via Mann-Whitney test. Correlation between quantitative variables was assessed with a Spearman's correlation coefficient. A p value <0.05 was significant.

RESULTS

Oral ulcerations occur in 0.2% of the subjects, anal ulcerations are present between 0.07% and 0.37% of patients. Oral and distal GI involvements are the most common ADR (28-29% and 27-31% of all GI ADR, respectively). The hepatobiliary system, the pancreas and salivary glands are not affected by nicorandil exposure. The time to develop oral ulcerations is 74 weeks among people on <30 mg/day compared to only 7.5 weeks in individuals on higher regimens (p = 0.47). There is a significant correlation between dose and ulcer healing time (Spearman's 0.525, p < 0.001).

CONCLUSIONS

Ulcerative disease is a very commonly reported GI ADR. A delayed ulcerative tendency supports the hypothesis of an ulcerogenic metabolite. Nicorandil seems to act as a cause of the ulcerations, but appears to also work in synergy with other promoting factors. Whether the action of the metabolites relies on a specific mechanism or a simple chemical ulceration is still to be established.

Nicorandil associated pinna ulceration: a new entity for an otolaryngologist

Nicorandil induced ulceration is a phenomenon that is becoming increasingly recognised in clinical practice. However, most cases of Nicorandil induced ulcers appear at the muco-cutaneous interface zones. We report a case of Pinna ulceration where Nicorandil appeared to be the chief aetiological factor. Having ruled out all reasonable alternatives Nicorandil treatment was discontinued and a rapid improvement in the ulcer was observed. To the best of our knowledge this is the first recorded case of external ear ulceration related to Nicorandil use.

Nicorandil: more cases of mucocutaneous ulceration

Prolonging marketing authorisation is unacceptable.

Painful chronic ulceration linked with nicorandil: the vagina too

Nicorandil is an antiangina drug with minor efficacy, which is known to cause painful ulceration of the gastrointestinal tract (from mouth to anus), and possibly the cornea. According to one detailed case report, a large, very painful, chronic vaginal ulceration only healed after permanent discontinuation of nicorandil. Prior to that, it had led to the patient undergoing hysterectomy and vaginal wall surgery that were ineffective. In practice, we must stop exposing patients unnecessarily to nicorandil.

Nicorandil Induced Perianal Ulceration

Nicorandil is a cardioprotective drug which is used in the prophylaxis and long-term treatment ofangina pectoris. Debilitating perianal ulcer is a rare complication of Nicorandil therapy which cancause diagnostic and management dilemmas. We describe the management of a case of Nicorandilinducedperianal ulcer and review pertinent contemporary literature.Key Words: cardioprotection, ischaemia, Nicorandil, perianal ulcer

Nicorandil: serious gastrointestinal ulceration

(1) Nicorandil is a vasodilator with limited efficacy, marketed for symptomatic relief of angina pectoris. Oral ulcerations, sometimes quite large, are an adverse effect of nicorandil that has been known since the 1990s. Cases of painful anal ulceration were reported later. (2) More recently, it has emerged that nicorandil can also cause very painful chronic ulceration of the colon and small intestine. Painful parastomal ulceration has also been reported in patients with ileostomies or colectomies. (3) Gastrointestinal ulceration has been reported from the mouth to the perineum. It is sometimes associated with skin ulcers. (4) In some cases the lesions are sufficiently extensive and refractory to warrant surgery (colostomy) or immunosuppressant treatment. However, simply withdrawing nicorandil generally leads to recovery with a few weeks. (5) Nicorandil should not be considered a standard treatment for angina pectoris. It is better to choose another drug such as a betablocker. Nicorandil must be withdrawn if cutaneous or gastrointestinal ulceration occurs.

Dual pathology: cervicofacial actinomycosis and nicorandil-induced oral ulceration

INTRODUCTION

Oral ulceration has many causes and is a common presenting symptom in otolaryngology.

CASE REPORT

This article presents an unusual case of dual pathology oral ulceration in an elderly patient. Oral malignancy was initially suspected, but the history, examination and investigation showed that the oral ulceration was caused by actinomycosis infection and by nicorandil use.

DISCUSSION

Cervicofacial acinomycosis is a rare, suppurative bacterial disease in which abscesses can form in the tissues and break through the skin, creating pus-discharging lesions. Nicorandil is a potassium channel blocker used in the treatment of ischaemic heart disease. It has been recently recognised as a cause of persistent ulcerative stomatitis.

CONCLUSION

This case highlights the importance of a high index of suspicion for unusual and reversible causes of oral ulceration, and of dual pathology as a cause. Such vigilance enables early recognition and treatment of potentially reversible conditions.

Nicorandil-associated ulcerations

This leading article refers to the paper by Abdelrazeq AS, Owen C, Smith L, McAdam JG, Pearson HJ, Leveson SH. Nicorandil-associated para-stomal ulceration: case series Eur J Gastroenterol Hepatol 2006; 18:1293-1295. We apologise to all concerned for the dissociation between the two papers, which was due to an administrative error. Nicorandil is used widely in patients with coronary artery disease. Nicorandil is well tolerated with only minor side effects. Nicorandil's association with oral, anal, gastrointestinal ulceration, and more recently para-stomal ulceration has been reported. Medical awareness of nicorandil association with ulcerations should be high to help avoid unnecessary and harmful treatment as only cessation of the drug would heal the ulceration. Nicorandil is an antianginal drug used for the treatment of symptomatic coronary artery disease. It is characterized by an arterial and venous vasodilator effect with dual mechanism of action. Nicorandil is not a first-line agent in the management of angina but it is used in combination with other antianginal medications in stable and unstable angina. It is generally well tolerated with minor side effects such as headache, nausea, flushing and dizziness. The association of nicorandil with mouth and anal ulcers as well as the association with ulceration throughout the gastrointestinal tract has been reported, and recently, an association with para-stomal ulceration has also been described. Medical awareness of the association of nicorandil with ulceration in any part of the gastrointestinal tract should be highlighted among all medical professionals to help avoid delays in withdrawing the treatment and to avoid unnecessary and sometimes invasive and costly interventions.

Nicorandil related anal ulcer

BACKGROUND

Anal ulceration is uncommon. Patients are typically referred because of severe anal pain, bleeding, discharge, and ulceration. It is important to exclude anal carcinoma, and to consider more unusual causes.

METHODS

A 74-year-old lady presented with severe anal pain and ulceration. This was subsequently noted to be related to nicorandil, a potassium channel activator used in the treatment of angina. Discontinuation of nicorandil and faecal diversion allowed symptom relief and ulcer healing.

CONCLUSION

Knowledge of the association between nicorandil and anal ulceration is essential in order to appropriately diagnose and manage this condition.

[Nicorandil-associated anal ulceration]

BACKGROUND

Nicorandil is a potassium-channel activator used in the treatment of angina pectoris. The first cases of anal ulcerations induced by nicorandil were published in 2002.

CASE REPORT

A 71-year-old man presented with a 2-year history of anal ulcerations occurring within a few months of initiation of treatment with Nicorandil. Histological tests on a biopsy sample showed granulation tissue with non-specific chronic inflammation. Nicorandil was stopped and this resulted in complete healing of the ulcers after three months.

DISCUSSION

Nicorandil can induce chronic and extensive anal ulcerations. The pathogenesis is unknown. Patients are usually treated with high doses of nicorandil. Dermatologists should be aware of this rare side-effect which heals after withdrawal of the drug.

Nicorandil-associated para-stomal ulceration: Case series

Nicorandil is a vasodilator used to control severe angina. It has been associated with oral and anal ulceration that resolves upon withdrawal of the drug. We report a series of four patients, all of whom were receiving nicorandil therapy and developed nonspecific para-stomal ulcerations of similar clinical and histological appearance. All ulcers healed on withdrawal of nicorandil with no relapse. To the best of our knowledge, nicorandil-associated para-stomal ulcers have not been reported before. It is imperative to be aware of this association to prevent the persistence of these extremely painful ulcerations, and to avoid unnecessary and inappropriate interventions with substantial morbidity in a group of high-risk patients.

Anal ulceration associated with Nicorandil: case series and review of the literature

BACKGROUND

Use of Nicorandil in the treatment of ischaemic heart disease has been associated with oral, ileal and more recently anal ulceration. We report a series of six cases of peri-anal ulceration in patients on nicorandil therapy, their response to withdrawal of the drug and review the literature.

METHODOLOGY

Systematic case note review of all patients with anal ulceration presenting to a single colorectal unit. Including detailed medical and drug history, morphological and histological appearances of the peri-anal ulcer after biopsy. Nicorandil therapy stopped in conjunction with physician and the progress of the ulcer monitored. Photographs taken before and after cessation of Nicorandil after informed consent. A literature search on Nicorandil combined with the key words: anal, peri-anal, ulceration and adverse drug effects was performed using the Cochrane Library Medline (January 1966 to June 2005) and Embase (January 1974 to June, 2005).

RESULTS

Six patients were identified from our hospital records. Histological examination of all ulcers revealed nonspecific chronic inflammation. Five patients demonstrated healing of ulceration within six weeks of withdrawal of Nicorandil, the remaining patient had circumferential involvement of the anal canal and has not improved at 3-month review. One patient was recommenced on Nicorandil after healing due to refractory angina and ulceration recurred.

CONCLUSIONS

We believe ulceration due to Nicorandil remains widely under diagnosed and the mechanism of ulceration is unclear. Despite diversion colostomy one of our patients continued with peri-anal ulceration, which may suggest a systemic mechanism rather than local irritation. Biopsy of these lesions is essential to exclude neoplastic process and inflammatory bowel disease.

Intrathecal Nicorandil and Small-Dose Morphine Can Induce Spastic Paraparesis After a Noninjurious Interval of Spinal Cord Ischemia in the Rat

We investigated the interaction between nicorandil, a K(+)ATP channel opener, and morphine on motor function after a noninjurious interval of spinal cord ischemia in the rat. Spinal ischemia was induced by aortic occlusion for 6 min with a balloon catheter in Sprague-Dawley rats. All animals received intrathecal (IT) injection of morphine (1-60 microg) 1 h after ischemia. In addition to IT injection of morphine, group M (control), group MN (combination of morphine and nicorandil), and group MNG (combination of morphine, nicorandil, and glibenclamide) received IT saline, nicorandil (10 microg), and both glibenclamide (10 microg) and nicorandil (10 microg) after 150 min of reperfusion, respectively. A quantal bioassay for the effect of IT morphine on neurological function after ischemia was performed to calculate 50% effective dose values (ED50) for inducing paraparesis at 3 h of reperfusion. The ED50 in group M and group MN was 15.1 +/- 4.9 microg and 2.9 +/- 1.0 microg of IT morphine, respectively (P < 0.05). In Group MNG, the dose-response curve shifted back to the right and the ED50 for inducing paraparesis was 11.6 +/- 4.7 microg of IT morphine. The present study demonstrates that IT small-dose morphine combined with nicorandil induces spastic paraparesis after noninjurious interval of spinal cord ischemia in the rat.

Nicorandil: anal ulcerations an additional concern

(1) Nicorandil, a vasodilator marketed for symptomatic relief of angina pectoris, is known to cause mouth ulcers, which can sometimes be very large. (2) Cases of anal ulceration have also been reported, associated with pain and, sometimes, a bloody discharge. These anal ulcerations heal very slowly (several weeks) after nicorandil withdrawal.