Nicorandil-induced severe oral ulceration: a newly recognized drug reaction

A review and guide to drug-associated oral adverse effects-Oral mucosal and lichenoid reactions. Part 2

Dental practitioners and other health professionals commonly encounter and manage adverse medicine effects that manifest in the orofacial region. Numerous medicines are associated with a variety of oral adverse effects. However, due to lack of awareness and training, these side effects are not always associated with medicine use and are underreported to pharmacovigilance agencies by dentists and other health professionals. This article aims to inform health professionals about the various oral adverse effects that can occur and the most commonly implicated drugs to improve the management, recognition and reporting of adverse drug effects. This article follows on from Part 1; however, the focus here is on lichenoid reactions and oral mucosal disorders including oral aphthous-like ulceration, mucositis and bullous disorders such as drug-induced pemphigus, pemphigoid, Stevens-Johnson syndrome and toxic epidermal necrolysis.

Adverse Drug Reactions in the Orofacial Region

A wide spectrum of drugs can sometimes give rise to numerous adverse orofacial manifestations, particularly dry mouth, taste disturbances, oral mucosal ulceration, and/or gingival swelling. There are few relevant randomized double-blind controlled studies in this field, and therefore this paper reviews the data from case reports, small series, and non-peer-reviewed reports of adverse drug reactions affecting the orofacial region (available from a MEDLINE search to April, 2003). The more common and significant adverse orofacial consequences of drug therapy are discussed.

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.

Drug-induced skin reactions: a pathologist viewpoint

Cutaneous drug reactions are common adverse effects that occur in about 2-3% of the hospitalized patients. They have both immunologic and non-immunologic underlying mechanisms. These reactions are clinically and histologically similar to dermatoses. Their significant clinical indicators include: history of drug intake, atypical clinical features and improvement after cessation of the offending drugs. Their diagnostic histological clues include the presence of mixed histological patterns, apoptotic keratinocytes, eosinophils (dermis and epidermis), papillary dermal edema and extravasations of erythrocytes. However, no single clinical or histological feature is specific of drug eruptions. This work attempts to classify the histomorphologic reactions to various drugs in defined categories for assistance in morphologic diagnosis.

Ulceration of the nasal dorsum: a rare cause?

INTRODUCTION

Non-healing ulcers can be caused by a number of conditions, including vascular disease, diabetes, malignancy and some infections. Drug-related ulcers are rare, and a high index of clinical suspicion is required for diagnosis, in parallel with exclusion of more sinister underlying causes.

CASE REPORT

We present a patient with a complex medical background, who had a 10-week history of a non-healing ulcer on his nasal bridge. Inflammatory, autoimmune and malignant causes for the ulcer were excluded by histopathology.

CONCLUSION

Nicorandil was deemed to be the most likely cause for the patient's ulcer. Nicorandil is an anti-anginal medication known to cause oral ulceration and skin lesions in the perianal and peristomal regions and around surgical wounds. However, there are no previously reported cases of facial ulcers. The ulcer required surgical debridement and healed completely within six months, following discontinuation of nicorandil. This case highlights the importance of having a high index of clinical suspicion regarding non-healing ulcers, and of considering drugs as an aetiological factor, especially in patients with a complex medical background who are taking numerous medications.

Nicorandil-induced severe perianal ulceration

BACKGROUND

Nicorandil is a potassium channel activator used in the prevention and long-term treatment of angina pectoris. It is widely prescribed and its use is supported by data from powerful randomised controlled trials. The colorectal community is becoming increasingly aware of a subgroup of patients with anal ulceration and other gastrointestinal manifestations of nicorandil use.

METHODS

This study is a retrospective review of patients identified as having nicorandil-induced perianal ulceration. We report our experience of 11 patients.

RESULTS

All eleven patients experienced severe debilitating ulceration of the perianal area and perineum. Multiple therapies were tried unsuccessfully before the association with nicorandil was recognised. Upon recognition of the association of nicorandil with these ulcers, the therapy was stopped resulting in resolution of the perianal symptoms.

CONCLUSIONS

Nicorandil is a rare cause of severe perianal ulceration. This association should be recognised as these ulcers are resistant to other forms of treatment but heal well on ceasing nicorandil use.

Úlceras orales

Ulcers commonly occur in the oral cavity, their main symptom being pain. There are different ways to classify oral ulcers. The most widely accepted form divides them into acute ulcers--sudden onset and short lasting--and chronic ulcers--insidious onset and long lasting. Commonest acute oral ulcers include traumatic ulcer, recurrent aphthous stomatitis, viral and bacterial infections and necrotizing sialometaplasia. On the other hand, oral lichen planus, oral cancer, benign mucous membrane pemphigoid, pemphigus and drug-induced ulcers belong to the group of chronic oral ulcers. It is very important to make a proper differential diagnosis in order to establish the appropriate treatment for each pathology.

Pemphigus mimicking aphthous stomatitis

BACKGROUND

The aim of this report is to highlight the case that pemphigus vulgaris (PV) may mimic aphthous stomatitis. Pemphigus classically causes persistent oral ulceration.

METHODS AND RESULTS

We report five patients from southern Europe, who presented with recurrent oral ulceration mimicking aphthous stomatitis, but who proved by histology, immunostaining and antibodies against epithelial intercellular substance to have PV.

CONCLUSION

It is advisable to assay antibodies against desmoglein 3 in patients who appear to suffer recurrent aphthous stomatitis (RAS) with atypical ulceration for location and in adulthood.

Nicorandil induced oral ulceration

Oral ulceration has many different causes. The association between Nicorandil and oral ulceration is not a new phenomenon. There have been several previous case reports regarding a possible association although none in publications for general dental practice. In this report we have a case series of seven patients and we compared our findings with those in the current literature.

Study of the viral infections and cytokines associated with recurrent aphthous ulceration

Mouth ulcers are one of the most common oral complaints. However, the association between oral ulceration and viruses and cytokines is uncertain. We detected the presence of human papilloma virus (HPV), cytomegalovirus (CMV), Epstein-Barr virus (EBV), herpes simplex virus (HSV)-1, HSV-2 and human herpesvirus (HHV)-8 DNA in oral tissues by polymerase chain reaction (PCR) and Southern hybridization techniques, and quantified the serum levels of cytokines including interleukin (IL)-2, IL-4, granulocyte-macrophage colony-stimulating factor (GM-CSF), soluble Fas (sFas) and the Fas ligand (FasL) by enzyme-linked immunosorbent assay (ELISA) for 67 recurrent aphthous ulcer (RAU) patients and 72 normal individuals. Seven patient specimens were excluded from the study due to the negative PCR results for the beta-globin used as the internal control. Among the 32 (53.3%) virus-positive results from 60 patients' samples, 8 (13.3%) HPV, 4 (6.7%) HSV-1, 11 (18.3%) CMV, 9 (15.0%) EBV, and 16 (26.7%) HHV-8 samples proved to be positive. No HSV-2-positive samples were found. The percentage of single-virus infection (56.3%) was significantly greater than that of double-virus co-infection (31.3%) and the percentage of double-virus co-infection was significantly greater than the percentage of triple-virus co-infection (12.5%) (P < 0.05). In the 72 normal oral-tissue specimens, no viral DNA was detected. The mean serum cytokine level for patients was significantly (P < 0.05) greater than for controls for most of the separate age groups. The mean serum cytokine concentrations for the patient group demonstrated a diffuse pattern covering a wide range of serum concentrations, a very different result from the compact serum concentration pattern and lower mean serum cytokine concentrations revealed by the normal group. Overall association between viruses and recurrent aphthous ulceration is HHV-8 > CMV > EBV > HPV > HSV-1, regarding the frequency of prevalence (P < 0.05).

Nicorandil: a review of its use in the management of stable angina pectoris, including high-risk patients

Nicorandil (Adancor, Angicor, Dancor, Nikoril [Europe], Ikorel [Europe and Oceania], Sigmart [Japan, Korea and Taiwan]) is an adenosine triphosphate (ATP)-sensitive potassium (KATP) channel agonist with nitrate-like properties used in the management of stable angina pectoris. With well established monotherapeutic antianginal activity and a beneficial effect (when added to optimal antianginal therapy) on clinical outcomes in high-risk patients with stable angina, twice-daily oral nicorandil is a useful alternative or addition to other antianginal therapy.

Recurrent aphthous ulcers today: a review of the growing knowledge

Recurrent aphthous ulcers represent a very common but poorly understood mucosal disorder. They occur in men and women of all ages, races and geographic regions. It is estimated that at least 1 in 5 individuals has at least once been afflicted with aphthous ulcers. The condition is classified as minor, major, and herpetiform on the basis of ulcer size and number. Attacks may be precipitated by local trauma, stress, food intake, drugs, hormonal changes and vitamin and trace element deficiencies. Local and systemic conditions, and genetic, immunological and microbial factors all may play a role in the pathogenesis of recurrent aphthous ulceration (RAU). However, to date, no principal cause has been discovered. Since the aetiology is unknown, diagnosis is entirely based on history and clinical criteria and no laboratory procedures exist to confirm the diagnosis. Although RAU may be a marker of an underlying systemic illness such as coeliac disease, or may present as one of the features of Behcet's disease, in most cases no additional body systems are affected, and patients remain otherwise fit and well. Different aetiologies and mechanisms might be operative in the aetiopathogenesis of aphthous ulceration, but pain, recurrence, self-limitation of the condition, and destruction of the epithelium seem to be the ultimate outcomes. There is no curative therapy to prevent the recurrence of ulcers, and all available treatment modalities can only reduce the frequency or severity of the lesions.

Persistent nicorandil induced oral ulceration

Four patients with nicorandil induced ulceration are described, and the literature on the subject is reviewed. Nicorandil induced ulcers are very painful and distressing for patients. Clinically they appear as large, deep, persistent ulcers that have punched out edges. They are poorly responsive to topical steroids and usually require alteration of nicorandil treatment. The ulceration tends to occur at high doses of nicorandil and all four cases reported here were on doses of 40 mg per day or greater. In these situations reduction of nicorandil dose may be sufficient to promote ulcer healing and prevent further recurrence. However, nicorandil induced ulcers have been reported at doses as low as 10 mg daily and complete cessation of nicorandil may be required.

Review article: oral ulceration--aetiopathogenesis, clinical diagnosis and management in the gastrointestinal clinic

Oral ulceration is a common complaint of patients attending out-patient clinics. The aim of this review is to provide the gastroenterologist with a differential diagnosis of oral ulceration, and a practical guide for the management of recurrent aphthous stomatitis, including topical and systemic therapy. The association of recurrent aphthous stomatitis with Behçet's disease and other systemic disorders, including coeliac disease, is discussed. Recent evidence concerning the immunopathogenesis of Behçet's disease is reviewed, including renewed interest in the role of Streptococcus sanguis and possible infectious triggering of an inappropriate immunoinflammatory response, resulting in tissue damage. The efficacy and limitations of conventional treatment for this mutisystem disorder are outlined together with the potential role of novel biological agents, such as anti-tumour necrosis factor-alpha therapy. Oral ulceration, as a manifestation of inflammatory bowel disease and a complication of drug therapy, is described. Guidance is given concerning indications for referral of patients with oral ulceration to an oral physician/surgeon for further investigations, including biopsy if appropriate.

Oral nicorandil-induced lesions are not aphthous ulcers

OBJECTIVES

(i) To accurately define these lesions determining whether oral nicorandil-induced lesions are aphthous ulcers; (ii) To determine clinical characteristics of oral nicorandil-induced lesions.

MATERIALS AND METHODS

Two slide conferences were held. A total of 60 dermatologists assigned diagnosis and clinical criteria to 11 photographs of oral nicorandil-induced lesions. Two slides were randomly selected and duplicated to be used as control. The panel of slides included independent lesions and photographs of different lesions of the same patient. Statistical analysis used chi2-test, estimation of the percentage interobserver agreement, and kappa-values.

RESULTS

The diagnosis of non-aphthous ulcer (71.8%) was significantly held in comparison with the diagnosis of oral aphthous ulcer (28.2%; P<0.001). To differentiate aphthous ulcer from non-aphthous ulcer, physicians significantly used three clinical criteria. The diagnosis of non-aphthous ulcer were significantly associated with the absence of yellow-based ulceration (P<0.001), with the linear shape (P=0.006) and the absence of inflammatory halo (P=0.003).

CONCLUSION

Oral nicorandil-induced lesions are not aphthous ulcers. We propose that at this stage of our knowledge, oral nicorandil-induced ulcer is the most suitable terminology.

The diagnosis and management of recurrent aphthous stomatitis: a consensus approach

BACKGROUND

Recurrent aphthous stomatitis, or RAS, is a common oral disorder of uncertain etiopathogenesis for which symptomatic therapy only is available. This article reviews the current data on the etiopathogenesis, diagnosis and management of RAS in a primary care setting.

METHODS

The authors reviewed publications on Medline from 1995 through 2000, the period since the last major reviews were published.

RESULTS

RAS may have an immunogenetic background owing to cross-reactivity with Streptococcus sanguis or heat shock protein. Predisposing factors seen in a minority include haematinic (iron, folate or vitamin B12) deficiency, stress, food allergies and HIV infection. While topical corticosteroids remain the mainstay for therapy, a number of other immunomodulatory modalities now are available.

CONCLUSIONS

There is still no conclusive evidence relevant to the etiopathogenesis of RAS, and therefore therapy can attempt only to suppress symptoms rather than to address the basic issues of susceptibility and prevention.

CLINICAL IMPLICATIONS

In the majority of patients, symptomatic relief of RAS can be achieved with topical corticosteroids alone, with other immunomodulatory topical agents or by combination therapy.

Periodontal management of patients with cardiovascular diseases

Periodontists are often called upon to provide periodontal therapy for patients with a variety of cardiovascular diseases. Safe and effective periodontal treatment requires a general understanding of the underlying cardiovascular diseases, their medical management, and necessary modifications to dental/periodontal therapy that may be required. In this informational paper more common cardiovascular disorders will be discussed and dental management considerations briefly described. This paper is intended for the use of periodontists and members of the dental profession.

Safety of oral nicorandil before coronary artery bypass graft surgery

Nicorandil is a K(ATP) channel opener used to treat angina. It is cardioprotective and a vasodilator. We conducted a prospective, randomized, double-blind, placebo-controlled study to assess oral nicorandil in patients undergoing coronary artery bypass grafting (CABG) with cardiopulmonary bypass (CPB). Twenty-two patients received nicorandil (10 mg twice a day) and 23 patients received placebo. Haemodynamic data were recorded before induction of anaesthesia (T0), 5 and 20 min after starting mechanical ventilation (T1, T2), before aortic cannulation (T3), after 30 min of CPB (T4), 10 min after CPB (T5) and after 3, 8 and 18 h in the intensive care unit (T6, T7, T8). Serum proteins (creatine kinase metabolite and cardiac troponin I) were measured before and 8 and 18 h after surgery. Haemodynamic values did not differ between the two groups. There was no tachycardia during the study, no significant difference in hypotensive episodes, ST segment changes and no changes in cardiac enzymes. Myocardial infarction after surgery was similar in the two groups. Vasoactive therapy was similar in the two groups. Nicorandil can be continued safely up to premedication without deleterious haemodynamic consequences, but a myocardial protective effect of nicorandil in CABG surgery was not found.

Resolution of oral ulcerations after decreasing the dosage of tacrolimus in a liver transplantation recipient

Oral ulcers have may possible causes, including immunosuppression and drug therapy. Severe cases of oral ulceration merit special consideration because the ulcers may become large enough to alter the quality of life of the patient. The present case involves a male patient who in 1994 received an orthotopic liver transplantation because of alcoholic cirrhosis. The initial immunosuppressive regimen was induced with tacrolimus (4 mg/d) and prednisone (20 mg/d). Ten months after orthotopic liver transplantation, the patient complained of multiple recurrent oral ulcers, dysphagia, and severe oral pain, which did not respond to any of the treatments over a 3-year period. Approximately 3(1/4) years after these unresponsive ulcers appeared, the reduction of the oral dosage of tacrolimus resulted in the total remission of the ulcers. A retrospective analysis demonstrated that appearance of the ulcers coincided with a dose of 9 mg/d of tacrolimus (whole blood levels of 12 ng/mL); the ulcers did not disappear until the dose was reduced to 4 mg/d (whole blood level of 6.6 ng/mL).

Nicorandil can induce severe oral ulceration

OBJECTIVE

To increase physicians' and dentists' awareness that nicorandil is a potential inducer of severe mouth ulceration.

STUDY DESIGN

Nine new cases of ulceration from 3 European countries were included in this study.

RESULTS

Oral ulceration developed within 9 months of beginning nicorandil therapy, and ulcers resolved within 1 month of withdrawal of the drug. No lesions developed on other epithelia.

CONCLUSIONS

A number of drugs used in the care of patients with cardiovascular disease can cause oral adverse effects. Nicorandil, a new potassium-channel activator used in some countries to treat angina pectoris, precipitates persistent ulcerative stomatitis in some patients.

Role of drug exposure in aphthous ulcers: a case-control study

BACKGROUND

Drug-induced aphthous ulcers have been the subject of several isolated and heterogeneous case reports for the last three decades.

OBJECTIVES

To perform a case-control study to evaluate the risks linked to drug exposure in aphthous ulcers.

METHODS

Eighty patients with typical clinical patterns of aphthous ulcers and 152 control patients who had had consultations for skin tumours were studied. A standardized questionnaire, concerning clinical features, life-style and medications taken during the last month, was completed for each patient.

RESULTS

Case patients had a much higher intake of medications than control patients, respectively, 5.1 and 2. 8 medications per patient (P < 0.0001). Multivariate paired analysis showed an association between aphthous ulcers and two classes of drugs: non-steroidal anti-inflammatory drugs (P < 0.001) and beta-blockers (P = 0.002). Smoking could have a protective effect against aphthous ulcers (P < 0.001).

CONCLUSIONS

Previous case reports and the results of this study suggest a real link between beta-blockers and aphthous ulcers. Our study did not confirm a role of other drugs but a few interesting case reports with positive reintroduction have to be considered. These results could be beneficial for patients, as healing may occur when the incriminated drug is discontinued.

Advances in oral medicine

This paper reviews some of the more important areas of oral medicine where significant advances have been made in the past decade. There have been developments in the definition of new entities causing orofacial pain, and new therapies. Oral cancer has been recognised as increasing in incidence and the genetic basis is becoming clearer, along with improvements in early diagnostic techniques and treatment. The basis of aphthae is being unravelled and new therapies are appearing. There is greater understanding of the aetiopathogenesis and treatment of various dermatoses that present in the mouth. Treatment and prevention of leukoplakias is improving and the importance of candidosis has become evident.