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Mokool L, Rooney H, Ramsay A, James A, Nalagatla SK. Nicorandil-induced penile ulceration - surgical excision: case series and review of literature. Scott Med J 2018; 63:140-143. [PMID: 30165793 DOI: 10.1177/0036933018785513] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
Nicorandil, a nicotinamide ester, is used in the prevention of angina pectoris. There is now a well-established association of perianal ulceration and the use of the drug. However, in the recent years, there have been reports of penile skin, vulval and even vaginal ulcers caused by nicorandil. We report three cases of nicorandil-induced penile ulcers which were surgically managed, and present a review of current literature.
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Affiliation(s)
- L Mokool
- SAS in Urology, Department of Urology, Monklands General District Hospital, UK
| | - H Rooney
- CT3 in Urology, Department of Urology, Monklands General District Hospital, UK
| | - A Ramsay
- Consultant Urologist, Department of Urology, Monklands General District Hospital, UK
| | - A James
- Consultant Urologist, Department of Urology, Stobhill Hospital, UK
| | - S K Nalagatla
- Consultant Urologist, Department of Urology, Monklands General District Hospital, UK
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Babic V, Petitpain N, Guy C, Trechot P, Bursztejn AC, Faillie JL, Vial T, Schmutz JL, Gillet P. Nicorandil-induced ulcerations: a 10-year observational study of all cases spontaneously reported to the French pharmacovigilance network. Int Wound J 2018; 15:508-518. [PMID: 29767853 PMCID: PMC7949779 DOI: 10.1111/iwj.12845] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/02/2017] [Accepted: 10/01/2017] [Indexed: 11/26/2022] Open
Abstract
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.
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Affiliation(s)
- Valérie Babic
- Department of DermatologyUniversity HospitalVandoeuvre‐les‐NancyFrance
| | - Nadine Petitpain
- Regional Center of PharmacovigilanceUniversity HospitalNancyFrance
| | - Claire Guy
- Regional Center of PharmacovigilanceUniversity HospitalSaint‐EtienneFrance
| | - Philippe Trechot
- Regional Center of PharmacovigilanceUniversity HospitalNancyFrance
| | | | - Jean Luc Faillie
- Regional Center of Pharmacovigilance, Department of Medical Pharmacology and Toxicology, CHU MontpellierUniversity of MontpellierMontpellierFrance
| | - Thierry Vial
- Regional Center of PharmacovigilanceUniversity HospitalLyonFrance
| | - Jean Luc Schmutz
- Department of DermatologyUniversity HospitalVandoeuvre‐les‐NancyFrance
| | - Pierre Gillet
- Regional Center of PharmacovigilanceUniversity HospitalNancyFrance
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Pisano U, Deosaran J, Leslie SJ, Rushworth GF, Stewart D, Ford I, Watson AJM. Nicorandil, Gastrointestinal Adverse Drug Reactions and Ulcerations: A Systematic Review. Adv Ther 2016; 33:320-44. [PMID: 26861848 DOI: 10.1007/s12325-016-0294-9] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/07/2015] [Indexed: 11/25/2022]
Abstract
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.
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Affiliation(s)
- Umberto Pisano
- Department of General Surgery, Raigmore Hospital, Inverness, UK.
| | | | | | | | - Derek Stewart
- School of Pharmacy and Life Sciences, Robert Gordon University, Aberdeen, UK
| | - Ian Ford
- Robertson Centre for Biostatistics, University of Glasgow, Glasgow, UK
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Use of nicorandil is Associated with Increased Risk for Gastrointestinal Ulceration and Perforation- A Nationally Representative Population-based study. Sci Rep 2015; 5:11495. [PMID: 26118431 PMCID: PMC4483775 DOI: 10.1038/srep11495] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/06/2015] [Accepted: 05/07/2015] [Indexed: 02/08/2023] Open
Abstract
Nicorandil is a vasodilatory drug used to relieve angina symptoms. Several healthcare products regulatory agencies have issued a warning associating the use of nicorandil and gastrointestinal (GI) ulceration. We aimed to evaluate the association between use of nicorandil and GI ulceration/perforation. A population-based cohort study involving 1 million randomly sampled participants in Taiwan’s National Health Insurance Research Database was carried out. We estimated the association between use of nicorandil and GI ulceration/perforation by a Cox proportional hazards regression model. A nicorandil-specific propensity score (PS) was also created for adjustment of 75 covariates and matching. 25.8% (183/710) of nicorandil-treated patients developed new GI ulcer events and 1.6% (20/1254) developed new GI perforation events in the three-year follow-up period, as compared to 9.3% (61,281/659,081) and 0.3% (2,488/770,537) in the general population comparator cohort. Patients treated with nicorandil were at significantly increased risk of GI ulcer (PS adjusted hazard ratio 1.43, 95% CI, 1.23 to 1.65, 6848 excess cases per 100,000 person years) or GI perforation (aHR 1.60, 95% CI 1.02–2.51, 315 excess cases per 100,000 person years) compared with the nicorandil unexposed population. Our finding may warn the clinicians to weigh the overall risk-benefit balance of nicorandil treatment in patients.
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Lee MTG, Lin HY, Lee SH, Lee SH, Chang SS, Chen SC, Lee CC. Risk of skin ulcerations associated with oral nicorandil therapy: a population-based study. Br J Dermatol 2015; 173:498-509. [PMID: 25939634 DOI: 10.1111/bjd.13884] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 03/25/2015] [Indexed: 11/27/2022]
Abstract
BACKGROUND Although healthcare products regulatory agencies have issued warnings on risk of ulceration associated with the use of nicorandil, a population-based study has not been carried out. OBJECTIVES To determine the relationship between use of nicorandil and skin ulceration. METHODS We carried out a population-based study using a cohort of 1 million people assembled from Taiwan's national health insurance database. The association between nicorandil use and skin ulcers was estimated by a Cox proportional hazards regression model adjusting for a nicorandil-specific propensity score (PS) comprising of 86 potential predictors (c-statistic = 0·91). RESULTS The prospective cohort was longitudinally followed from January 2005 to December 2009, during which 1268 new users of nicorandil and 771 136 nonusers were identified. A higher frequency of skin ulcers (29 of 1268; 2·3%) was observed for users of nicorandil compared with nonusers (3231 of 771 136; 0·4%). Compared with nonusers, the crude hazard ratio (HR) associating nicorandil use with skin ulcers was 5·52 [95% confidence interval (CI) 3·82-7·95] and the PS-adjusted HR was 1·85 (95% CI 1·27-2·69). A risk period analysis showed that the risk of skin ulceration among users of nicorandil was greatest in the first year. Subgroup analysis found that the interaction term reached statistical significance (P < 0·05) for age and diabetes. CONCLUSIONS Use of nicorandil was found to be associated with an increased risk for skin ulceration, especially in the first year after incident exposure. We suggest that regulatory agencies re-evaluate the risk for skin ulceration associated with use of nicorandil.
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Affiliation(s)
- M-T G Lee
- Department of Emergency Medicine, National Taiwan University Hospital, Taipei, Taiwan
| | - H-Y Lin
- Department of Dermatology, Taipei Medical University-Shuang Ho Hospital, Taipei, Taiwan.,Hsin-Yi Lin Dermatological Clinic, Taipei, Taiwan
| | - S-H Lee
- Department of Emergency Medicine, National Taiwan University Hospital, Taipei, Taiwan
| | - S-H Lee
- Department of Rehabilitation and Physical Medicine, Taipei Veteran General Hospital, Taipei, Taiwan.,College of Medicine, National Yang Ming University Hospital, Taipei, Taiwan
| | - S-S Chang
- Department of Family Medicine, Chang Gung Memorial Hospital, Taoyuan, 333, Taiwan.,College of Medicine, Graduate Institute of Clinical Medical Sciences, Chang Gung University, Taoyuan, 333, Taiwan
| | - S-C Chen
- Department of Emergency Medicine, National Taiwan University Hospital, Taipei, Taiwan
| | - C-C Lee
- Department of Emergency Medicine, National Taiwan University Hospital, Taipei, Taiwan.,Department of Emergency Medicine, National Taiwan University Hospital Yunlin Branch, Douliou, 640, Taiwan.,Department of General Medicine, National Taiwan University Hospital Yunlin Branch, Douliou, 640, Taiwan
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Trechot P, Jouzeau JY, Brouillard C, Scala-Bertola J, Petitpain N, Cuny JF, Gauchotte G, Schmutz JL, Barbaud A. Role of nicotinic acid and nicotinamide in nicorandil-induced ulcerations: from hypothesis to demonstration. Int Wound J 2013; 12:527-30. [PMID: 24028540 DOI: 10.1111/iwj.12147] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/20/2013] [Revised: 07/30/2013] [Accepted: 07/31/2013] [Indexed: 11/29/2022] Open
Abstract
Nicorandil, a nicotinamide ester, was first reported to be involved in the induction of oral ulcers in 1997. Since then, many reports of single or multiple nicorandil-induced ulcerations (NIUs) have been reported. We hypothesised that in the case of high-dosage nicorandil or after an increased dosage of nicorandil, nicotinic acid and nicotinamide (two main metabolites of nicorandil) cannot appropriately merge into the endogenous pool of nicotinamide adenine dinucleotide/phosphate, which leads to abnormal distribution of these metabolites in the body. In recent or maintained trauma, nicotinamide increases blood flow at the edge of the raw area, inducing epithelial proliferation, while nicotinic acid ulcerates this epithelial formation, ultimately flooding the entire scar. We demonstrate, by comparison to a control patient non-exposed to nicorandil, an abnormal amount of nicotinic acid (×38) and nicotinamide (×11) in the ulcerated area in a patient with NIUs. All practitioners, especially geriatricians, dermatologists and surgeons, must be aware of these serious and insidious side effects of nicorandil. It is critical to rapidly reassess the risk-benefit ratio of this drug for any patient, and not only for those with diverticular diseases.
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Affiliation(s)
- Philippe Trechot
- Department of Clinical Pharmacology, University Hospital, Nancy, France
| | | | | | | | | | | | | | | | - Annick Barbaud
- Department of Dermatology, University Hospital, Nancy, France
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Yap T, Philippou P, Perry M, Lam W, Corbishley C, Watkin N. Nicorandil-induced penile ulcerations: a case series. BJU Int 2011; 107:268-71. [DOI: 10.1111/j.1464-410x.2010.09463.x] [Citation(s) in RCA: 25] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/01/2022]
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Current awareness: Pharmacoepidemiology and drug safety. Pharmacoepidemiol Drug Saf 2009. [DOI: 10.1002/pds.1654] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/07/2022]
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