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Noyes JD, Mordi IR, Zeb Q, Lang CC. Nicorandil-induced colovesical fistula in a patient with diverticular disease. Clin Case Rep 2021; 9:1737-1741. [PMID: 33768926 PMCID: PMC7981709 DOI: 10.1002/ccr3.3888] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/30/2020] [Revised: 01/21/2021] [Accepted: 01/22/2021] [Indexed: 11/08/2022] Open
Abstract
Nicorandil's adverse effects can cause severe patient morbidity and can present to any specialty. Those with underlying diverticular disease are most susceptible. Medication reviews are vital for patients presenting with ulcer or fistula symptoms.
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Affiliation(s)
- James D. Noyes
- Division of Molecular & Clinical MedicineSchool of MedicineUniversity of DundeeDundeeUK
| | - Ify R. Mordi
- Division of Molecular & Clinical MedicineSchool of MedicineUniversity of DundeeDundeeUK
| | - Qaiser Zeb
- Division of Molecular & Clinical MedicineSchool of MedicineUniversity of DundeeDundeeUK
| | - Chim C. Lang
- Division of Molecular & Clinical MedicineSchool of MedicineUniversity of DundeeDundeeUK
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Noyes JD, Mordi IR, Doney AS, Palmer CNA, Pearson ER, Lang CC. Genetic Risk of Diverticular Disease Predicts Early Stoppage of Nicorandil. Clin Pharmacol Ther 2020; 108:1171-1175. [PMID: 32535905 DOI: 10.1002/cpt.1941] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/13/2020] [Accepted: 05/27/2020] [Indexed: 11/11/2022]
Abstract
Gastrointestinal fistulation has been widely reported as an adverse effect of nicorandil therapy in Europe. People who have underlying diverticular disease are most at risk of this side effect. In Western countries, diverticular disease is highly prevalent and can be clinically silent. This study aimed to identify diverticular disease genetic risk scores (GRSs) associated with early nicorandil stoppage, a surrogate marker for drug intolerance. A case-control study was carried out on 1,077 patients from the Genetics of Diabetes Audit and Research Tayside Scotland (GoDARTS) database. Cases were defined as having < 9 nicorandil prescriptions with no identifiable reason for stopping (n = 230). Controls had either ≥ 9 prescriptions, treatment continuation to death/study end or stoppage post-myocardial infarction. Two diverticular GRSs were created and used in logistic regression models. Isosorbide mononitrate was used as a control analysis. Patients with a raised diverticular GRS, based on 23 replicable loci, had increased risk of stopping nicorandil therapy early (univariate (odds ratio (OR) 2.26; P = 0.04], multivariate (OR 3.96; P = 0.01)). Similar trends were noted when using the full 42 variant diverticular score but statistical significance was not reached. The isosorbide control analysis did not reach statistical significance. Our analysis demonstrates a novel positive association between a raised diverticular GRS and early stoppage of nicorandil therapy.
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Affiliation(s)
- James D Noyes
- Division of Molecular & Clinical Medicine, School of Medicine, University of Dundee, Dundee, UK
| | - Ify R Mordi
- Division of Molecular & Clinical Medicine, School of Medicine, University of Dundee, Dundee, UK
| | - Alexander S Doney
- Population Health and Genomics, School of Medicine, University of Dundee, Dundee, UK
| | - Colin N A Palmer
- Population Health and Genomics, School of Medicine, University of Dundee, Dundee, UK
| | - Ewan R Pearson
- Population Health and Genomics, School of Medicine, University of Dundee, Dundee, UK
| | - Chim C Lang
- Division of Molecular & Clinical Medicine, School of Medicine, University of Dundee, Dundee, UK
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Roy Chowdhury U, Dosa PI, Fautsch MP. ATP sensitive potassium channel openers: A new class of ocular hypotensive agents. Exp Eye Res 2019; 178:225. [PMID: 27353766 PMCID: PMC10518901 DOI: 10.1016/j.exer.2016.06.013] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/15/2016] [Accepted: 06/16/2016] [Indexed: 11/16/2022]
Affiliation(s)
- Uttio Roy Chowdhury
- Department of Ophthalmology, Mayo Clinic, 200 First Street SW, Rochester, MN 55905, United States.
| | - Peter I Dosa
- Institute for Therapeutics Discovery and Development, Department of Medicinal Chemistry, University of Minnesota, 717 Delaware Street SE, Minneapolis, MN 55414, United States.
| | - Michael P Fautsch
- Department of Ophthalmology, Mayo Clinic, 200 First Street SW, Rochester, MN 55905, United States.
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Trechot P, Conart JB, Petitpain N, Trechot F. Severe headaches and 3rd or 6th nerve palsy associated with nicorandil: A hypothesis. Am J Emerg Med 2018; 36:1500-1501. [DOI: 10.1016/j.ajem.2017.12.001] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/10/2017] [Accepted: 12/01/2017] [Indexed: 11/25/2022] Open
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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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McCormack P, Skelly R. A demonstration of peristomal ulceration in the setting of nicorandil therapy. BMJ Case Rep 2014; 2014:bcr-2014-206599. [PMID: 25391826 DOI: 10.1136/bcr-2014-206599] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/03/2022] Open
Affiliation(s)
- Paul McCormack
- Department of General Surgery, Causeway Hospital, Coleraine, UK
| | - Roderick Skelly
- Department of General Surgery, Causeway Hospital, Coleraine, UK
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De novo rectovaginal fistulation and multisite ulceration as a consequence of nicorandil therapy. Int J Colorectal Dis 2014; 29:415-6. [PMID: 24281429 DOI: 10.1007/s00384-013-1799-1] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 11/18/2013] [Indexed: 02/04/2023]
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Schmutz JL, Trechot P. Nicorandil, ulcérations et fistules : une enquête auprès de dermatologues. Ann Dermatol Venereol 2013; 140:749-50. [DOI: 10.1016/j.annder.2013.06.004] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/28/2022]
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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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Medford ARL. Nicorandil and calcium antagonists: remember oro-anal ulceration and reflux cough too. Clin Med (Lond) 2013; 13:323. [PMID: 23760723 PMCID: PMC5922693 DOI: 10.7861/clinmedicine.13-3-323a] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
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Trechot F, Batta B, Petitpain N, Bazard MC, Angioi K, Trechot P. A case of nicorandil-induced unilateral corneal ulceration. Int Wound J 2013; 11:238-9. [PMID: 23651162 DOI: 10.1111/iwj.12081] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022] Open
Abstract
Nicorandil, a second-generation nitro derivative, has been reported to induce single or multiple ulcerations in many locations, including oral, anal, perianal, vulvovaginal, perivulval, penile, gastrointestinal, colic, peristomal and skin locations. Ocular locations are now highly suspected. Herein, we report the case of a 78-year-old woman who experienced corneal ulceration at second cataract surgery (right eye) while being treated with nicorandil for 3 years. Four years before, she had had an uneventful first cataract surgery (left eye). The ulcers healed within 6 weeks after simple withdrawal of nicorandil, an expected delay for this type of chemical ulcer. The substitution of nicorandil with classic nitric oxide donors has already been done without complication. Surgical intervention is unnecessary and inappropriate. Case reports of ocular side effects induced by nicorandil are rare and probably underestimated.
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Affiliation(s)
- Fanny Trechot
- Department of Ophthalmology, CHU Nancy, Vandoeuvre lès Nancy, France
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