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Ali K, Raja M, Osman S, Zulfiqar G, Janjua O. Recognition and management of drug-associated oral ulceration: a review. Br Dent J 2022; 233:564-568. [PMID: 36241814 DOI: 10.1038/s41415-022-5032-x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/20/2021] [Accepted: 01/27/2022] [Indexed: 12/24/2022]
Abstract
The number of people who are using prescribed medications is on the rise, largely due to an ageing population in the UK, but also because of early diagnosis and prompt medical management of a variety of conditions. Systemic medications may contribute to the development of oral side effects and translate into an increasing number of patients presenting in general dental practice settings. The aim of this paper is to provide an outline of oral side effects of systemic medications followed by a review of drug-associated oral ulcers (DAOUs). The paper also provides recommendations for early recognition and management of DAOUs in general dental practice settings, including referral to general medical practitioners and specialists in oral medicine.
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Affiliation(s)
- Kamran Ali
- Professor of Oral Surgery, Qatar University College of Dental Medicine, Qatar; Honorary Professor of Dental Education, Plymouth University, UK.
| | | | - Safa Osman
- Research Assistant, Qatar University, Qatar
| | - Gulraiz Zulfiqar
- Associate Professor, Oral and Maxillofacial Surgery, Jinnah Hospital Lahore, Pakistan
| | - Omer Janjua
- Professor, Oral and Maxillofacial Surgery, Faisalabad Medical University, Faisalabad, Pakistan
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Aziz Y, Rademacher WMH, Hielema A, Wishaw SBP, van Diermen DE, de Lange J, Vissink A, Rozema FR. Oral adverse effects: drug-induced tongue disorders. Oral Dis 2020; 27:1528-1541. [PMID: 33052611 PMCID: PMC8451755 DOI: 10.1111/odi.13680] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/01/2020] [Revised: 09/21/2020] [Accepted: 10/05/2020] [Indexed: 11/28/2022]
Abstract
Objectives Due to a worldwide increase in drug consumption, oral healthcare professionals are frequently confronted with patients using one or more drugs. A large number of drugs can be accompanied with adverse drug reactions in the orofacial region, amongst others of the tongue. This paper aims to give an overview of drugs that are known to be accompanied with tongue disorders. Materials and methods The national drug information database for Dutch pharmacists, composed of scientific drug information, guidelines and summaries of product characteristics, was analysed for drug‐induced tongue disorders. “MedDRA classification” and “Anatomical Therapeutic Chemical codes” were used to categorize the disorders. Results The database comprises of 1645 drugs of which 121 (7.4%) are documented to be accompanied with tongue disorders as an adverse effect. Drug‐induced tongue disorders are predominantly observed in the following drug categories: “nervous systems,” “anti‐infectives for systemic use” and “alimentary tract and metabolism”. The most common drug‐induced tongue disorders are glossitis, tongue oedema, tongue discoloration and burning tongue. Conclusion Healthcare professionals are frequently confronted with drugs that can cause tongue disorders. The overview of drugs reported in this article supports clinicians in their awareness, diagnosis and treatment of drug‐induced tongue disorders.
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Affiliation(s)
- Yalda Aziz
- Department of Oral Medicine, Academic Center for Dentistry Amsterdam (ACTA), Amsterdam, The Netherlands.,Department of Oral Maxillofacial Surgery, Amsterdam UMC, University of Amsterdam, Amsterdam, The Netherlands
| | - Willem Maria Hubertus Rademacher
- Department of Oral Medicine, Academic Center for Dentistry Amsterdam (ACTA), Amsterdam, The Netherlands.,Department of Oral Maxillofacial Surgery, Amsterdam UMC, University of Amsterdam, Amsterdam, The Netherlands
| | - Atty Hielema
- Department of Medicines Information Centre, Royal Dutch Pharmacists Association (KNMP), Den Hague, The Netherlands
| | - Scott Bradley Patton Wishaw
- Department of Medicines Information Centre, Royal Dutch Pharmacists Association (KNMP), Den Hague, The Netherlands
| | - Denise Edwina van Diermen
- Department of Oral Medicine, Academic Center for Dentistry Amsterdam (ACTA), Amsterdam, The Netherlands
| | - Jan de Lange
- Department of Oral Medicine, Academic Center for Dentistry Amsterdam (ACTA), Amsterdam, The Netherlands.,Department of Oral Maxillofacial Surgery, Amsterdam UMC, University of Amsterdam, Amsterdam, The Netherlands
| | - Arjan Vissink
- Department of Oral Maxillofacial Surgery, University Medical Center Groningen, University of Groningen, Groningen, The Netherlands
| | - Frederik Reinder Rozema
- Department of Oral Medicine, Academic Center for Dentistry Amsterdam (ACTA), Amsterdam, The Netherlands.,Department of Oral Maxillofacial Surgery, Amsterdam UMC, University of Amsterdam, Amsterdam, The Netherlands
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Affiliation(s)
- Patricia McGettigan
- William Harvey Research Institute, Queen Mary University of London, London, UK
| | - Robin E Ferner
- West Midlands Centre for Adverse Drug Reactions, City Hospital, Birmingham, 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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Systemic and environmental risk factors for recurrent aphthous stomatitis in a Polish cohort of patients. Postepy Dermatol Alergol 2018; 36:196-201. [PMID: 31320854 PMCID: PMC6627261 DOI: 10.5114/ada.2018.74638] [Citation(s) in RCA: 12] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/16/2018] [Accepted: 02/02/2018] [Indexed: 11/17/2022] Open
Abstract
Introduction Recurrent aphthous stomatitis (RAS) is a common oral mucosal disease without a clearly defined etiology. Aim To analyze the influence of systemic diseases, medications, smoking and a family history of RAS on the prevalence and the course of the condition in Polish patients with RAS. Material and methods Seventy-eight patients with RAS and 72 subjects without a history of RAS were enrolled in the study. All participants underwent a detailed oral examination and a full blood count. The results were statistically analyzed with Statistica 10 (StatSoft, Krakow, Poland) with Mann-Whitney, Kruskal-Wallis, χ2 and Fisher tests, with p < 0.05 considered as the significance level. Results The most common systemic conditions observed in patients with RAS were hypertension, allergies and anemia. Both HT and anemia were prevalent in the RAS group. A positive RAS family history occurred more frequently in the study group than in controls. However, no association was found between smoking and RAS prevalence, although a higher percentage of smokers was observed in the RAS subgroup with a low frequency of RAS episodes. Conclusions The potential role of hypertension and anemia as modifiers of the immune reaction in RAS has been implied in this study but confirmation of this association requires further studies on a larger sample of patients. However, there appears to be no correlation between smoking and the occurrence of RAS. The positive family history observed in this study in the majority of RAS patients confirms the genetic background of the condition.
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Drug-induced oral lichenoid reactions: a real clinical entity? A systematic review. Eur J Clin Pharmacol 2017; 73:1523-1537. [PMID: 28905092 DOI: 10.1007/s00228-017-2325-0] [Citation(s) in RCA: 21] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/27/2017] [Accepted: 08/21/2017] [Indexed: 11/27/2022]
Abstract
PURPOSE Drug-induced oral lichenoid reactions (DIOLRs) have been extensively reported in the literature, but the validity of the causality relationship between any drug and the oral lichenoid lesions (OLLs) still remains questionable. We sought to determine whether this causality relationship really exists, whether a resolution of the oral lesions upon withdrawal occurs, and what the most common alleged offending medications are. METHODS Nine electronic databases from January 1966 to December 2016 were systematically searched to identify all relevant studies selected with specific inclusion criteria (a clinical and histopathological diagnosis of DIOLRs, and clearly statement on the systemic offending medication). Searched terms included but not limited to oral lichen planus/oral lichenoid lesions/oral lichenoid reactions, the adverse effects of medication, and drug-induced. Statistical analyses conducted. RESULTS The search retrieved a total of 817 articles, of which only 46 were included into a qualitative synthesis: 40 case reports/series and 6 studies. The causality assessment was done only in 14.8% of cases with the C-D-R protocol. The Naranjo algorithm was not reported in the majority of cases (98.2%). Culprit medication was withdrawn in 68.5% of the cases, obtaining a partial or complete resolution without treatment in 16.7% of cases and with treatment in 27.7% of cases. The median number of culprit medication(s) described was 1 with the most frequent ones being Methyldopa (20.37%), Interferon (IFN)-alpha (11.11%), and Imatinib and Infliximab (9.26%). CONCLUSION This systematic review demonstrated that there is no strong scientific evidence to support the causal relationship between any drug and oral lichenoid lesions; therefore, in all reviewed cases, we must question whether the DIOLRs represent a real and separate clinical entity. Further and more thorough investigations using one of the available algorithms for adverse drug reaction are warranted.
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Abstract
The people who are treated in the community setting will often have multiple comorbidities. Systemic medical conditions can have a negative impact on oral health. In addition, the medications used to treat systemic conditions may also themselves cause oral symptoms. As a large proportion of patients treated by the community nursing team will be elderly, this paper will focus on common geriatric conditions that can display oral or dental symptoms. The effects of medications will be discussed and linked to oral complaints patients may express. The primary aims are to give a broad overview of the oral effects of ageing, of illness and of polypharmacy and advise on how these can be best managed by the nursing team.
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Affiliation(s)
- Diana Critchlow
- Senior Dental Officer, Northeast London NHS Foundation Trust, Dental Department, Grays Health Centre
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Nicorandil-induced penile ulcerations: A case report and review of the penile cutaneous circulation. JPRAS Open 2016. [DOI: 10.1016/j.jpra.2016.03.002] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/22/2022] 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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Affiliation(s)
- Su‐Yun Li
- Department of Epidemiology School of Public Health Shandong University Jinan Shandong Province People's Republic of China
- Department of Dermatology Warren Alpert Medical School Brown University Providence RI U.S.A
| | - Wen‐Qing Li
- Department of Dermatology Warren Alpert Medical School Brown University Providence RI U.S.A
- Department of Epidemiology School of Public Health Brown University Providence RI U.S.A
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Samra K, Manikam L, Pathmakanthan S. When treatment can be worse than the disease: nicorandil-induced colitis. BMJ Case Rep 2015; 2015:bcr-2015-209799. [PMID: 26009604 DOI: 10.1136/bcr-2015-209799] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/03/2022] Open
Abstract
A 75-year-old woman presented with severe abdominal pain and diarrhoea. Symptoms started 10 years earlier but multiple investigations failed to offer a clear diagnosis. On recent admission, blood tests, endoscopies and CT scans indicated chronic colonic inflammation. Treatment strategies for bowel inflammation were unsuccessful and the patient was subsequently discussed at a multidisciplinary team meeting with surgeons for consideration of colectomy. A drug review highlighted that the patient was taking an antiangina drug, nicorandil, thought to cause bowel ulceration. This was discontinued, which dramatically improved symptoms and avoided surgery and the patient was discharged within days. Follow-up colonoscopy showed much improved colitis, and the diarrhoea had resolved. It is important that clinicians are aware of the link between pharmacotherapy, specifically nicorandil and gastrointestinal ulceration and inflammation causing severe diarrhoea. Drug cessation is the only necessary and immediately effective treatment. Awareness of this will become more clinically relevant as nicorandil use increases.
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Affiliation(s)
- Kiran Samra
- University Hospitals of North Midlands, Stoke-On-Trent, UK
| | | | - Shri Pathmakanthan
- Department of Gastroenterology, Queen Elizabeth Hospital, Birmingham, Birmingham, UK
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Sani HD, Eshraghi A, Nezafati MH, Vojdanparast M, Shahri B, Nezafati P. Nicorandil Versus Nitroglycerin for Symptomatic Relief of Angina in Patients With Slow Coronary Flow Phenomenon: A Randomized Clinical Trial. J Cardiovasc Pharmacol Ther 2015; 20:401-6. [PMID: 25701829 DOI: 10.1177/1074248415571457] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/12/2014] [Accepted: 12/22/2014] [Indexed: 11/15/2022]
Abstract
OBJECTIVE Patients with the coronary slow flow phenomenon frequently experience angina episodes. The present study aimed to compare the efficacy of nicorandil versus nitroglycerin for alleviation of angina symptoms in slow flow patients. METHODS In a single-center, single-blind, parallel-design, comparator-controlled, randomized clinical trial (NCT02254252), 54 patients with slow flow and normal or near-normal coronary angiography who presented with frequent angina episodes were randomly assigned to 1-month treatment with nicorandil 10 mg, 2 times a day (n = 27) or sustained-release glyceryltrinitrate 6.4 mg 2 times a day (n =27). Frequency of angina episodes, pain intensity, and the Canadian Cardiovascular Society (CCS) grading of angina pectoris were assessed at baseline and after 1 month of treatment. RESULTS In all, 25 patients in the nicorandil arm and 24 patients in the nitroglycerin arm were analyzed. After 1 month, patients treated with nicorandil had fewer angina episodes (adjusted mean number of episodes per week, nicorandil versus nitroglycerin; 1.68 ± 0.15 vs 2.29 ± 0.15, P = .007, effect size = 14.6%). Patients also reported greater reductions in pain intensity with nicorandil versus nitroglycerin (adjusted mean of self-reported pain score; 3.03 ± 0.29 vs 3.89 ± 0.30, P = .046, effect size = 8.4%). A significantly higher proportion of patients in the nicorandil arm were categorized in CCS class I (76% vs 33.3%, P = .004) or class II (16.0% vs 45.8%, P = .032). CONCLUSION In slow flow patients, nicorandil provides better symptomatic relief of angina than nitroglycerin.
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Affiliation(s)
- Hashem Danesh Sani
- Atherosclerosis Prevention Research Center, Imam Reza Hospital, Mashhad University of Medical Sciences, Mashhad, Iran
| | - Ali Eshraghi
- Atherosclerosis Prevention Research Center, Imam Reza Hospital, Mashhad University of Medical Sciences, Mashhad, Iran
| | - Mohammad Hassan Nezafati
- Department of Cardiac Surgery, Imam Reza Hospital, Mashhad University of Medical Sciences, Mashhad, Iran
| | - Mohammad Vojdanparast
- Atherosclerosis Prevention Research Center, Imam Reza Hospital, Mashhad University of Medical Sciences, Mashhad, Iran
| | - Bahram Shahri
- Atherosclerosis Prevention Research Center, Imam Reza Hospital, Mashhad University of Medical Sciences, Mashhad, Iran
| | - Pouya Nezafati
- Department of Cardiac Surgery, Imam Reza Hospital, Mashhad University of Medical Sciences, Mashhad, Iran Student Research Committee, Mashhad University of Medical Sciences, Mashhad, Iran
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Carlile A, Sheikh E, Shakeel M, Maini SK. Nicorandil associated pinna ulceration: a new entity for an otolaryngologist. Am J Otolaryngol 2013; 34:586-8. [PMID: 23787276 DOI: 10.1016/j.amjoto.2013.01.015] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/09/2013] [Accepted: 01/18/2013] [Indexed: 11/18/2022]
Abstract
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.
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Affiliation(s)
- Andrew Carlile
- University of Aberdeen, Aberdeen Royal Infirmary, Aberdeen, Scotland
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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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Kamath S, Taylor M, Bhagwandas K. An unusual case of nicorandil-induced conjunctival erosions. Clin Exp Dermatol 2012; 37:681-2. [DOI: 10.1111/j.1365-2230.2011.04309.x] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
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Nicorandil-induced oral ulceration: report of 3 cases and review of the Japanese literature. ACTA ACUST UNITED AC 2011; 112:754-9. [DOI: 10.1016/j.tripleo.2011.05.031] [Citation(s) in RCA: 11] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/04/2011] [Revised: 05/16/2011] [Accepted: 05/24/2011] [Indexed: 11/23/2022]
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Nicorandil associated colonic ulceration: case series of an increasingly recognized complication. Dig Dis Sci 2011; 56:2404-8. [PMID: 21380762 DOI: 10.1007/s10620-011-1634-x] [Citation(s) in RCA: 43] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/01/2010] [Accepted: 02/14/2011] [Indexed: 12/09/2022]
Abstract
BACKGROUND Nicorandil is widely accepted in the therapeutic armamentarium of ischemic heart disease and, although nicorandil-induced oral and anal ulcerations have been established in the literature, only five cases have reported the possibility of nicorandil-induced ulceration elsewhere in the gastrointestinal tract. There have been recent case reports which have suggested the possible causative association between nicorandil and colonic ulceration, either in isolation or in combination with anal ulceration. METHODS We report a case series of eight patients prescribed with nicorandil therapy presenting with gastrointestinal symptoms and subsequently diagnosed with colonic ulceration on colonoscopy. RESULTS Eight patients were identified (five female, three male). Colonoscopic findings varied from solitary to multiple colonic ulcers. No concomitant oral or anal ulcerations were noted in these patients. Biopsies from the ulcers showed only non-specific inflammation. Cessation of nicorandil therapy resulted in resolution of symptoms and complete healing of colonic ulcers. CONCLUSION Nicorandil therapy appears to be an emerging etiology in the development of idiopathic colonic ulceration and therefore should be considered as a differential diagnosis in a selected group of patients.
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McDaid J, Reichl C, Hamzah I, Fitter S, Harbach L, Savage AP. Diverticular fistulation is associated with nicorandil usage. Ann R Coll Surg Engl 2010. [PMID: 20819332 DOI: 10.1308/003588410x12699663904673] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/22/2022] Open
Abstract
INTRODUCTION We observed that a number of patients presenting to our clinic with diverticular fistulation were taking nicorandil for angina. Recognised side effects of nicorandil include gastrointestinal and genital ulceration. The aim of our study was to determine whether nicorandil is an aetiological agent in diverticular fistulation. PATIENTS AND METHODS We conducted a case-control study of patients with diverticular disease related enteric fistulae. Two patient groups were identified: a study group of patients with diverticular fistulae, and a control group with uncomplicated diverticular disease. The proportion of patients who had ever used nicorandil was compared between the two groups. RESULTS A total of 153 case notes were analysed, 69 patients with fistulae and 84 control patients with uncomplicated diverticular disease. Female to male ratio in both groups was 2:1. The mean age was 71 years in the fistula group and 69 years in the control diverticular disease group (P = ns). Of those with colonic fistulae, 16% were taking nicorandil compared with 2% of the control group (odds ratio 7.8; 95% confidence interval 1.5-39.1; P = 0.008). There was no significant difference in rates of ischaemic heart disease between fistula and control groups. CONCLUSIONS Nicorandil is associated with fistula formation in diverticular disease.
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Affiliation(s)
- James McDaid
- Department of Surgery, Queen Elizabeth Hospital, Birmingham, UK.
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Kinney M, O'Rourke D, O'Kane H, Keane P, Nambirajan T. Nicorandil induced penile ulceration. THE ULSTER MEDICAL JOURNAL 2010; 79:123-4. [PMID: 22375086 PMCID: PMC3284717] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Accepted: 06/29/2010] [Indexed: 12/05/2022]
Abstract
We report the unusual complication of penile ulceration caused by Nicorandil, a nicotinamide ester used in the treatment of symptomatic angina pectoris.
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McDaid J, Reichl C, Hamzah I, Fitter S, Harbach L, Savage AP. Diverticular fistulation is associated with nicorandil usage. Ann R Coll Surg Engl 2010; 92:463-5. [DOI: 10.1308/rcsann.2010.92.6.463] [Citation(s) in RCA: 13] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/22/2022] Open
Abstract
INTRODUCTION We observed that a number of patients presenting to our clinic with diverticular fistulation were taking nicorandil for angna. Recognised side effects of nicorandil include gastrointestinal and genital ulceration. The aim of our study was to determine whether nicorandil is an aetiological agent in diverticular fistulation. PATIENTS AND METHODS We conducted a case-control study of patients with diverticular disease related enteric fistulae. Two patient groups were identified: a study group of patients with diverticular fistulae, and a control group with uncomplicated diverticular disease. The proportion of patients who had ever used nicorandil was compared between the two groups. RESULTS A total of 153 case notes were analysed, 69 patients with fistulae and 84 control patients with uncomplicated diverticular disease. Female to male ratio in both groups was 2:1. The mean age was 71 years in the fistula group and 69 years in the control diverticular disease group (P = ns). Of those with colonic fistulae, 16% were taking nicorandil compared with 2% of the control group (odds ratio 7.8; 95% confidence interval 1.5–39.1; P = 0.008). There was no significant difference in rates of ischaemic heart disease between fistula and control groups. CONCLUSIONS Nicorandil is associated with fistula formation in diverticular disease.
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Affiliation(s)
- James McDaid
- Department of Surgery, Queen Elizabeth Hospital Birmingham, UK
| | - Claire Reichl
- Department of General Surgery, Russell's Hall Hospital Dudley, UK
| | - Ihsan Hamzah
- Department of Colorectal Surgery, Russell's Hall Hospital Dudley, UK
| | - Samantha Fitter
- Department of Clinical Audit, Russell's Hall Hospital Dudley, UK
| | - Laura Harbach
- Department of Clinical Audit, Russell's Hall Hospital Dudley, UK
| | - Adrian P Savage
- Department of Colorectal Surgery, Russell's Hall Hospital Dudley, UK
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Mosley F, Bhasin N, Davies JB, Ausobsky JR. Life-threatening haemorrhage secondary to nicorandil-induced severe peri-anal ulceration. Ann R Coll Surg Engl 2010; 92:W39-40. [PMID: 20615301 DOI: 10.1308/147870810x12699662981519] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/22/2022] Open
Abstract
Nicorandil-induced ulceration is rare but has been reported at multiple sites throughout the gastrointestinal tract. We report a life-threatening complication of such ulceration - catastrophic per-rectal haemorrhage requiring emergency surgery with no prior symptoms. Whilst nicorandil should be considered in cases of chronic peri-anal and peristomal ulceration which fail to respond to conventional treatments, this case highlights its importance in the setting of acute surgical presentations.
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Affiliation(s)
- F Mosley
- Department of General Surgery, Bradford Royal Infirmary, Bradford, UK.
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Malde S, Wilson A. Rectal ulceration caused by the anti-anginal nicorandil: Case report of a preventable complication. Patient Saf Surg 2010; 4:10. [PMID: 20591192 PMCID: PMC2902425 DOI: 10.1186/1754-9493-4-10] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/08/2010] [Accepted: 06/30/2010] [Indexed: 11/26/2022] Open
Abstract
The association of the anti-anginal drug nicorandil with oral and anal ulceration is becoming more widely recognised, but there are no reports of isolated nicorandil-induced rectal ulceration. Awareness of this condition is poor, and patients often undergo unnecessary surgery for a condition which resolves on stopping the medication. We report a case of nicorandil-induced rectal ulceration causing rectal bleeding. The patient was spared surgery after awareness of the link with this drug. This diagnosis should be considered in patients with unexplained gastrointestinal ulceration after exclusion of serious underlying causes. We hope this report will increase awareness amongst physicians and surgeons of this reversible condition.
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Affiliation(s)
- Sachin Malde
- Department of Urology, Wythenshawe Hospital, Southmoor Road, Manchester, M23 9LT, UK.
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Riddell AD, Minhas U, Williams GL, Harding KJ. The role of Nicorandil in non-healing surgical wounds. Ann R Coll Surg Engl 2010; 92:W16-8. [PMID: 20566033 DOI: 10.1308/147870810x12699662981113] [Citation(s) in RCA: 10] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/22/2022] Open
Abstract
We report two patients with non-healing surgical wounds, which healed after the withdrawal of Nicorandil therapy. Nicorandil should be recognised as an aetiological factor for non-healing wounds or ulcers once other inflammatory and malignant causes have been excluded. This may avoid surgery for high-risk patients and may also reduce complications for patients who undergo surgery for non-healing wounds. As Nicorandil is used in patients with severe coronary artery disease, it is recommended that the advice of a cardiologist is sought prior to cessation or adjustment to its dose.
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Affiliation(s)
- A D Riddell
- Department of General Surgery, Royal Free Hospital, London, UK.
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Goh C, Wong SC, Borland C. Persistent orocutaneous and anal fistulae induced by nicorandil: a case report. J Med Case Rep 2009; 3:119. [PMID: 19946537 PMCID: PMC2783060 DOI: 10.1186/1752-1947-3-119] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/26/2008] [Accepted: 11/12/2009] [Indexed: 11/24/2022] Open
Abstract
Introduction Although nicorandil is prescribed widely, awareness of its potential to cause serious complications to the gastrointestinal tract mucosa is limited. Whilst nicorandil-induced oral and anal ulceration is well documented in the literature, nicorandil-induced fistulation is not. This is the first report in the literature of a single patient demonstrating simultaneous orocutaneous and anal fistulae during nicorandil therapy. Two separate cases of orocutaneous and anal fistulae associated nicorandil usage have previously been documented in specialist journals. Case presentation A 71-year-old Caucasian man presented with a 3-year history of concurrent orocutaneous and anal fistulae. He had been exposed to 30 mg twice-daily nicorandil therapy for 4 years. Both fistulae responded poorly to intensive and prolonged conventional treatment but healed promptly on reduction and eventual withdrawal of nicorandil therapy. Conclusion Management of resistant cases of orocutaneous and anal fistulae in patients on high-dose nicorandil therapy may be impossible without reduction or even withdrawal of nicorandil.
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Affiliation(s)
- Cyndi Goh
- Department of Medicine, Hinchingbrooke Hospital, Hinchingbrooke Heath Care NHS Trust, Huntingdon, Cambridgeshire PE29 6NT, UK
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Bertini F, Costa NCS, Brandão AAH, Cavalcante ASR, Almeida JD. Ulceration of the oral mucosa induced by antidepressant medication: a case report. J Med Case Rep 2009; 3:98. [PMID: 19946515 PMCID: PMC2783098 DOI: 10.1186/1752-1947-3-98] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/30/2008] [Accepted: 11/03/2009] [Indexed: 11/10/2022] Open
Abstract
Introduction Ulcers are frequent lesions of the oral mucosa. Generally, they are circumscribed round or elliptical lesions surrounded by an erythematous halo and covered with an inflammatory exudate in their central portion, and are accompanied by painful symptoms. Oral ulcers affect 20% of the population, especially adolescents and young adults. The etiopathogenesis includes immunological alterations, infections, nutritional deficiency, trauma, food and contact allergies, autoimmune diseases, neoplasms, and psychosomatic, genetic and environmental factors. Case presentation A 78-year-old Caucasian woman was referred by her dentist to our outpatient clinic with a 4-week history of an oral ulceration after using an antidepressant (sertraline hydrochloride). On the basis of the clinical findings and anamnesis, the occurrence of the lesion was attributed to the use of the drug. Exfoliative cytology was performed, to reassure the patient that it was not oral cancer, which revealed the presence of a nonspecific inflammatory reaction. The drug was replaced and resolution of symptoms was observed. Conclusion Exfoliative cytology should be the complementary examination of choice in cases of oral ulcers with a suspicion of drug interaction. Although this is a rare event in dental practice, dentists should be aware of the diagnostic possibility of drug-induced ulcers and should cooperate with the clinician to adjust the prescribed medication to resolve the symptoms.
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El-Dars LD, Bhagwanadas K, Hemmadi S, Hughes J. Nicorandil associated vulval and inguinal ulceration. J OBSTET GYNAECOL 2009; 29:674-5. [PMID: 19757286 DOI: 10.1080/01443610903104486] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/20/2022]
Affiliation(s)
- L D El-Dars
- Department of Dermatology, Royal Gwent Hospital, Newport, UK.
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van de Nieuwenhof HP, van der Vleuten CJ, de Hullu JA, Dukel L. Never forget medication as a cause: vaginal ulceration caused by nicorandil. Am J Obstet Gynecol 2009; 201:e5-6. [PMID: 19608146 DOI: 10.1016/j.ajog.2009.05.027] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/12/2009] [Revised: 05/08/2009] [Accepted: 05/14/2009] [Indexed: 10/20/2022]
Abstract
A patient was referred to our vulvar outpatient clinic because of a vaginal ulceration that persisted for 3 years and that had been unresponsive to any prescribed therapy. After a possible association was found with nicorandil therapy, this medication was stopped. Thereafter, the ulceration fully healed within 6 months.
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Chan SK, Harris MD, Baldwin PJW, Sterling JC. Vulvovaginal ulceration during prolonged treatment with nicorandil. BJOG 2009; 116:1403-5. [DOI: 10.1111/j.1471-0528.2009.02259.x] [Citation(s) in RCA: 13] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/28/2022]
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Compilato D, Cirillo N, Termine N, Kerr AR, Paderni C, Ciavarella D, Campisi G. Long-standing oral ulcers: proposal for a new `S-C-D classification system’. J Oral Pathol Med 2008; 38:241-53. [DOI: 10.1111/j.1600-0714.2008.00722.x] [Citation(s) in RCA: 13] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/16/2022]
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Titi MA, Seow C, Molloy RG. Nicorandil-induced colonic ulceration: a new cause of colonic ulceration. Report of four cases. Dis Colon Rectum 2008; 51:1570-3. [PMID: 18299928 DOI: 10.1007/s10350-008-9218-3] [Citation(s) in RCA: 20] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/13/2006] [Revised: 10/25/2006] [Accepted: 12/26/2006] [Indexed: 02/08/2023]
Abstract
PURPOSE Nicorandil is a widely used third-line treatment for ischemic heart disease. It can be associated with the development of stomatitis and oro-anal ulceration. The current report suggests an association between nicorandil and the development of colonic ulceration, both in isolation and in combination with anal ulceration. METHODS This is a case report of four patients with new onset lower gastrointestinal symptoms. All had a history of ischemic heart disease and angina. All were taking several cardiac medications, including nicorandil. RESULTS Four patients (3 men) were investigated. Colonoscopy revealed both solitary and multiple colonic ulcers. Pathology showed acute nonspecific inflammation. Two patients also displayed concomitant anal ulceration. Nicorandil therapy was stopped in all patients. No other active treatment was offered. All patients became asymptomatic within six weeks of cessation of nicorandil therapy with resolution of the anal and colonic ulceration. CONCLUSION Nicorandil may induce colonic ulceration and should be considered in the differential diagnosis of idiopathic colonic ulceration in appropriate patients.
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Affiliation(s)
- M A Titi
- Department of Surgical Gastroenterology, Gartnavel General Hospital, Glasgow, Scotland, United Kingdom.
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Yamamoto S, Yamada T, Kotake Y, Takeda J. Cardioprotective Effects of Nicorandil in Patients Undergoing On-Pump Coronary Artery Bypass Surgery. J Cardiothorac Vasc Anesth 2008; 22:548-53. [DOI: 10.1053/j.jvca.2008.02.011] [Citation(s) in RCA: 13] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/23/2007] [Indexed: 11/11/2022]
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Kamath S, Kembrey K, Bhagwandas K. Perianal fistula, colorectal surgery and nicorandil. Clin Exp Dermatol 2008; 33:192-3. [DOI: 10.1111/j.1365-2230.2007.02548.x] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/28/2022]
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Baker RP, Al-Kubati W, Atuf M, Phillips RKS. Nicorandil-induced severe perianal ulceration. Tech Coloproctol 2007; 11:343-5. [PMID: 18060591 DOI: 10.1007/s10151-007-0378-2] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/20/2007] [Accepted: 09/18/2007] [Indexed: 11/30/2022]
Abstract
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.
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Affiliation(s)
- R P Baker
- Department of Coloproctology, Clarendon Wing, Leeds General Infirmary, Great George Street, Leeds, West Yorkshire, UK.
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Cupples HEV, McGahey DT. Dual pathology: cervicofacial actinomycosis and nicorandil-induced oral ulceration. The Journal of Laryngology & Otology 2007; 122:422-4. [PMID: 17498334 DOI: 10.1017/s002221510700816x] [Citation(s) in RCA: 10] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Abstract
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.
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Affiliation(s)
- H E V Cupples
- Ear, Nose & Throat - Regional Head & Neck Cancer Centre, The Royal Group of Hospitals and Social Services Trust, Belfast, Northern Ireland, UK.
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Williams C, Tamuno P, Smith AJ, Walker SL, Lyon CC. Perianal ulceration and other cutaneous ulcerations complicating nicorandil therapy. J Am Acad Dermatol 2007; 56:S116-7. [PMID: 17434035 DOI: 10.1016/j.jaad.2006.05.034] [Citation(s) in RCA: 10] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/11/2006] [Revised: 02/22/2006] [Accepted: 05/19/2006] [Indexed: 10/23/2022]
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Abstract
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.
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Ogden S, Mukasa Y, Lyon CC, Coulson IH. Nicorandil-induced peristomal ulcers: is nicorandil also associated with gastrointestinal fistula formation? Br J Dermatol 2007; 156:608-9. [PMID: 17300271 DOI: 10.1111/j.1365-2133.2006.07698.x] [Citation(s) in RCA: 27] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
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Rival AL, Allombert-Blaise C, Ly A, Grandjean JP, Faure M, Claudy A. [Nicorandil-associated anal ulceration]. Ann Dermatol Venereol 2007; 133:781-3. [PMID: 17072194 DOI: 10.1016/s0151-9638(06)71043-2] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
Abstract
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.
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Affiliation(s)
- A-L Rival
- Service de Dermatologie, Hôpital Edouard Herriot, place d'Arsonval, 69437 Lyon Cedex 03
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Abdelrazeq AS, Owen C, Smith L, McAdam JG, Pearson HJ, Leveson SH. Nicorandil-associated para-stomal ulceration: Case series. Eur J Gastroenterol Hepatol 2006; 18:1293-5. [PMID: 17099379 DOI: 10.1097/01.meg.0000243880.02197.8b] [Citation(s) in RCA: 27] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/10/2022]
Abstract
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.
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Biggins J, Barrow E, Watson AJM. Non-healing anal ulcers associated with nicorandil. J Wound Care 2006; 15:197-8. [PMID: 16711172 DOI: 10.12968/jowc.2006.15.5.26914] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/11/2022]
Affiliation(s)
- J Biggins
- Colorectal Unit, Department of Surgery, Manchester Royal Infirmary, Manchester
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Katory M, Davies B, Kelty C, Arasaradnam R, Skinner P, Brown S, Bagley J, Shorthouse AJ, Hunt LM, Slater R. Nicorandil and idiopathic anal ulceration. Dis Colon Rectum 2005; 48:1442-6. [PMID: 15906129 DOI: 10.1007/s10350-005-0027-7] [Citation(s) in RCA: 33] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/08/2023]
Abstract
PURPOSE Several reports have implicated nicorandil as a reversible cause of anal ulceration. We have recently commenced a specialist clinic for patients presenting with severe anal ulceration to assess treatment in this difficult group. Recognition of this association may avoid unnecessary surgery. METHODS Twenty-six patients treated with nicorandil had severe painful anal ulceration. Examination under anesthesia was required to biopsy the lesions to exclude neoplasia or inflammatory bowel disease. In total, three patients had proximal diverting stomas without subsequent ulcer resolution, two had perineal debridement with one requiring subsequent skin grafting, and one had an abdominoperineal excision for unremitting pain. RESULTS The association of perianal ulceration with nicorandil became apparent only in the latter part of this series. Ten ulcers successfully re-epithelialized when nicorandil was stopped. Nine patients reported anal pain relief and partial healing on clinical examination at two months but failed to show subsequent complete resolution. One patient agreed to nicorandil cessation and reported symptomatic anal pain relief at two weeks but subsequently developed unstable angina requiring hospital admission. Nicorandil was recommenced with anal pain relapse. CONCLUSIONS Failure to recognize nicorandil as an etiologic factor in the development of anal ulceration, when other potential underlying well-recognized inflammatory or neoplastic processes have been excluded, may lead to unnecessary surgical intervention in a group of high-risk patients. One of our patients had a potentially avoidable abdominoperineal resection. Pharmaceutical manipulation with alternative antiangina medication may induce healing. Pharmacologic manipulation should be coordinated with a physician to minimize precipitation of unstable angina.
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Affiliation(s)
- Mark Katory
- Sheffield Teaching Hospitals NHS Trust, Sheffield, South Yorkshire, United Kingdom
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Current awareness: Pharmacoepidemiology and drug safety. Pharmacoepidemiol Drug Saf 2004. [DOI: 10.1002/pds.924] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/09/2022]
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