nicorandil: clinical use

Prescribing considerations

• Reserve for stable angina inadequately controlled by, or unsuitable for, first-line anti-anginal therapies.
• Actively consider nicorandil when unexplained oral, ocular, cutaneous, perianal or gastrointestinal ulceration develops; ulceration may arise years after initiation.
• Diverticular disease may increase the risk of fistula or bowel perforation.
• Use caution in advanced heart failure, G6PD deficiency and with medicines that lower blood pressure or increase potassium.
• Nicorandil is not recommended for children because safety and efficacy have not been established.

Contraindications and cautions

• Hypersensitivity to nicorandil or an excipient
• Shock, including cardiogenic shock
• Severe hypotension
• Left-ventricular dysfunction with low filling pressure or cardiac decompensation
• Hypovolaemia
• Acute pulmonary oedema
• Concurrent PDE5 inhibitor treatment
• Concurrent soluble guanylate-cyclase stimulator treatment

Monitoring

• Assess angina symptom control and treatment tolerability.
• Check blood pressure where hypotension, dizziness or interacting treatment is relevant.
• Consider potassium monitoring when renal impairment or potassium-raising treatment increases risk.
• Investigate new ulceration promptly, including ocular, oral, skin, perianal and gastrointestinal sites.
• Review unexplained bleeding, abdominal pain, weight loss, fistula or abscess for possible nicorandil-related ulceration.

Clinical pharmacology

Nicorandil combines ATP-sensitive potassium-channel opening with nitrate-mediated cGMP activity, producing arterial and venous vasodilation. It is rapidly absorbed, has limited protein binding, undergoes hepatic denitration and is eliminated mainly in urine as inactive metabolites.

Formulation and product differences

• The selected product is an uncoated, scored tablet that can be divided into equal halves.
• It is moisture-sensitive and supplied in blister packaging with separately marked silica-gel desiccant units that must not be swallowed.
• Keep the blister in the outer carton and use an opened strip within the product’s stated storage period.

Tablet

Route: Oral

Strengths: 10 mg, 20 mg