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Nicorandil Mucosal Ulceration — EECC MCQ

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ModerateCoronary Artery DiseaseNicorandil Mucosal UlcerationEECC

A 65-year-old man with stable angina on bisoprolol and amlodipine asks about nicorandil. He develops oral ulceration after 6 months of treatment. Is this drug-related?

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Correct answer: A — Yes — nicorandil (a K-ATP channel opener with nitrate-like properties) is associated with mucosal ulceration (oral, GI, perianal) in 2-5% of patients, which can be severe; the ulcers resolve on drug discontinuation but may take weeks

Nicorandil has a dual mechanism: (1) K-ATP channel opener (vasodilation of arterial resistance vessels); (2) nitric oxide donor (venodilation, similar to nitrates). It reduces preload and afterload, improving myocardial oxygen balance. The 2024 ESC CCS Guidelines include nicorandil as a second-line anti-anginal. Its unique adverse effect is mucosal ulceration — oral aphthous ulcers, GI ulcers (oesophageal, gastric, small bowel), and perianal ulceration/fistula. Mechanism: possibly related to NO-mediated tissue damage. The MHRA has issued safety warnings. Management: stop nicorandil — ulcers typically heal within weeks to months of discontinuation. It should NOT be co-prescribed with PDE5 inhibitors (like nitrates, the combination causes severe hypotension).

Reference: ESC (2024): CCS Guidelines; MHRA Safety Alert; BNF