1. Introduction
Nicorandil is a vasodilatory medication used in the management of chronic stable angina. It works by acting as both a potassium channel activator and nitrate donor, resulting in relaxation of vascular smooth muscles, reduced myocardial oxygen demand, and improved blood flow to the heart. Nicorandil is particularly useful in patients who do not tolerate conventional anti-anginal therapies.
2. Indications
- Long-term management of chronic stable angina
- Treatment of angina in patients intolerant to or inadequately controlled with beta-blockers or calcium channel blockers
3. Dosage
Adults:
- Initial dose: 10 mg twice daily (reduce to 5 mg twice daily if side effects occur).
- Maintenance dose: 10–20 mg twice daily, depending on clinical response.
- Maximum dose: 40 mg/day.
Elderly:
- Start with the lowest effective dose (5 mg twice daily), as elderly patients may be more sensitive to hypotensive effects.
Children:
- Not recommended for use in children due to a lack of safety and efficacy data.
4. Administration
- Take orally with water, with or without food.
- Do not crush or chew tablets; swallow whole.
- Take doses at the same time each day to maintain consistent therapeutic levels.
5. Forms Available
- Tablets: 5 mg, 10 mg, 20 mg
6. Side Effects
6.1 Common Side Effects:
- Headache (most common, especially during initiation)
- Dizziness
- Flushing
- Nausea
6.2 Less Common Side Effects:
- Palpitations
- Weakness
- Abdominal pain
6.3 Rare but Serious Side Effects:
- Severe ulcerations (oral, gastrointestinal, perianal)
- Hypotension
- Stevens-Johnson syndrome (rare allergic reaction)
7. Warnings
- Ulcerations: Nicorandil has been associated with severe, sometimes life-threatening ulcers, particularly in the gastrointestinal tract. Discontinue immediately if ulcerations occur.
- Hypotension: May cause significant drops in blood pressure, especially in patients with hypovolaemia or those on antihypertensives.
- Heart Failure: Use cautiously in patients with left ventricular dysfunction.
8. Precautions
- Avoid in patients with severe hypotension or cardiogenic shock.
- Use cautiously in patients with a history of gastrointestinal ulcers or diverticular disease.
- Monitor for signs of dehydration, as Nicorandil may worsen volume depletion.
9. Interactions
- Phosphodiesterase-5 inhibitors (e.g., sildenafil, tadalafil): Increased risk of severe hypotension; avoid concurrent use.
- Antihypertensive medications: Additive hypotensive effects.
- Alcohol: May enhance the blood pressure-lowering effect of Nicorandil.
10. Monitoring Parameters
- Blood pressure and heart rate (especially during dose adjustments).
- Monitor for the development of ulcers, particularly in patients reporting abdominal pain.
- Assess symptom relief and exercise tolerance in patients with angina.
11. Use in Children
- Not recommended due to insufficient safety and efficacy data in paediatric populations.
12. Use in Pregnancy
- Use only if the potential benefit justifies the risk to the foetus. Limited safety data are available.
13. Use in Elderly
- Start with lower doses due to increased sensitivity to hypotension. Monitor closely for dizziness, syncope, or hypotensive episodes.
14. Use in Kidney Disease
- No dose adjustment required in mild to moderate renal impairment. Use cautiously in severe renal impairment due to limited data.
15. Use in Liver Disease
- No specific dose adjustments are required, but use cautiously in severe hepatic impairment due to limited data.
16. Patient Counselling Points
- Take Nicorandil exactly as prescribed; do not stop taking it suddenly without consulting your doctor.
- Inform your doctor if you experience persistent headaches, abdominal pain, or unusual ulcers.
- Avoid using medications like sildenafil (for erectile dysfunction) while on Nicorandil due to the risk of severe drops in blood pressure.
- If you feel dizzy or lightheaded, sit or lie down until the symptoms resolve.
- Store the medication in a cool, dry place away from moisture and heat.
17. Table of Brand Names, Manufacturer, and Prices in USD
Brand Name | Manufacturer | Strength/Dosage Form | Price (USD) |
---|---|---|---|
Ikorel | Servier | 10 mg Tablet | $40 (30 tablets) |
Generic Nicorandil | Various | 10 mg Tablet | $20 (30 tablets) |
18. 15 FAQs (Frequently Asked Questions)
1. What is Nicorandil used for?
Nicorandil is used for the long-term management of chronic stable angina.
2. How does Nicorandil work?
It acts as a potassium channel activator and nitrate donor, improving blood flow and reducing the workload on the heart.
3. What is the usual dose of Nicorandil?
The typical dose is 10–20 mg twice daily, with a maximum of 40 mg/day.
4. Can Nicorandil cause headaches?
Yes, headaches are a common side effect, particularly during the initial stages of treatment.
5. Can Nicorandil be used in children?
No, it is not recommended for children.
6. Can Nicorandil cause ulcers?
Yes, Nicorandil has been associated with severe ulcerations. Report any signs of ulcers immediately.
7. Is Nicorandil safe during pregnancy?
It should be used only if the benefits outweigh the risks. Consult your doctor before use.
8. Can Nicorandil be used with sildenafil?
No, combining Nicorandil with sildenafil or other PDE-5 inhibitors can cause severe hypotension.
9. How long does it take for Nicorandil to work?
It begins working within 30–60 minutes, but full effects may take longer depending on the condition.
10. What should I do if I miss a dose?
Take the missed dose as soon as you remember, but skip it if it is close to the next scheduled dose. Do not double the dose.
11. Can Nicorandil cause low blood pressure?
Yes, it may cause hypotension, particularly in dehydrated patients or those on antihypertensives.
12. Can I stop taking Nicorandil suddenly?
No, stopping suddenly may worsen angina. Consult your doctor for a proper tapering plan if needed.
13. What are the alternatives to Nicorandil?
Alternatives include beta-blockers, calcium channel blockers, and nitrates.
14. How should Nicorandil be stored?
Store at room temperature, away from moisture and heat.
15. Do I need a prescription for Nicorandil?
Yes, Nicorandil is a prescription-only medication.