Letter: Nicorandil-Induced Peristomal Ulceration

Dear Sirs Nicorandil (Ikorel; Rhône–Poulenc Rorer, Guildford, UK) is a potassium-channel activator used in the treatment of severe ischaemic heart disease. It causes anal and oral ulceration. We report the case of the rare phenomenon of Nicorandil-induced peristomal ulceration, the severity of which almost required plastic surgery input. A 71-year-old lady, who had a Hartmann’s procedure 5 years before for a vesicocolic fistula, was presented to the community stoma team with a tender area adjacent to her colostomy. She had an extensive cardiac history including two previous coronary artery bypass grafts coronary artery bypass grafts (CABG) and more recently coronary stenting. In the year 1999, she was commenced on Nicorandil for unstable angina, in combination with numerous other cardioprotective drugs. Two weeks following presentation, ulceration occurred that failed to respond to a variety of dressings. No bacterial growth was identified. After 3 months of progressive deterioration of the ulcer, preliminary discussions were held regarding the possible need for plastic surgery involvement to provide skin cover. At that time, Nicorandil was identified as a possible cause and stopped immediately. Within a week, an improvement was noticed with no further progression and slight granulation occurring. Four weeks after stopping Nicorandil, the ulcer had almost completely resolved. This case demonstrates a dramatic improvement associated with stopping Nicorandil. Although Nicorandil is undoubtedly the cause, the fact that it was initially commenced in excess of 5 years prior to the development of symptomatic ulceration suggests that there is a yet unidentified precipitant. Interestingly, it is possible that the vesicocolic fistula, for which the Hartmann’s procedure was performed, may have been as a result of Nicorandil. Whilst the exact aetiology has yet to be fully elucidated, anal ulceration with Nicorandil is well documented (1). More recently a number of alternative sites have been reported including penile (2), vaginal (3) and oral sites (4). In comparison to other sites, stomal ulceration is relatively rare, although it is by no means a new phenomenon (5). However, this case reinforces the importance of considering relatively simple causes, prior to consideration of involvement of specialist’s services such as plastic surgery, and that all personnel potentially be involved in providing care to be aware of adverse drug reactions.