A demonstration of peristomal ulceration in the setting of nicorandil therapy.

To cite: McCormack P, Skelly R. BMJ Case Rep Published online: [please include Day Month Year] doi:10.1136/bcr-2014206599 DESCRIPTION Nicorandil is a nicotinamide ester commonly prescribed for management of angina. Since the late 1990s it has been linked with drug-induced ulceration. The current British National Formulary suggests that between 1 in 10 000 and 1 in 1000 cases may be affected. Initially lesions were reported in the buccal cavity, subsequently throughout the gastrointestinal (GI) tract and at the anus, with a recent association to parastomal breakdown. Cases involving fistulation to adjacent organs have also been described. Metabolites of nicorandil, nicotinic acid and nicotinamide have been suggested as factors in ulcer formation, particularly with higher doses. A 62-year-old woman on nicorandil 30 mg twice daily for angina with a history of peripheral vascular disease, systemic lupus erythematosus, chronic obstructive pulmonary disease and hypothyroidism presented with a rectovaginal fistula. She was on no other medications associated with GI complications. Flexible sigmoidoscopy demonstrated a rectovaginal fistula. Biopsies demonstrated only granulation tissue and ulcer slough. A loop colostomy was fashioned to treat the fistula. Two months postoperatively, the patient represented with significant peristomal ulceration. Nicorandil was considered as a potential causative agent and treatment was discontinued. No further biopsies were taken at this stage. Within a 2-month period the peristomal ulceration had healed. The images demonstrate the significance of the peristomal disease developed while on nicorandil (figure 1) and the subsequent improvement on cessation (figure 2). It would appear likely in this case that nicorandil has contributed to the patient’s presentation and subsequent events. This medication needs to be considered when patients are being considered for surgical intervention.