NICORANDIL
Indications
prophylaxis and treatment of stable angina (second-line)

Cautions
low systolic blood pressure; acute myocardial infarction with acute left ventricular failure and low filling pressures; hyperkalaemia; G6PD deficiency; heart failure (class III–IV); diverticular disease (risk of fistula formation or bowel perforation); interactions: Appendix 1 (nicorandil)

Driving
Patients should be warned not to drive or operate machinery until it is established that their performance is unimpaired

Nicorandil-induced ulceration
Nicorandil can cause serious skin, mucosal, and eye ulceration; including gastro-intestinal ulcers, which may progress to perforation, haemorrhage, fistula or abscess. Stop treatment if ulceration occurs and consider an alternative.

Mohan- I would only start with 5mg bd in Indian patients .

Contra-indications
cardiogenic shock; left ventricular failure with low filling pressures; severe hypotension; hypovolaemia; acute pulmonary oedema

Pregnancy
manufacturer advises use only if potential benefit outweighs risk—no information available

Breast-feeding
no information available—manufacturer advises avoid

Side-effects
nausea, vomiting, rectal bleeding, cutaneous vasodilation with flushing, increase in heart rate (at high doses), dizziness, headache (especially on initiation, usually transitory), weakness;
less commonly oral ulceration, hypotension, myalgia, angioedema;
rarely gastro-intestinal ulceration, anal ulceration, abdominal pain, hepatitis, cholestasis, jaundice, skin ulceration, rash, pruritus; very rarely; eye ulceration; also reported gastrointestinal haemorrhage

Dose
Initially 10 mg twice daily (if susceptible to headache 5 mg twice daily), then increased if tolerated to 40 mg twice daily; usual dose 10–20 mg twice daily.

Mohan- I would only start with 5mg bid in Indian patients , and titrate upwards with close monitoring.