Nicorandil
A dual-action anti-anginal that combines nitrate-like venodilation with ATP-sensitive potassium (KATP) channel opening, producing arterial and coronary vasodilation. Widely used for angina in Europe and Japan. Not WADA-banned. Notable for causing painful mucosal ulceration with chronic use.
01 Overview
Nicorandil is a nicotinamide-nitrate ester with two vasodilatory mechanisms: it donates nitric oxide (like organic nitrates) to relax veins and reduce preload, and it opens KATP channels in vascular smooth muscle to relax arteries and dilate coronary vessels, reducing afterload. This balanced pre- and afterload reduction improves myocardial oxygen supply-demand balance. KATP opening is also implicated in ischaemic preconditioning.
It is used for angina refractory to or intolerant of first-line agents. A distinctive and sometimes serious adverse effect of long-term use is painful ulceration of the mouth, gastrointestinal tract, skin and perianal region.
02 Mechanism
Combines nitric-oxide-mediated venodilation (reducing preload) with ATP-sensitive potassium (KATP) channel opening in arterial smooth muscle (reducing afterload and dilating coronaries), improving myocardial oxygen balance.
03 Dosing
| Tier | Dose | Route | Notes |
|---|---|---|---|
| Starting dose | 5–10 mg | Oral | 5-10 mg twice daily. |
04 Effects
| Effect | Magnitude | Evidence | |
|---|---|---|---|
| Reduced angina and ischaemiaReduces anginal episodes and improved cardiac outcomes as add-on therapy (IONA trial). | moderate | Clinical | |
| Coronary vasodilation / preconditioningDilates coronary arteries and may mimic ischaemic preconditioning via KATP opening. | Clinical |
05 Side effects
| Effect | Severity | Frequency | Evidence | Countermeasures |
|---|---|---|---|---|
| HeadacheNitrate-type headache, common on initiation. | Mild | Very common early | Clinical | |
| Hypotension / flushingDizziness, flushing and low blood pressure from vasodilation. | Mild | Common | Clinical | |
| Mucocutaneous ulcerationPainful oral, gastrointestinal, anal and skin ulcers that resolve only on discontinuation. | Severe | With chronic use | Clinical |