Age and Ageing Advance Access originally published online on May 12, 2006
Age and Ageing 2006 35(4):451; doi:10.1093/ageing/afl022
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Nicorandil-associated anal ulceration
SIR—We wish to highlight the association between nicorandil use and anal ulceration to the geriatric medical community.Nicorandil is a potassium-channel activator, with adjunct nitrate effect, used in the treatment of severe ischaemic heart disease. Whilst the association between nicorandil use and oral ulceration is well recognised, only recently have a number of published series highlighted the association with anal ulceration [1–5]. To date, 61 cases have been described. In addition, one reported case of small bowel ulceration [6] questions whether the entire gastrointestinal tract may be involved in this phenomenon.
Patients typically present with severe, painful anal ulceration, refractory to surgical management (Figure 1). It may follow iatrogenic injury such as minor anorectal surgery or biopsy [5]. Macroscopically, the ulcers vary in size but are well circumscribed, with undermined edges. Histological examination usually reveals non-specific inflammatory change. The patients have frequently been extensively investigated, and inflammatory bowel disease, neoplasia, tuberculosis, sarcoid and sexually transmitted infection have been excluded. They may have undergone high-risk procedures such as diversion colostomy or perineal skin grafting, which failed to facilitate healing.
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The suspicion of the association and cessation of nicorandil led to spontaneous re-epithelialisation of the ulcers in all the described cases. Median healing time has been reported as 12 weeks [5].
Proposed mechanisms of the ulceration include a vascular steal phenomenon because of nicorandil-induced redistribution of arterial and venous flow or a direct local toxic effect of the drug or a metabolite.
Given that this is a group of patients with severe cardiovascular disease, a multidisciplinary approach to their care is essential. Specialist geriatric, medical and cardiology input ensures the safe substitution of nicorandil for other anti-anginal preparations. It is also important that those prescribing nicorandil be aware of this important adverse reaction to the drug.
Colorectal Unit, Department of General Surgery, Manchester Royal Infirmary, Oxford Road, Manchester M13 9WL, UK
* To whom correspondence should be addressed: Email: emmabarrow77{at}hotmail.com
References
- Watson A, Al-Ozhari O, Fraser A, Loudon M, O’Kelly T. Nicorandil-associated anal ulceration. Lancet 2002; 360: 546–7.[CrossRef][Medline]
- Vella M, Molloy RG. Nicorandil-associated anal ulceration. Lancet 2002; 360: 1979.[Medline]
- Passeron T, Lacour JP, Mantoux F, Fabiani P, Dubois D, Ortonne JP. Chronic anal ulceration due to nicorandil. Br J Dermatol 2004; 150: 394–6.[Medline]
- Watson A, Suttie S, Fraser A, O’Kelly T, Loudon M. Nicorandil associated anal ulceration. Colorectal Dis 2004; 6: 330–1.[Medline]
- Katory M, Davies B, Kelty C et al. Nicorandil and idiopathic anal ulceration. Dis Colon Rectum 2005; 48: 1442–6.[Medline]
- King PM, Suttie SA, Jansen JO, Watson AJM. Perforation of the terminal ileum: a possible complication of nicorandil therapy. Surg J R Coll Surg Edinb Irel 2004; 2: 56–7.
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