Drug reference

Nicorandil

Vasodilator · Antianginal

VasodilatorAntianginal

CDSCO approved

EXCRETION

—

not curated

INTERACTIONS

7 major

incl. contraindicated

PREGNANCY

—

not curated

Top interactionssee all 12 →

RiociguatContraindicatedDatabase
SildenafilContraindicatedDatabase
TadalafilContraindicatedDatabase
VardenafilContraindicatedDatabase

Mechanism

Nicorandil has a unique dual mechanism: it opens ATP-sensitive potassium channels (K-ATP) in vascular smooth muscle, causing hyperpolarization and vasodilation of arterioles (reducing afterload), and it possesses a nitrate moiety that releases nitric oxide, dilating capacitance veins (reducing preload) and epicardial coronary arteries. This combination of arteriolar and venodilator effects reduces both preload and afterload while improving coronary blood flow. The IONA trial demonstrated that nicorandil reduces major adverse coronary events in stable angina.

Indications

Prophylaxis and treatment of stable anginalittle use in heart failureStable anginaVasospastic anginaAcute MI (during angioplasty)Prevention of recurrent episodes of vasospastic angina

Dosing

Adult: Initially 5–10 mg twice daily by mouth, then increased if tolerated to 40 mg twice daily; usual dose 10–20 mg twice daily, use lower initial dose regimen if patient susceptible to headache.
Max dose: 80 mg/day (40 mg twice daily)

Pharmacokinetics

Onset

well absorbed orally

Half-life

initial rapid phase t½ is 1 hour and later slow phase t½ is 12 hours

Metabolism

nearly completely metabolized in liver

Excretion

in urine

Contraindications

Acute pulmonary oedema
Hypovolaemia
Left ventricular dysfunction with low ﬁlling pressure

Side effects

Common

Oral ulcerationHeadacheflushingpalpitationweaknessdizzinessnauseavomitinglarge painful aphthous ulcers in the mouth

Drug interactions

Riociguat

Contraindicated

Database

Profound and prolonged systemic hypotension, syncope.

Concomitant use is absolutely contraindicated. Patients on nicorandil should not be prescribed riociguat.

Sildenafil

Contraindicated

Database

Extreme hypotension, potentially life-threatening.

PDE5 inhibitors should not be prescribed to patients receiving any form of nitrate. Patients should be warned not to use PDE5 inhibitors and nitrates concurrently. No PDE5 inhibitor should be used in the 24 hours prior to initiating nitrate therapy. If significant hypotension occurs, fluids and α adrenergic receptor agonists may be used for support.

Tadalafil

Contraindicated

Database

Profound and prolonged systemic hypotension, syncope, myocardial ischemia, and even death.

Concomitant use is absolutely contraindicated. Patients on nicorandil should not be prescribed tadalafil or other PDE5 inhibitors (sildenafil, vardenafil).

Vardenafil

Contraindicated

Database

Profound and prolonged systemic hypotension, syncope, myocardial ischemia, and even death.

Concomitant use is absolutely contraindicated. Patients on nicorandil should not be prescribed vardenafil or other PDE5 inhibitors (sildenafil, tadalafil).

Isosorbide Dinitrate

Severe

Database

Additive hypotensive effects, potentially leading to severe hypotension, dizziness, syncope, and reflex tachycardia.

Avoid concomitant use if possible. If co-administration is necessary, monitor blood pressure closely and consider reducing the dose of one or both agents. Educate the patient about symptoms of hypotension.

Isosorbide Mononitrate

Severe

Database

Additive hypotensive effects, potentially leading to severe hypotension, dizziness, syncope, and reflex tachycardia.

Nitroglycerin

Severe

Database

Additive hypotensive effects, potentially leading to severe hypotension, dizziness, syncope, and reflex tachycardia.

Amlodipine

Moderate

Database

Additive hypotensive effects, potentially leading to symptomatic hypotension, dizziness, and syncope.

Monitor blood pressure closely, especially during initiation or dose titration of either drug. Consider starting with lower doses of both agents or adjusting doses based on blood pressure response. Educate the patient about symptoms of hypotension.

Furosemide

Moderate

Database

Additive hypotensive effects, potentially leading to symptomatic hypotension, dizziness, and syncope, especially in volume-depleted patients.

Monitor blood pressure and hydration status closely. Adjust doses of either drug as needed. Ensure adequate hydration. Educate the patient about symptoms of hypotension.

Metoprolol

Moderate

Database

Additive hypotensive effects, potentially leading to symptomatic hypotension, dizziness, and syncope. However, beta-blockers can also counteract reflex tachycardia induced by nicorandil.

Monitor blood pressure closely, especially during initiation or dose titration of either drug. Adjust doses as needed. Educate the patient about symptoms of hypotension.

Telmisartan

Moderate

Database

Additive hypotensive effects, potentially leading to symptomatic hypotension, dizziness, and syncope.

Aspirin

Mild

Database

Potentially increased risk of bleeding, although typically mild and not well-documented as a significant interaction.

Monitor for signs of bleeding (e.g., bruising, epistaxis). Generally, co-administration is safe and often indicated in cardiovascular patients. No dose adjustment is usually required unless other risk factors for bleeding are present.