page155
NICORANDIL
Indications
prophylaxis and treatment of angina
Cautions
hypovolaemia; low systolic blood pressure;
acute pulmonary oedema; acute myocardial infarction
with acute left ventricular failure and low filling
pressures;
interactions: Appendix 1 (nicorandil)
Driving
Patients should be warned not to drive or operate
machinery until it is established that their performance is
unimpaired
Contra-indications
cardiogenic shock; left ventricular
failure with low filling pressures;
hypotension
Pregnancy
manufacturer advises use only if potential
benefit outweighs risk—no information available
Breast-feeding
no information available—manufac-
turer advises avoid
Side-effects
headache (especially on initiation,
usually transitory);
cutaneous vasodilatation with
flushing; nausea,
vomiting,
dizziness,
weakness also
reported;
rarely
oral ulceration, myalgia,
and rash;
at
high dosage,
reduction in blood pressure and/or
increase in heart rate;
angioedema,
hepatic dysfunc-
tion,
and anal ulceration also reported
Dose
. Initially 10 mg twice daily (if susceptible to headache
5 mg twice daily); usual dose 10–20 mg twice daily; up
to 30 mg twice daily may be used
Ikorel
c
(Sanofi-Aventis) A
Tablets
,
scored,
nicorandil 10 mg,
net price 60-tab
pack = £7.71;
20 mg,
60-tab pack = £14.64
RANOLAZINE
Indications
as adjunctive therapy in the treatment of
stable angina in patients inadequately controlled or
intolerant of first-line antianginal therapies
Cautions
moderate to severe congestive heart failure;
QT interval prolongation; elderly;
body-weight less
than 60 kg;
interactions: Appendix 1 (ranolazine)
Hepatic impairment
use with caution in mild impair-
ment;
avoid in moderate and severe impairment
Renal impairment
use with caution if eGFR 30–
80 mL/minute/1.73 m
2
;
avoid if eGFR less than
30 mL/minute/1.73 m
2
Pregnancy
manufacturer advises avoid unless essen-
tial—no information available
Breast-feeding
manufacturer advises avoid—no
information available
Side-effects
constipation,
nausea,
vomiting;
dizzi-
ness,
headache,
asthenia;
less commonly
abdominal
pain,
weight loss,
dry mouth,
dyspepsia,
flatulence;
hot flush,
hypotension,
syncope,
prolonged QT
interval, peripheral oedema;
dysponea,
cough, epis-
taxis;
lethargy,
hypoaesthesia, drowsiness,
tremor,
anxiety,
insomnia,
anorexia;
dysuria,
haematuria,
chromaturia; dehydration; pain in extremities, muscle
cramp,
joint swelling;
visual disturbance;
tinnitus;
pruritus, sweating;
rarely
pancreatitis,
erosive duo-
denitis;
cold extremities;
throat tightness;
amnesia,
loss of consciousness,
disorientation;
erectile dys-
function;
parosmia,
impaired hearing;
allergic
dermatitis,
urticaria,
rash
Dose
.
ADULT
over 18 years, initially 375 mg twice daily,
increased after 2–4 weeks to 500 mg twice daily and
then adjusted according to response to max. 750 mg
twice daily (reduce dose to 375–500 mg twice daily if
not tolerated)
Ranexa
c
(Menarini) T A
Tablets
,
m/r,
ranolazine 375 mg (blue),
net price 60-
tab pack = £48.98;
500 mg (orange),
60-tab pack =
£48.98;
750 mg (green),
60-tab pack = £48.98.
Label:
25,
patient alert card
2.6.4
Peripheral vasodilators
and related drugs
Peripheral vascular disease can be either occlusive (e.g.
intermittent
claudication
)
in which occlusion of
the
peripheral
arteries
is
caused by atherosclerosis,
or
vasospastic (e.g.
Raynaud’s syndrome
).
Peripheral
arterial
occlusive disease is associated with
an increased risk of
cardiovascular events;
this risk is
reduced by measures such as smoking cessation (sec-
tion 4.10.2), effective control of blood pressure (section
2.5),
regulating blood lipids (section 2.12),
optimising
glycaemic
control
in diabetes
(section 6.1),
taking
aspirin in a dose of
75 mg daily (section 2.9),
and
possibly weight reduction in obesity (section 4.5). Exer-
cise training,
treatment with cilostazol
or naftidrofuryl
(see below),
and possibly statin therapy can improve
symptoms of intermittent claudication.
Cilostazol
is licensed for use in intermittent claudica-
tion to improve walking distance in patients without
peripheral tissue necrosis who do not have pain at rest.
Patients
receiving cilostazol
should be assessed for
improvement
after 3 months.
The
Scottish Medicines
Consortium
(p.
4) has advised (October 2005) that cilos-
tazol
is not
recommended for the treatment
of
inter-
mittent claudication within NHS Scotland.
Naftidrofuryl
can alleviate symptoms of
intermittent
claudication and improve pain-free walking distance in
moderate disease.
Patients taking naftidrofuryl
should
be assessed for improvement after 3–6 months.
Inositol
nicotinate,
pentoxifylline,
and cinnarizine are
not established as being effective for the treatment of
intermittent claudication.
Management
of
Raynaud’s syndrome
includes avoid-
ance of exposure to cold and stopping smoking.
More
severe symptoms may require vasodilator
treatment,
which is most
often successful
in primary Raynaud’s
syndrome.
Nifedipine (section 2.6.2) is useful for redu-
cing the frequency and severity of vasospastic attacks.
Alternatively,
naftidrofuryl may produce symptomatic
improvement; inositol nicotinate (a nicotinic acid deri-
vative) may also be considered. Cinnarizine, pentoxifyl-
line,
prazosin,
and moxisylyte are not
established as
being
effective
for
the
treatment
of
Raynaud’s
syndrome.
Vasodilator therapy is not established as being effective
for
chilblains
(section 13.13).
CILOSTAZOL
Indications
intermittent claudication in patients
without rest pain and no peripheral tissue necrosis
Cautions
atrial or ventricular ectopy, atrial fibrillation,
atrial flutter; diabetes mellitus (higher risk of intra-
ocular bleeding); concomitant drugs that increase risk
of bleeding;
interactions: Appendix 1 (cilostazol)
Contra-indications
predisposition to bleeding (e.g.
active peptic ulcer, haemorrhagic stroke in previous 6
months,
surgery in previous 3 months,
proliferative
diabetic retinopathy,
poorly controlled hypertension);
BNF 61
2.6.4 Peripheral vasodilators and related drugs
135
2
Cardiovascular system