SUMMARY OF PRODUCT CHARACTERISTICS

1    NAME OF THE MEDICINAL PRODUCT

Ikorel 10mg Tablets or

Nicorandil 10mg Tablets

2    QUALITATIVE AND QUANTITATIVE COMPOSITION

Nicorandil 10mg

For a full list of excipients, see section 6.1

3    PHARMACEUTICAL FORM

Tablet

Off-white, round, with faceted edges, scored on one side and bearing the inscription IK10.

4    CLINICAL PARTICULARS

4.1    Therapeutic indications

Ikorel tablets are indicated for the following:

•    The prevention and long term treatment of chronic stable angina pectoris

•    A reduction in the risk of acute coronary syndromes in patients with chronic stable angina and at least one of the following risk factors:

Previous MI

Previous CABG

CHD on angiography or a positive exercise test together with one of the following: LVH on ECG, left ventricular dysfunction, Age > 65, diabetes mellitus (type I or II excluding those on sulphonylureas, see section 5.1), hypertension or documented vascular disease

Route of administration: oral.

Adults: The recommended starting dose is 10mg nicorandil twice daily, although 5mg twice daily may be employed in patients particularly susceptible to headache. Subsequently the dosage should be titrated upward depending on the clinical response. The usual therapeutic dosage is in the range 10 to 20mg nicorandil twice daily, although up to 30mg twice daily may be employed if necessary.

Elderly:

For elderly patients use of the lowest effective dose is recommended.

Children: A paediatric dosage has not been established and use of nicorandil is not recommended.

4.3 Contraindications

Ikorel is contraindicated in patients with hypersensitivity to nicorandil or any of the excipients.

Nicorandil must not be used in the case of cardiogenic shock, hypotension or left ventricular failure with low filling pressure. .

Concurrent use of nicorandil and phosphodiesterase 5 inhibitors (e.g. sildenafil, tadalafil, vardenafil) is contraindicated since it can lead to a serious drop in blood pressure.

4.4 Special warnings and precautions for use

Gastrointestinal ulcerations, skin and mucosal ulceration have been reported with nicorandil (see section 4.8).

Gastrointestinal ulcerations

Nicorandil induced ulceration may occur at different locations in the same patient. They are refractory to treatment and most only respond to withdrawal of nicorandil treatment. If ulcerations develop, nicorandil should be discontinued (see section 4.8)

Gastrointestinal haemorrhage secondary to gastrointestinal ulceration has been reported with nicorandil. The patients taking concomitantly acetylsalicylic acid are at increased risk for severe complications such as gastrointestinal haemorrhage. Therefore caution is advised when concomitant use of acetylsalicylic acid and nicorandil is considered (see section 4.5).

If advanced, ulcers may develop into perforation, fistula, or abscess formation. Patients with diverticular disease may be at particular risk of fistula formation or bowel perforation during nicorandil treatment.

Gastrointestinal perforations in context of concomitant use of nicorandil and corticosteroids have been reported. Caution is advised when concomitant use is considered.

Eye ulcerations

Very rare conjunctivitis, conjunctival ulcer and corneal ulcer have been reported with nicorandil. Patients should be advised of the signs and symptoms and monitored closely for corneal ulcerations. If ulceration(s) develops, nicorandil should be discontinued (see section 4.8).

Hyperkalaemia

Severe hyperkalaemia has been reported very rarely with nicorandil. Nicorandil should be used with care in combination with other medical products that may increase potassium levels (see sections 4.5 and 4.8).

Nicorandil must be used with caution in patients who may have blood volume depletion or in those who present, low systolic blood pressure (e.g below 100 mm Hg), acute pulmonary oedema or acute myocardial infarction with acute left ventricular failure and low filling pressures.

Caution is advised if nicorandil is used in combination with other medicinal products with blood pressure lowering effect (see section 4.5).

The tablets are sensitive to moisture; hence the patients should be advised to keep the tablets in their blister until intake. Besides the nicorandil tablets, each blister contains active substance-free silica gel tablets as desiccant in a separate blister segment which is marked accordingly. The patients should be advised not to take these tablets. Although any accidental intake of this desiccant is usually harmless, it may alter the scheduled intake of the active tablets.

Paediatric patients

Ikorel is not recommended in paediatric patients since its safety and efficacy have not been established in this patient group.

4.5 Interaction with other medicinal products and other forms of interaction

Caution is advised when nicorandil is used in combination with other medical products that may increase potassium levels (see sections 4.4 and 4.8).

In patients receiving concomitantly acetylsalicylic acid there is an increased risk for severe complications such as gastrointestinal haemorrhage (see section 4.4).

Gastrointestinal perforations in the context of concomitant use of nicorandil and corticosteroids have been reported. Caution is advised when concomitant use is considered.

Concurrent use of nicorandil and phosphodiesterase 5 inhibitors, e.g. sildenafil, tadalfil, vardenafil, is contraindicated, since it can lead to a serious drop in blood pressure.

Therapeutic doses of nicorandil may lower the blood pressure of hypotensive patients. If nicorandil is used concomitantly with antihypertensive agents or other medicinal products with blood-pressure-lowering effect (e.g vasodilators, tricyclic antidepressants, alcohol) the blood-pressure-lowering effect may be increased.

4.6 Pregnancy and lactation

Pregnancy: Although animal studies have not shown any teratogenic effect of nicorandil, the medicinal product has not been studied in human pregnancy; therefore, Ikorel must only be used in pregnant women if the anticipated benefit outweighs any potential risks.

Lactation: Animal studies have shown that nicorandil is excreted in small amounts into the breast milk. It is not known whether nicorandil is excreted in human milk, therefore Ikorel is not recommended during breastfeeding.

4.7 Effects on ability to drive and use machines

Blood pressure-lowering effects of nicorandil can reduce the ability to drive or to use machines. This effect can be increased in conjunction with alcohol or other products with blood-pressure-lowering effect (e.g. vasodilators, tricyclic antidepressants). (see section 4.5).

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

4.8 Undesirable effects

The following definitions apply to the frequency terminology used hereafter:

Very common (>1/10); common (>1/100, <1/10); uncommon (>1/1,000, <1/100); rare (>1/10,000, <1/1,000); very rare (<1/10,000); unknown (cannot be estimated from the available data).

SOC	FREQUENCY	ADR
Metabolism and nutrition Disorders	Very rare	Hyperkalaemia (see section 4.4)
Nervous system disorders	Very common	Headache, particularly during the first few days of treatment.
	Common	Dizziness
Cardiac disorders	Common	Increase in heart rate, following the

Vascular disorders    Common    Cutaneous vasodilation with flushing

Uncommon Decrease in blood pressure.

Gastrointestinal disorders	Common	Nausea and vomiting
	Rare	Gastrointestinal ulcerations such as stomatitis, mouth ulcers, tongue ulcers, small intestine ulcers, large intestine ulcers and anal ulcers. These ulcers, if advanced, may develop into perforation, fistula, or abscess formation. Weight loss has been reported in association with nicorandil induced ulcers and fistulas (see section 4.4).
	Unknown	Gastrointestinal haemorrhage (see section 4.4)
Hepato-biliary disorders	Very rare	Liver disorders such as hepatitis, cholestasis, or jaundice.
Skin and subcutaneous tissue disorders	Rare	Different types of rash, pruritus.

Very rare    Angio-oedema. Skin and mucosal

ulcerations (mainly peri-anal ulcerations, genital ulcerations and parastomal ulcerations (see section 4.4).

Musculoskeletal & connective tissue disorders	Rare	Myalgia
General disorders and administration site conditions	Common	Feeling of weakness
Eye disorders	Very rare	Conjunctivitis, conjunctival ulcer and corneal ulcer

Additional Information

In addition, the following events have been reported at a different frequency in the IONA (Impact of Nicorandil in Angina) study which was conducted in subjects at high risk of cardiovascular events only.

Skin and subcutaneous tissue disorders

Uncommon - angio-oedema

Gastrointestinal disorders

Common - rectal bleeding.

Uncommon - mouth ulcers

Very rare - abdominal pain

Musculoskeletal & connective tissue disorders

Uncommon - myalgia

Reporting of suspected adverse reactions

Reporting suspected adverse reactions after authorisation of the medicinal product is important. It allows continued monitoring of the benefit/risk balance of the medicinal product. Healthcare professionals are asked to report any suspected adverse reactions via the Yellow Card Scheme at www.mhra.gov.uk/yellowcard.

4.9 Overdose

Symptoms

In case of acute overdose, the likely symptomatology may be peripheral vasodilation with a fall in blood pressure and reflex tachycardia.

Management

Monitoring cardiac function and general supportive measures are recommended. If not successful, increase in circulating plasma volume by fluid resuscitation is recommended. In life-threatening situations, administration of vasopressors must be considered. There is no experience of massive overdosage in humans, although the LD₅₀ in dogs is in the range 62.5 to 125 mg/kg and in rodents it is in the order of 1200 mg/kg.

5 PHARMACOLOGICAL PROPERTIES

5.1 Pharmacodynamic properties

Pharmacotherapeutic group: Other vasodilators used in cardiac disease, ATC code: C01DX16

Nicorandil provides a dual mode of action leading to relaxation of vascular smooth muscle. A potassium channel opening action provides arterial vasodilation, thus reducing afterload, while the nitrate component promotes venous relaxation and a reduction in preload. Nicorandil has a direct effect on coronary arteries without leading to a steal phenomenon. The overall action improves blood flow to poststenotic regions and the oxygen balance in the myocardium.

A reduction of coronary heart disease complications has been shown in patients suffering from angina pectoris who were treated with nicorandil in the IONA study.

The study was a randomised, double blind, placebo controlled, cardiovascular endpoint study carried out in 5126 patients to determine if Nicorandil could reduce the frequency of coronary events in men and women with chronic stable angina and

standard anti anginal treatment at high risk of cardiovascular events defined by either: 1) previous myocardial infarction, or 2) coronary artery bypass grafting , or 3) coronary artery disease confirmed by angiography, or a positive exercise test in the previous two years, together with one of the following: left ventricular hypertrophy on the ECG, left ventricular ejection fraction < 45%, or an end diastolic dimension of >55 mm, age > 65, diabetes (either type 1 or type 2), hypertension, peripheral vascular disease, or cerebrovascular disease. Patients were excluded from the study if they were receiving a sulphonylurea as it was felt these patients may not benefit; (sulphonylurea agents have the potential to close potassium channels and may thus antagonise some of the effects of nicorandil). Study follow up for endpoint analysis was between 12 and 36 months with a mean of 1.6 years.

The primary endpoint of coronary heart disease (CHD) death, non-fatal myocardial infarction, or unplanned hospital admission for cardiac chest pain, occurred in 13.1% of patients treated with nicorandil compared with 15.5% of patients receiving placebo (hazard ratio 0.83, p=0.014). The rate of acute coronary syndrome (CHD death, non fatal MI or unstable angina) was 6.1% in patients treated with nicorandil compared with 7.6% in patients receiving placebo (hazard ratio 0.79, p=0.028). All cardiovascular events were significantly less in the nicorandil than placebo group 14.7% vs 17.0% (hazard ratio 0.86 p=0.027). The validity of these findings was confirmed by re-analysing the primary endpoint using all cause rather than cardiovascular mortality (nicorandil 14.9% compared with placebo 17.3%, hazard ratio 0.85, p=0.021). The study was not expressly powered to, nor did it detect any statistically significant reduction in any individual component endpoints.

5.2 Pharmacokinetic properties

Nicorandil is well absorbed with no significant first-pass metabolism. Maximum plasma concentrations are achieved in 30 to 60 minutes and are directly related to the dosage. Metabolism is mainly by denitration of the molecule into the nicotinamide pathway with less than 20% of an administered dose being excreted in the urine. The main phase of elimination has a half-life of about 1 hour. Nicorandil is only slightly bound to plasma proteins.

No clinically relevant modifications in the pharmacokinetic profile have been seen in the elderly or in patients with liver disease or chronic renal failure.

5.3 Preclinical safety data

There are no preclinical data of relevance to the prescriber which are additional to that included in other sections of the SPC.

List of excipients

Maize starch, croscarmellose sodium, stearic acid and mannitol.

6.2 Incompatibilities

None stated.

6.3 Shelf life

18 months.

Each blister strip should be used within 30 days of opening.

6.4 Special precautions for storage

Store in a dry place below 25^oC.

6.5 Nature and contents of container

Ikorel tablets 10mg and 20mg are presented in hard tempered aluminium foil/ (Polyamide/aluminium/PVC) blister strips of 10 tablets, in which each tablet is linked to a silica gel capsule dessicant.

The blister strips are packaged in cartons of 10, 20, 30, 40, 50, 60, 70, 80, 90 or 100 tablets.

6.6 Special precautions for disposal

None stated.

MARKETING AUTHORISATION HOLDER

Aventis Pharma Limited

One Onslow Street

Guildford

Surrey

GU1 4YS

UK

Trading as:

Sanofi-aventis or Sanofi

One Onslow Street

Guildford

Surrey

GU1 4YS

UK

8    MARKETING AUTHORISATION NUMBER(S)

PL 04425/0327

9 DATE OF FIRST AUTHORISATION/RENEWAL OF THE AUTHORISATION

16 August 2007

10 DATE OF REVISION OF THE TEXT

24/11/2014