Mouth ulcers scenario: which medication in this patient's regimen is most likely contributing to mouth ulcers?

• A. Ramipril
• B. GTN 400 microgram spray
• C. Ibuprofen 5% gel
• D. Nicorandil

Answer: (D)

Mouth ulcers can be a drug-related adverse effect, and some medicines are known to cause mucosal ulceration in the mouth. Nicorandil is a vasodilator used for angina that has a well-recognized association with oral and other mucosal ulcers, sometimes occurring with long-term use or higher doses. The exact mechanism isn’t fully clear, but the ulceration is a documented and relatively common adverse effect, so it fits best with a patient presenting mouth ulcers.

The other drugs listed don’t have this pattern. Ramipril (an ACE inhibitor) commonly causes cough, hyperkalemia, and sometimes angioedema, not mouth ulcers. Glycerol trinitrate spray can irritate mucosa locally but is not a typical cause of persistent mouth ulcers. Ibuprofen gel is topical to the skin and would cause local skin irritation rather than oral ulcers. So the medication most likely contributing to mouth ulcers is nicorandil.