Topical application of medications commonly used for hypertensive and cardiovascular conditions have found a place in therapy in possibly preventing surgery of anal fissures. Topical diltiazem, (Cardizem) or Topical Nitroglycerin or Topical Nifedipine (Procardia,Adalat ) were shown to be effective in reducing maximal anal resting pressure in patients with anal fissures. Patients with anal fissures often have abnormally high resting sphincter pressures. The healing of fissures is facilitated by reduction of maximum resting pressures of the anal sphincter. From 77 to 86% had resolution of anal pain/bleeding and absence of fissure on examination within 8 weeks with a diltiazem or nitroglycerin ointment formulation, respectively.

With 6 to 8 weeks of treatment, both topical nitroglycerin (NTG) and topical diltiazem twice daily were equally effective in healing chronic anal fissure and improving symptom scores, while diltiazem was better tolerated, particularly in regards to treatment-emergent headache and miscellaneous gastrointestinal complaints. Sixty consecutive adult patients who met entry requirements (long-standing pain after defecation; sentinel anal tag; exposure of horizontal fibers of the internal anal sphincter) were randomized to treatment.

Since similar therapeutic benefit was expected, the primary outcome was side effects (headache) with the anticipated rate with nitroglycerin being nearly 60% and estimated 10% for diltiazem, and the observed rates 58% and 25%, respectively (p=0.01). After 8 weeks, 25 of 29 NTG patients (86%) were healed (n=12) or improved (n=13), compared to 77% (24 of 31; 8 healed, 16 improved) with diltiazem (p=0.2) (Kocher et al, 2002.) Headache induced by 0.2% nitroglycerin is generally transient and relieved by oral analgesia.
These formulations are not commercially available but are routinely compounded by our Compounding Pharmacy (S&P Prescription Compounding Services. Levittown, NY) with a doctor Prescription. For more information and a physician referral call us at 516-644-2470.

Ref.: Carapeti EA, Kamm MA, and Evans BK et al: Topical Diltiazem and bethanechol decrease anal sphincter pressure without side effects. Gut 1999; 45:719-722. Carapeti EA, Kamm MA & Phillips RKS: Topical diltiazem and bethanechol decrease anal sphincter pressure and heal anal fissures without side effects. Dis Colon Rectum 2000; 43(10):1359-1362. Hyman NH & Cataldo PA: Nitroglycerin ointment for anal fissures: effective treatment or just a headache? Dis Colon Rectum 1999; 42(3):383-385. Lund JN & Scholefield JH: A randomised, prospective, double-blind, placebo-controlled trial of glyceryl trinitrate ointment in treatment of anal fissure. Lancet 1997; 349:11-14. Manookian CM, Fleshner P, Moore B et al: Topical nitroglycerin in the management of anal fissure: an explosive outcome. Am Surg 1998; 64(10):962-964.
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