The most interesting development in medicinal treatment of hemorrhoids has to do with the use of agents that relax the anal sphincter. There is evidence that hemorrhoid sufferers have increased tightness of the anal sphincter , and some studies are showing that a variety of anal sphincter-relaxing remedies may promote improvement in prolapsed internal hemorrhoids and thrombosed external hemorrhoids, possibly avoiding surgery, or make it possible to to use techniques short of scalpel hemorrhoidectomy .
(2) [Oral nifedipine reduces resting anal pressure and heals chronic anal fissure. Br J Surg 1999 Oct;86(10):1269-73 (ISSN: 0007-1323) Cook TA; Humphreys MM; McC Mortensen NJ ]
(this study showed that oral nifedipine, like the topical version, can also promote anal fissure healing, with tolerable side effects in some patients)
(Colorectal surgeons from Amercican Society of Colon/Rectal Surgeons have an E-mail exchange on topical calcium channel blockers)
From: SF
To: ASCRS
Sent: Sunday, October 27, 2002 10:25 PM
Subject: Re: Topical Medications for Anal Fissure
> I have the pharmacist mix 60 mg of nifedipine (adalat) in 30 gm of
petroleum
> jelly. This is 0.2% concentration. I've stopped using
nitroglycerine, I
> can't remember a patient who it either worked on or was tolerated .
The
> adalat seems very well tolerated and seems to at least work in some
> patients. Basically I tell them to use the adalat, stool softeners
and see
> how they go. If they are still miserable in 4-6 weeks, I will offer
them an
> operation. I've had limited experience with Botox, seems to work,
but
> nothing works as well as an operation. Personally if I had a
fissure, I
> would give the Botox a try, if it doesn't work, can always do the
> sphincterotomy later.
>
> SF
> Toronto
-------------------------
Date: Mon, 28 Oct 2002 17:25:54 -0000
From: NR
Subject: Re: Topical Medications for Anal Fissure
Our Pharmacist also uses petrolatum but we use 2% Nifedipine and not
0.2%. I
think the manufacturers of Adalat are already making the ointment. So
your
pharmacist can relax.
NR
Consultant Colorectal surgeon
UK.
----------------------------
Date: Tue, 29 Oct 2002 17:48:05 EST
From: RP
Subject: Re: Topical Medications for Anal Fissure
Joshua
I talked with my pharmacist and we do use 0.2% Nifedipine ointment. He
also
makes a suppository that combines Xylocaine 5% and the 0.2% Nifedipine.
In
reference to the article by Jonas et al.they use topical 2% Diltiazem
with
good results when compared with oral. I feel the same way as Stan, the
incidence of side effects is much lower with Nifedipine than with NTG.
It
would be interesting to try a 2%Nifedipine plus Xylocaine 5%
suppository and
see how it works out.
Sincerely,
RP MD FASCRS
West VA
---------------------------
Date: Wed, 30 Oct 2002 16:57:14 -0500
From: JK
Subject: Re: Topical Medications for Anal Fissure
Thanks. I will try this. What is the mixing agent for the nifedipine
(or do you just mix it with the 5% xylocaine.
JK, M.D.
George Washington University School of Medicine
-----------------------------
Date: Wed, 30 Oct 2002 18:03:30 EST
From: RP
Subject: Re: Topical Medications for Anal Fissure
Joshua:
The mixture is called MBK and is a fatty acid base that is used for
the
suppositories, the reason you have different concentrations in the
preparations is that they (in U.K.)are using different type of Ca
Channel
blocker (Nifedipine vs Diltiazem) look article DCR 1999,Vol 42 No 8 pg.
1011,
this was a multicenter study out of Univ. of Naples, Italy by Antropoli
et al
they used Nifedipine 0.2% gel. they obtained an impressive 95%
remission in
nifedipine treated pts at 21 days. Obviously some of those patients
will
recurr after they stop the medication.
Sincerely
RP, MD, FASCRS
West Va
-----------------------------
Date: Thu, 31 Oct 2002 19:15:45 -0500
From: D and D
Subject: Re: Topical Medications for Anal Fissure
Nagesh:
nifedipine(Procardia, Adalat) and diltiazem(Cardizem, Cartia) are the
generic names. They are both Ca channel blockers, but are different
drugs with different pharmacologic properties.
------------------------------
Date: Thu, 31 Oct 2002 21:02:41 EST
From: RP
Subject: Re: Topical Medications for Anal Fissure
Nagesh
Diltiazem and Nifedipine ARE generic names!
I have the feeling that Nifedipine is stronger than Diltiazem that is
the
reason that you guys use 2% concentration instead of 0.2.
Sincerely,
RP MD FASCRS
West Va
-------------------------------
Date: Thu, 31 Oct 2002 23:50:33 -0000
From: N
Subject: Re: Topical Medications for Anal Fissure
Roger,
I think, Nifedipine and Diltiazem are one and the same. Are you not
getting
confused with the generic and pharmacological names!!!!
N
---------------------------------
Date: Thu, 31 Oct 2002 08:32:34 +0100
From: EL
Subject: topical medications in anal fissure
Does anyone know the profile of safety of topical medications in
pregnancy or in lactating women?
My last two "fissure patients" were a pregnant woman in the first
trimester and a lactating woman.
I prescribed a course of Dilatan (Sapimed, Italy), in order to achieve
a
progressive dilatation by threee progressive plastic anal dilators.
EL
Ospedale civile di Pescara
Italy
--------------------------
Date: Fri, 1 Nov 2002 22:21:31 +0200
From: HP and DP
Subject: Re: Topical Medications for Anal Fissure
No they are not. Although they are both calcium channel blockers, they
are very different, including their affect on the cardiovascular
system.
Furthermore, diltiazem is water soluble while nifedipine is almost
insoluble in water.
I have been following this discussion for a while and it seems that
there are a lot of confusion regarding preparations with these two
drugs.
For the treatment of anal fissures either one can use either nifedipine
0.2% or diltiazem 2%. The two preparations are different mainly due to
the difference in solubility in water. You should consult with your
pharmacist and he will advise you on which he can best produce.
Anyhow don't confuse, they are NOT the same.
As for nitroglycerine preparations it is always 0.2%.
HP
Dept. of Surgery "A"
Meir Hospital, Kfar-Sava
Israel
----------------------------
Date: Fri, 1 Nov 2002 11:04:01 -0500
From: JK
Subject: Re: Topical Medications for Anal Fissure
Nifedipine and Dilitiazem are both calcium channel blockers; nifedipine
acts more peripherally and has almost no antiarrythmic effect.
Diltiazem act more centrally and can be used as an antiarrythmic.
Prior
to this exchange I was unaware that topical nifedipine could be use for
perianal disease; the only literature I have is on Diltiazem.
JK, M.D.
George Washington University School of Medicine
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