Anal fissure topical therapy
Topical therapy that relaxes the internal anal sphincter is recommended for chronic anal fissure. [1] Topical options recommended by major guidance include glyceryl trinitrate (nitroglycerin) ointment and topical calcium channel blocker ointment such as diltiazem 2%. [1], [2], [3]
Recommended ointment options
- Glyceryl trinitrate (GTN; nitroglycerin) ointment (reported dosing guidance includes 0.4% GTN rectal ointment). [2], [3]
- Diltiazem 2% cream or ointment (topical calcium channel blocker). [2]
Medication selection algorithm
For chronic anal fissure, topical pharmacologic sphincter relaxation is generally selected from: [1], [2]
- Nitric oxide donor therapy: glyceryl trinitrate (nitroglycerin) ointment. [1], [2]
- Calcium channel blocker therapy: diltiazem 2% cream or ointment. [1], [2]
Key evidence supporting topical ointment therapy
Topical calcium channel blocker therapy has demonstrated similar healing efficacy to topical nitroglycerin therapy in guideline comparisons. [1] Topical calcium channel blockers have a more favorable adverse-effect profile than topical nitroglycerin, particularly regarding headache. [1]
Treatment duration
A course of topical GTN or diltiazem for chronic anal fissure is recommended on the order of weeks (guidance describes treatment for approximately 2 months). [2] In the UK, 0.4% GTN rectal ointment is licensed for relief of pain associated with chronic anal fissure in adults for a maximum of 8 weeks. [3]
Targets or goals of therapy
The goal of topical ointment therapy is healing of the anal fissure and reduction of anal pain associated with chronic disease. [2], [3]
Common pitfalls to avoid
Topical nitrates can cause headaches, so a calcium channel blocker such as diltiazem is favored when headache limits tolerance. [1]
Practical prescribing considerations
Compounded topical nitroglycerin products are used in some settings, while licensed GTN formulations may be available depending on country and formulary. [1], [3] Topical therapy is typically used as part of comprehensive conservative management for anal fissure. [1], [2]