Topical diltiazem and glyceryl-trinitrate for chronic anal fissure: A meta-analysis of randomised controlled trials

Objectives: Surgical management of chronic anal fissure can result in permanent fecal incontinence. Topical treatments have a lower risk of severe complication and are less expensive than surgical intervention. Rates of healing and compliance with topical agents vary in the reported literature. The aim of this study was to compare healing rates, incidence of headaches, and recurrence rates of chronic anal fissure in patients treated with topical diltiazem (DTZ) and topical glyceryl-trinitrate (GTN), with a view of identifying which agent should be used as first line non-operative therapy.

Material and methods: Randomized controlled trials (RCTs), published since January 2000, comparing topical DTZ and GTN for treatment of chronic anal fissure were identified and compared. End points included healing rates, headache due to treatment, and late recurrence (>12 weeks). A random effects meta-analysis model was used to compare outcomes.

Results: All studies used 2% DTZ and 0.2% or 0.5% GTN, and treatment was continued twice daily for between 6-12 weeks. Nine RCTs compared rates of healing with topical DTZ (n= 379) and GTN (n= 351), there was no difference between the two groups [RR 1.04 (0.93-1.16), p= 0.48]. Eight RCTs reviewed incidence of headaches, DTZ was better tolerated [RR 0.15 (0.07-0.34), p <0.00001]. Four RCTs reported late recurrence rates, DTZ was superior [RR 0.51 (0.27-0.96), p= 0.04].

Conclusion: Topical DTZ and GTN result in comparable healing rates; however, DTZ is superior with regards to headaches and late recurrence rates. DTZ should therefore be considered as first line non-operative treatment for chronic anal fissure.