Diltiazem cream (diltiazem hydrochloride cream) is a medicine prescribed in the UK to manage chronic anal fissure. Today I will answer the most common questions surrounding the use, availability and treatment with this cream.
- What is diltiazem cream used for?
- How does diltiazem help with anal fissures?
- Classification of anal fissures
- The legal classification of topical diltiazem
- Topical diltiazem: legal classification
- Can you buy diltiazem hydrochloride 2% cream?
- How often to apply diltiazem cream?
- Diltiazem hydrochloride 2% cream: common side effects
- Alterative options to diltiazem cream
What is diltiazem cream used for?
Diltiazem hydrochloride 2% cream is used in the treatment of anal fissures.
An anal fissure is common conditions characterise by a tear (a cut) or an ulcer present at the edge of the anal margin. Two main symptoms of an anal fissure are anal pain during bowel movement with or without the presence of bright blood, and anal spasm.
How does diltiazem help with anal fissures?
Diltiazem promotes healing and controls pain associated with anal fissure by relaxing the muscles and improving blood flow to the site of injury. Diltiazem is classified as a calcium channel blocker. Calcium channel blockers are a group of medicines used mainly in the management of high blood pressure and angina. For example, amlodipine is the most common prescription high blood pressure medication.
Classification of anal fissures
Anal fissures are classified according to the duration of symptoms present and underlying cause, if known (NICE, 2017):
- Acute: symptoms present for less than six weeks
- Chronic: symptoms present for longer than six weeks
- Primary: with uncertain cause for the fissure
- Secondary: the cause of anal fissure is known, for example, underlying conditions like inflammatory bowel disease (IBD), colorectal cancer or sexually transmitted infection (HIV and AIDS).
Diltiazem topical cream may be offered for the management of anal fissure together with other recommendations, for example, the use of simple analgesics like paracetamol or ibuprofen. Codeine containing products, such as co-codamol, may not be the best choice since codeine can cause constipation, possibly aggravating the condition.
Constipation can be managed with over the counter laxatives.
Diltiazem cream: legal classification
Diltiazem 2% cream is a prescription-only medicine (POM), which means a doctor needs to issue a prescription for the supply to happen.
Diltiazem 2% cream is not a first-line treatment choice for the management of anal fissures due to the fact that it is an unlicensed medication.
GTN ointment (available as Rectogesic 4 mg/g Rectal Ointment) is usually recommended in the first instance for the management of anal fissures. Even though diltiazem cream is an unlicensed medication, a doctor can prescribe it, for example, if a patient found GTN ointment not acceptable. GTN ointment can commonly cause severe headaches, which may cause some patients to stop the treatment.
One of the implications of unlicensed medicines is the immediate availability. Almost with certainty, pharmacies would not keep topical diltiazem as a part of the regular dispensing stock. Very often, unlicensed medicines are ordered from suppliers, which make and redistribute unlicensed products.
Diltiazem cream used to be manufactured as a special preparation for each order, which means it would take few days before the cream would reach the pharmacy and patient.
Recently, diltiazem became available as ready-made cream called Anozem 2% cream. Anozem 2% diltiazem cream comes in a pack size of 30g. The availability of Anozem 2% speeded up the supply process. It still has to be ordered from ‘specials’; however, it is usually delivered to the pharmacy the next day (depends on the timing of the order).
Can you buy diltiazem hydrochloride 2% cream?
Topical diltiazem is a prescription-only medication, which means it cannot be bought without a prescription. Some online clinics and pharmacies may offer a private service to supply the cream. This usually means a private online consultation with a doctor who then issues the medication. Alternatively, patients may be asked to complete a questionnaire (about their health and symptoms), which then is reviewed by a doctor. Patients are usually charged for the consultation and cream supplied (it may come as one fee).
How often to apply diltiazem topical cream?
When used to treat a chronic anal fissure, diltiazem cream is applied twice a day until the pain stops. The maximum recommended duration of the treatment is eight weeks (BNF, 2021). Please follow the prescriber’s directions on how often and for how long to use the cream.
Diltiazem hydrochloride 2% cream: common side effects
Common side effects may be experienced by 1 in 10 patients. The most common side effects which may be experienced when using diltiazem are:
- Dizziness or light-headedness
- Local irritation at the site of application, for example, burning or itching.
Alternative options for treatment of anal fissure
I already mentioned that GTN ointment (Rectogesic Rectal Ointment) is the preferred, first-line option in treating anal fissures.
Diltiazem can also be prescribed in the form of oral tablets for the treatment of anal fissures, taken twice a day (60mg) with a maximum duration of 8 weeks use.
A combination of steroid (hydrocortisone) and lidocaine (local anaesthetic) may provide relief from the pain and itchiness. Prescription-only Xyloproct ointment (5% of lidocaine and 0.275% of hydrocortisone) is licensed in the management of pain associated with haemorrhoids and anal fissure.
One over the counter haemorrhoid sprays contains the same combination of active ingredients. Perinal Cutaneous Spray is a pharmacy-only medication, which can only be purchased from registered chemists, including online pharmacies. Perinal Cutaneous Spray may not be stock by pharmacies, but it could possibly be ordered on an individual basis from the leading pharmaceutical suppliers for the same or next day delivery.
Perinal Cutaneous Spray is not licensed in the management of anal fissures and should not be applied on broken skin.
Surgery is a final option for patients who do not respond to drug treatment.
BNF (2021). Diltiazem hydrochloride. Available at: https://bnf.nice.org.uk/drug/diltiazem-hydrochloride.html Accessed on 02/04/2021
NICE (2017). Anal fissure. Available at: https://cks.nice.org.uk/topics/anal-fissure/ Accessed on 02/04/2021