Note that I think that the GTN ointment and NGT ointment both refer to glyceryl trinitrate. I do not know why there are two names for it.
Your page is most useful. A number of my patients have "visited" your page prior to seeing me.
The use of NTG ointment as the initial treatment of anal fissures has become more popular as evidence of the effectiveness of this therapy accumulates in the medical literature. The most recent article was published last Saturday in the Lancet (Lund and Scholefield. A randomized, prospective, double-blind, placebo-controlled trial of glyceryl trinitrate in treatment of anal fissures. Lancet 1997;349:11-14). This very elegant study showed that NTG healed 68% of fissures in 8 weeks or less whereas placebo healed only 8% in the same time. Headache was the only side effect.
I am a bit disturbed to see that some patients writing to you have been given NTG 2% by their doctors. The dosage used in the medical reports is 0.2%, ten times less concentrated. Headache with NTG 2% is a virtual certainty. I believe that the problem results from the fact that NTG 0.2% is not commercially available, whereas NTG 2% (for cardiac usage) is. Use of NTG 2% for fissures is NOT recommended! The pharmacy must compound the lower strength. The NTG 2% is diluted with white petrolatum 10:1. It must be used within the anal canal for maximal benefit.
I continue to use NTG 0.2% for my fissure patients with very gratifying results. Keep up the good work!
Stephen R. Gorfine, MD
I would be honored to have you post my paper on your home page. The one you picked is a review which was prepared for a course entitled Controversies in General Surgery. You may post the paper without revision.
If you want, I can offer some help with the email questions that you get. If you forward them to me (Dr. Gorfine), I can send you an answer that may be of some help. I don't think Dr. Gorfine answers email questions any more. 9/19/01 Jack.
Just a short note to let you know of my progress. I have been in touch with Dr. Gorfine and he truly is a remarkable man. I will foward you some valid information regarding the correct usage of NTG ointment. It seems my doctor's intructions were quite contradictory and therefore not as effective as it could have been. I think one very important element is time. My doctor was ready to operate after only 2 weeks on NTG therapy. If you read Dr. Gorfine's letter to me it is clear that most people given enough time will resolve the situation.
I am now 80% better and still have some occasional discomfort. My life for the mostpart has returned to normal. Thanks mostly to the advice of patient 6. I will now try and complete my recovery with the correct usage of NTG therapy as well as baths, metamusil, stool softeners and a diet with fiber and lots and lots of water. I also plan on fowarding Dr. Gorfine my file and seeing him instead of my local specialist. Luckily I live near enough to do that.
I spoke to Dr. Gorfine today at length. He is a rare and wonderful physician. I have an appointment with him on the 11th of Feb. He was incredibly helpful and supportive. Its very important that the ointment be used the correct way for maximum results. I now feel that I am well on my way to 100% cure. Just using the ointment 3 days correctly has already made a difference.
Dear Ms. XXXX,
I am glad to hear that you have improved on your current regimen. I have found that those people who have had fissures for a long period of time take the longest to heal with NTG therapy. One of my patients required 8 months to completely resolve her problem!
It is important that the NTG ointment be applied inside the anal canal. This can be done with a finger or an applicator. The usual dose is 2-3 times per day and after BMs. Remember to use the ointment sparingly so as not to get a headache. Wipe off any excess that is left on the outside of the anus.
There does not appear to be any upper limit to the amount of time one can use NTG for fissures. Your chances of healing on NTG therapy are time related. There are now 4 papers in the medical literature which show 65-88% healing rates at 6-12 weeks. Many of my patients who do not heal within this time frame elect to continue NTG therapy. Many of those will heal given enough time. Remember that cardiac patients use NTG in much higher doses for many years without ill effect. If you are not in pain, there is no urgency to perform sphincterotomy.
I am a practicing colon and rectal surgeon in Manhattan. Good luck with your treatment!
This was emailed to me on: Mon, 8 Jul 96 04:40:09 UT, many thanks to the anonymous donor of this information. I have not read these references, but I would like to get them someday and read them.
There is a new non-surgical treatment for anal fissures. Nitroglycerin ointment 0.2% applied to the anal canal has been shown to heal fissures within 6 to 8 weeks. see:
Joe is going to try this approach. I hope it works for him and that he lets us know how everything comes out.
Another source sent me this information:
Here's the info you asked for regarding the Dr. Gorfine study: The study was found in NEJM Home October 26, 1995 - - Volume 333, Number 17. Topical Nitroglycerin Therapy for Anal Fissures and Ulcers.
My husband actually spoke with Dr. Gorfine yesterday and he said that since the case study, he's treated over 250 patients with nitro with a 80% success rate. He has lowered the dosage from .3% to .2% to decrease the headaches. So there is hope. Although I just E-mailed a Dr. Brendler who calls himself the Butt Dr. He doesn't know much about the nitro, but he was concerned about unhealing ulcers ie. cancer. Yikes!
I wanted to let you and your readers know that Cellegy Pharmaceuticals is conducting a clinical trial to assess pain relief of chronic anal fissures using it's nitroglycerin ointment, Anogesic. This study will also assess healing of anal fissures as a result of treatment with nitroglycerin ointment. The study is being conducted in approximately 15 study centers nationwide. Further information, including study center locations, can be found at the following web site:
Thanks for passing on the news.
Michael P. Crowley, Ph.D.
Cellegy Pharmaceuticals, Inc.
349 Oyster Point Boulevard, Suite 200
South San Francisco, CA 94080
Nitroglycerin -(.2%) for those wanting to try this - you can order it yourself WITHOUT a prescription from:
Pharmacydirect in Australia
Phone: Sydney (02) 9648 8888 (have to get out of counrty first then dial this number - they take credit card)
FAX: Sydney Same number
It comes under the name rectogesic and costs about $25.00 - $30.00 U.S. dollars. It states on the box for Anal fissure. Only use a drop because any more can cause headaches. Directions are on the package. I didn't find this that useful. You have to get it inside which is very painful and it did not take away pain for me.