Topical Nitroglycerin Research Articles

Conservative Management of Anal Fissures

Background: Anal fissures are common, but most are short lived and heal spontaneously. Those which persist and require intervention cause considerable morbidity in an otherwise healthy young population. Glyceryl trinitrate is well in the conservative management of anal fissures.
 Material and Methods: The retrospective study was carried at Sher-i-Kashmir Institute of Medical Science Srinagar, Kashmir, India from Jan. 2005 to Dec. 2005. Total of 111 patients were studied, to evaluate the result of glyceryl trinitrate treatment in the management of anal fissures.
 Results: 80% of the fissures healed with topical glyceryl trinitrate treatment over a period of 6-8 weeks, with no recurrence during a one year follow up. The remaining 20% patients had to be managed with manual dilatation (8 patients) and lateral internal sphincterotomy (14 patients).
 Conclusion: Our conclusion is that glyceryl trinitrate induces a chemical sphincterortomy and produces healing of fissure in majority of patients. J Med Sci 2009;12(1):11-13.

A local approach to Raynaud phenomenon

The current treatment options for Raynaud phenomenon are often ineffective and can have undesirable adverse effects. Topical, or transdermal, treatments that increase digital blood flow without systemic adverse effects are, therefore, an attractive option. A novel topical nitroglycerin formulation has shown promise in treating Raynaud attacks.

Pharmacological Interventions to Treat Phlebitis

This study presents a systematic review for evaluating effective pharmacological actions for the treatment of phlebitis stemming from infusion therapy. The studies reviewed were categorized according to the type of therapeutic approach proposed by the author and by the level of evidence presented. The review found that topical nitroglycerin and notoginseny were more effective in the reduction of the inflammatory process when compared with other proposed alternatives. Nevertheless, the development of research related to possible alternatives for the treatment of phlebitis is important.

MQX‐503, a novel formulation of nitroglycerin, improves the severity of Raynaud's phenomenon: A randomized, controlled trial

Raynaud's phenomenon (RP) affects 3-9% of the general population and >90% of patients with systemic sclerosis. Nitrates are often prescribed for the treatment of RP, but currently available formulations are limited by side effects, particularly headaches, dizziness, and skin irritation. The purpose of this study was to evaluate the tolerability and efficacy of a novel formulation of topical nitroglycerin, MQX-503, in the treatment of RP in an ambulatory setting. We conducted a multicenter, randomized, placebo-controlled study with a 2-week single-blind run-in period to determine baseline severity, followed by a 4-week double-blind treatment phase. Two hundred nineteen adult patients with a clinical diagnosis of primary or secondary RP received 0.9% MQX-503 gel or matching placebo during the treatment period. Gel was applied immediately before or within 5 minutes of the beginning of an episode of RP (maximum of 4 applications daily). End points included the change in the mean Raynaud's Condition Score (RCS; scale 0-10), the frequency and duration of episodes, and subjective assessments at the target week (the week during the treatment phase that most closely matched the run-in period in terms of ambient temperature) compared with baseline. The mean (%) change in the RCS at the target week compared with baseline was significantly greater in the MQX-503 group (0.48 [14.3%]) than that in the placebo group (0.04 [1.3%]; P = 0.04). Changes in the frequency and duration of RP episodes and subjective assessments were not statistically different between the groups. MQX-503 had a side effect profile similar to that of placebo. MQX-503 is well tolerated and more effective than placebo for the treatment of RP.

Comparison of Topical Glyceryl Trinitrate with Diltiazem Ointment for the Treatment of Chronic Anal Fissure: a Randomized Clinical Trial

Background: The aim of this study was to compare the effect of topical glycerol trinitrate ointment (GTN) with topical diltiazem hydrochloride ointment (DTZ) in the treatment of chronic anal fissure.Method: Prospectively, 102 patients were treated randomly with either GTN ointment (0.2%) or DTZ ointment (2%) a couple of times daily for 12 weeks.Results: Forty-five patients (88.2%) in group DTZ and 36 patients (70.6%) in group GTZ had a reduction of symptoms. The decrease in the symptoms for group DTZ was significantly more than for group GTN (P = 0.02). Mean time for symptom reduction was 2.44 ± 0.30 in group DTZ and 2.50 ± 0.28 weeks in group GTN with no significant differences between the two groups (P > 0.05). Complete relief of symptoms was observed in 72.5% and 54.9% patients in groups DTZ and GTN, respectively. The frequency of complete relief of symptoms between the two groups was not significant (P > 0.05). Complete remission of anal fissure occurred in 66.7% patients in group DTZ and 54.9% patients in group GTN, which shows no significant difference. Mean time taken for fissure healing in the GTN group was dramatically less than in the DTZ group (P = 0.001). Finally, 33.3% of patients in the DTZ group and 45.1% of patients in the GTN group underwent operation. The need for operation was not significantly different between the two groups (P > 0.05). Conclusion: Both DTZ and GTN are equally effective and can be the preferred first-line treatment of chronic anal fissure. However, GTN is associated with a higher rate of headache, and should be replaced by DTZ.

Management options for accidental injection of epinephrine from an autoinjector: a case report

IntroductionEpinephrine autoinjector devices are used with increasing frequency to treat severe anaphylactic reactions. Accidental injection, usually involving a finger, is a potential complication.Case presentationA physician in a Family Practice training program accidentally injected epinephrine into his left thumb while reading the operating instructions of an autoinjector (Epipen®). He developed swelling, pallor, and pain in the thumb. Treatment included topical nitroglycerin, oral vasodilators and warming of the thumb. As expected, none caused an immediate response; however, after 8 hours, the thumb was pink and warm. There was full recovery 2 months after the accident. We reviewed the treatment of accidental epinephrine injection, and found that the use of parenteral adrenergic alpha blocker phentolamine would have produced immediate recovery.ConclusionsAll health professionals concerned with the use of epinephrine autoinjectors should receive adequate instruction on their use. A regimen for management of accidental epinephrine injection, in particular the use of phentolamine, should be emphasized.

Randomised, double-blind, placebo-controlled clinical trial of a new topical glyceryl trinitrate patch for chronic lateral epicondylosis

Objective:This study aimed to determine whether a new glyceryl trinitrate patch preparation is effective in treating chronic lateral epicondylosis.Design:Randomised double-blind controlled clinical trial.Setting:Private practice patients: 154 adult patients with chronic...

Topical Glyceryl Trinitrate and Noninsertional Achilles Tendinopathy

Background Topical glyceryl trinitrate (GTN) therapy has been advocated in the treatment of Achilles tendinopathy. The mechanism of action is unknown but may be related to modulation of local nitric oxide levels. Hypothesis Topical GTN therapy for noninsertional Achilles tendinopathy will significantly enhance clinical improvement and will be associated with increased collagen synthesis within the tendon. Study Design Randomized controlled clinical trial; Level of evidence, 1. Methods Forty patients were recruited. Twenty underwent standard nonoperative physical therapy, and 20 underwent physical therapy and topical GTN daily. Clinical outcome was assessed using the Ankle Osteoarthritis Scale (AOS) visual analog score. Patients who failed to improve with conservative measures and who underwent surgical decompression had histological and immunohistochemical examination of samples from the Achilles tendon. Results Glyceryl trinitrate did not offer any additional clinical benefit over standard nonoperative treatment for noninsertional Achilles tendinopathy. After 6 months of treatment, there was no significant difference in scores between the groups for pain (3.0 vs 3.1, P = .42) or disability (2.15 vs 2.25, P = .38). Histological examination did not show any difference in neovascularization, collagen synthesis, or stimulated fibroblasts between the 2 groups. There was no evidence of modulation of nitric oxide synthase, a marker of nitric oxide production, in those tendons treated with GTN. Conclusion and Clinical Relevance This study has failed to support the clinical benefit of GTN patches previously described in the literature. In the available tissue samples, there did not appear to be any histological or immunohistochemical change in Achilles tendinopathy treated with GTN compared with those undergoing standard nonoperative therapy.

Lateral Internal Sphincterotomy is Superior to Topical Nitroglycerin for Healing Chronic Anal Fissure and does not Compromise Long-Term Fecal Continence: Six-Year Follow-Up of a Multicenter, Randomized, Controlled Trial

Lateral Internal Sphincterotomy is Superior to Topical Nitroglycerin for Healing Chronic Anal Fissure and does not Compromise Long-Term Fecal Continence: Six-Year Follow-Up of a Multicenter, Randomized, Controlled Trial

Topical nitroglycerin may dilate options in Raynaud's disease

Topical nitroglycerin may dilate options in Raynaud's disease

Three-year Followup Study of Topical Glyceryl Trinitrate Treatment of Chronic Noninsertional Achilles Tendinopathy

Topical glyceryl trinitrate treatment has demonstrated short-term efficacy in chronic noninsertional Achilles tendinopathy. No long-term followup is reported. We aimed to assess if the demonstrated efficacy of this treatment persisted 3 years after discontinuation of therapy. A follow-up study of 52 patients (68 tendons) treated with 6 months of glyceryl trinitrate therapy or placebo was performed 3 years after cessation of therapy. Assessment included pain scores, return to previous activity, the Victorian Institute of Sport Achilles tendon scale (VISA-A), asymptomatic patient outcomes, clinical assessment of tendon tenderness, and functional hop test. Patients treated with topical glyceryl trinitrate had significantly less Achilles tendon tenderness (p = 0.03), and improved VISA-A scores (p = 0.04) than those in the placebo group; 88% (28 of 32 tendons) of patients were completely asymptomatic at 3 years (VISA-A score of 100) compared to 67% (24 of 36 tendons) of patients treated with rehabilitation alone (p = 0.03 with Chi square analysis). Other outcome measures showed nonsignificant trends towards improvement in the glyceryl trinitrate group (pain scores p = 0.07, functional hop test p = 0.07, and return to sport p = 0.16). The mean estimated effect size for all outcome measures was 0.21. Topical glyceryl trinitrate treatment has demonstrated efficacy in treating chronic noninsertional Achilles tendinopathy, and the treatment benefits continue at 3 years. Significant differences in asymptomatic patient outcomes for the glyceryl trinitrate group continue at 3 years, and this is confirmed by the effect size estimate. This suggests that the mechanism of action of topical glyceryl trinitrate on chronic tendinopathies is more than an analgesic effect.

CHRONIC ANAL FISSURES

Objective: The objective of this study was to compare the topical GTN andlateral internal sphincterotomy for the treatment of chronic anal fissure. Setting: This was a prospective randomizedcohort study conducted at Isra University Hospital, Hyderabad between September 2004 and August 2005. Materialand Methods: Fifty patients fulfilling the selection criteria were randomly divided into two equal groups. One group wastreated with topical glyceryl trinitrate (GTN) ointment and other group was treated with lateral internal sphincterotomy.Patients were followed up in outpatients department after regular intervals for about one year. The data was collectedand two groups were compared with special reference to pain relief, fissure healing and recurrence rate. Results: Painrelief was observed in 96% of the patients in GTN group as compared to 92% of the patients in sphincterotomy groupafter 6 weeks. Complete healing of fissure was observed in 92% of the patients in GTN group as compared to 88% ofthe patients in sphincterotomy group after 6 weeks. Recurrence was observed in 16% of the patients in GTN group ascompared to 4% of the patients in sphincterotomy group after one year. Conclusion: GTN and lateral internalsphincterotomy are comparable in terms of pain relief and fissure healing after 6 weeks. Topical GTN is suggested tobe the initial treatment whereas lateral internal sphincterotomy is suggested to be reserved for the patients notresponding to topical GTN or having recurrence after completion of treatment with GTN.

Topical nitroglycerin [glyceryl trinitrate] relieves the pain associated with transrectal ultrasonography-guided biopsy of the prostate,

Topical nitroglycerin [glyceryl trinitrate] relieves the pain associated with transrectal ultrasonography-guided biopsy of the prostate,

Comparison of topical glyceryl trinitrate with lignocaine ointment for treatment of anal fissure: A randomised controlled trial

Introduction Topical glyceryl trinitrate (GTN) has gained popularity as a treatment for anal fissure in the West. In our country, lignocaine is still the current treatment for the entity. This study was done to compare the effect of GTN with lignocaine in terms of healing rate and recurrence in South Asian population. Methods A prospective, double blinded, randomised controlled trial was conducted on 50 patients (both treatment arms included) of all ages and either gender with a clinical diagnosis of anal fissure. Group A was given 0.2% GTN ointment and Group B was given lignocaine ointment. Both subjective and objective signs of healing were assessed and adverse effects of the treatment were sought. Results Symptomatic relief was earlier with GTN as compared with lignocaine. Pain relief was steady and sustained in those treated with GTN but returned to pre-treatment status within 5 weeks in patients with lignocaine. After 8 weeks of treatment, 80% of patients in Group A showed clinical signs of healing compared to 32% in Group B ( p = 0.001). Headache was the main side effect of GTN. At 6-month follow-up, recurrence was seen in 3/8 patients in Group B compared to 8/20 in the GTN Group ( p = 1). Conclusion Topical GTN has earlier and a higher rate of clinical healing of anal fissure with acceptable side effects. The recurrence rate is high and comparable to lignocaine ointment. It is a safe and an effective treatment of anal fissure in a South Asian population.

A randomized controlled trial of topical glyceryl trinitrate before transrectal ultrasonography-guided biopsy of the prostate

To evaluate the use of topical glyceryl trinitrate (GTN) ointment as an adjunct to periprostatic nerve block in reducing pain associated with transrectal ultrasonography (TRUS)-guided prostatic biopsy. In all, 148 consecutive patients (mean age 67.0 years) having their first TRUS-guided biopsy were randomized to receive either 0.2% GTN ointment or placebo 10 min before biopsy. All patients had a biopsy preceded by an injection with 10 mL of 1% lidocaine local anaesthesia. A 10-point visual analogue score was used to record 'Overall discomfort due to the presence of the probe', the biopsy itself and pain after the procedure. There was no significant difference in age, PSA level and prostate volume between the groups. There was a significantly lower mean pain score due to probe insertion in the GTN than placebo group (1.94 vs 3.24, P < 0.01); pain perception was lower for the whole procedure in the GTN group, and was most pronounced in men aged <60 years (2.13 vs 4.61, P < 0.005). Topical GTN ointment is safe and effective in reducing the discomfort associated with TRUS-guided biopsy of the prostate, in particular the insertion of the ultrasound probe. It might be of maximum benefit in the younger patient and those having a repeat biopsy who previously failed to tolerate the procedure well.

In vitro Release Characteristics of Nitroglycerin from Microemulsion-Based Hydrogel System for Anal Fissure Treatment

To develop topical nitroglycerin (NTG) preparation far chronic anal fissure treatment, the release rate of NTG should be controlled carefully. For this, microemulsion was prepared from the phase diagram construction with Cremophor ELP, ethanol and Labrafil and the topical gel was prepared by dispersing NTG containing microemulsion into hydrophilic polymers. in viかo release characteristics were evaluated with Franz diffusion cell using cellulose membrane and compared with control hydrogels. The release rate of NTG was followed order kinetics and, when comparing the NTG release from control hydrogel with that from the microemulsion-based hydrogel, the NTG release rate was controlled by the content of polymers within continuous phase and the concentration of dispersed phase.

Lateral Internal Sphincterotomy is Superior to Topical Nitroglycerin for Healing Chronic Anal Fissure and does not Compromise Long-Term Fecal Continence: Six-Year Follow-Up of a Multicenter, Randomized, Controlled Trial

Although there is enthusiasm for nonoperative management of anal fissures, most trials have been of short duration (6-8 weeks) and long-term outcome is unknown. The purpose of this study was to assess long-term outcome in two cohorts of patients who had participated in a randomized, controlled trial to compare the effectiveness of topical nitroglycerin with internal sphincterotomy in the treatment of chronic anal fissure. Between February 1997 and October 1998, 82 patients with chronic anal fissure were accrued and randomized to 0.25 percent nitroglycerin ointment t.i.d. or lateral internal sphincterotomy. In 2004, a telephone survey of trial participants was conducted to determine symptom recurrence, the need for further medical and/or surgical treatment, and patient satisfaction. Furthermore, patients were assessed for symptoms of fecal incontinence using the Jorge and Wexner Fecal Incontinence Score and the Fecal Incontinence Quality of Life questionnaire. Overall, 51 of the original 82 patients (62 percent, 27 nitroglycerin, 24 lateral internal sphincterotomy) completed our survey. Mean follow-up was 79 (+/-1) months. Sphincterotomy patients were less likely to have experienced fissure symptoms within the past year (0 vs. 41 percent; P = 0.0004) and were less likely to require subsequent surgical treatment (0 vs. 59 percent; P < 0.0001) than patients treated with nitroglycerin. Patients in the lateral internal sphincterotomy group were more likely to say that they were "very" or "moderately" satisfied with their treatment (100 vs. 56 percent; P = 0.04) and that they would choose the same treatment again (92 vs. 63 percent; P = 0.02) than patients in the nitroglycerin group. Finally, the fecal incontinence and fecal incontinence quality of life scores at six-year follow-up were similar in both groups. After six years of follow-up, it seems that lateral internal sphincterotomy is a more durable treatment for chronic anal fissure compared with topical nitroglycerin therapy and does not compromise long-term fecal continence. Thus, sphincterotomy continues to be a good treatment for patients with chronic anal fissure.

Randomized clinical trial comparing botulinum toxin injections with 0·2 per cent nitroglycerin ointment for chronic anal fissure

In recent years treatment of chronic anal fissure has shifted from surgical to medical. This study compared the ability of two non-surgical treatments-botulinum toxin injections and nitroglycerin ointment-to induce healing in patients with idiopathic anal fissure. One hundred adults were assigned randomly to receive treatment with either type A botulinum toxin (30 units Botox or 90 units Dysport) injected into the internal anal sphincter or 0.2 per cent nitroglycerin ointment applied three times daily for 8 weeks. After 2 months, the fissures were healed in 46 (92 per cent) of 50 patients in the botulinum toxin group and in 35 (70 per cent) of 50 in the nitroglycerin group (P=0.009). Three patients in the botulinum toxin group and 17 in the nitroglycerin group reported adverse effects (P<0.001). Those treated with botulinum toxin had mild incontinence to flatus that lasted 3 weeks after treatment but disappeared spontaneously, whereas nitroglycerin treatment was associated with transient, moderate-to-severe headaches. Nineteen patients who did not have a response to the assigned treatment crossed over to the other therapy. Although treatment with either topical nitroglycerin or botulinum toxin is effective as an alternative to surgery for patients with chronic anal fissure, botulinum toxin is the more effective option.

Endosonographic and manometric evaluation of internal anal sphincter in patients with chronic anal fissure and its correlation with clinical outcome after topical glyceryl trinitrate therapy

Anorectal pressure studies have demonstrated internal anal sphincter (IAS) hypertonia in patients with chronic anal fissure. It is unknown however, if these changes in IAS function are associated with any abnormality in sphincter morphology. The first aim was to investigate the clinical characteristics and the manometric and endosonographic findings of the IAS in a cohort of patients with chronic anal fissure. The second aim was to investigate the association between these findings and the outcome with topical Glyceryl trinitrate (GTN) therapy. All patients who presented with chronic anal fissure from November 1999 to May 2004 were included after failure of conservative therapy. Anorectal manometry and anal endosonography were performed before treatment with 0.2% GTN ointment twice daily was initiated. Patients were evaluated after 8 weeks. One hundred and twenty-four patients (66 women, mean age, 45.2 +/- 14.8 years) were included. Hypertonia of the IAS was found in 84 (68%) patients. The mean maximum IAS thickness was 3.6 +/- 0.76 mm (1.6-5.5). An abnormally thick IAS, adjusted by age, was observed in 113 (91.1%) patients. We found no correlation between resting pressure and IAS thickness (r = 0.074; p = 0.41). At 8 weeks, 52 patients (42%) had healed with complete symptoms resolution. No statistically significant differences were observed when clinical features and manometric and endosonographic findings were compared between healing and no-healing fissures. The majority of patients with chronic anal fissure present an abnormally thick IAS. Clinical, manometric and endosonographic features had no association with outcome after GTN treatment.

Botulinum Toxin vs. Topical Glyceryl Trinitrate Ointment for Pain Control in Patients Undergoing Hemorrhoidectomy: A Randomized Trial

Patti, Rosalia M.D.1; Almasio, Piero Luigi M.D.2; Arcara, Matteo M.D.1; Sammartano, Sergio M.D.1; Romano, Pietro M.D.1; Fede, Calogero Ph.D.3; Di Vita, Gaetano M.D.1 Author Information