The efficacy of diltiazem, glyceryl trinitrate, nifedipine, minoxidil, and lidocaine for the medical management of anal fissure: a systematic review and network meta-analysis of randomized controlled trials.

PURPOSE: Anal fissure (AF) is a common anorectal condition causing pain, bleeding, and other perianal discomfort. This study conducts a network meta-analysis (NMA) to compare the efficacy and side effect profiles of pharmacological treatments for AF, including diltiazem (DTZ), glyceryl trinitrate (GTN), nifedipine (ND), minoxidil (MD), and lidocaine (LC).

METHODS

Following the Preferred Reporting Items for Systematic Reviews and Meta-Analysis guidelines, a systematic review and NMA were performed. Randomized controlled trials (RCTs) comparing non-surgical treatments for AF were sourced from PubMed, Cochrane Library, Embase, and Medline. The primary outcome was AF healing, with secondary outcomes including recurrence rates, pain reduction (visual analog scale), and adverse effects. Statistical analysis utilized odds ratios and surface under the cumulative ranking values for treatment ranking.

RESULTS

Twenty-two RCTs involving a total of 1770 participants were included in the analysis. ND demonstrated the highest healing rate, followed by DTZ and MD. LC exhibited the lowest healing rate. DTZ had the lowest recurrence rate and was the most effective in pain reduction, whereas LC had the highest recurrence rate and was the least effective in alleviating pain. The incidence of adverse effects with MD was relatively low, second only to LC, while GTN had the highest rate of adverse effects.

CONCLUSION

ND had the highest healing rate and should be considered as a first-line non-surgical treatment for AFs. Given the elevated incidence of adverse reactions associated with nitroglycerin, its use should be avoided in order to minimize the risk of significant toxicities and side effects. Additionally, because of its outstanding analgesic properties, DTZ is recommended as the preferred option for patients with heightened sensitivity to pain, but more studies are needed to evaluate its efficacy.