Nitroglycerin 0.4% ointment vs placebo in the treatment of pain resulting from chronic anal fissure: a randomized, double-blind, placebo-controlled study

Scott M Berry, Charles F Barish, Raj Bhandari, Gemma Clark, Gregory V Collins, Julian Howell, John E Pappas, Dennis S Riff, Michael Safdi, Ann Yellowlees, Scott M Berry, Charles F Barish, Raj Bhandari, Gemma Clark, Gregory V Collins, Julian Howell, John E Pappas, Dennis S Riff, Michael Safdi, Ann Yellowlees

Abstract

Background: Complications of chronic anal fissure (CAF) treatments are prompting interest in lower-risk therapies. This study was conducted to compare nitroglycerin (NTG) 0.4% ointment with placebo for pain associated with CAF.

Methods: In this randomized, double-blind, placebo-controlled trial, patients with one CAF and moderate-to-severe pain (≥50 mm on a 100 mm visual analog scale [VAS]) received 375 mg NTG 0.4% (1.5 mg active ingredient) or 375 mg placebo ointment applied anally every 12 hours for 21 days. The primary end point was change from baseline VAS score in 24-hour pain averaged over days 14-18. Review of data from patients who withdrew early was blinded to treatment. To control for the confounding effects of analgesics, all patients received 650 mg acetaminophen for headache prophylaxis before each application.

Results: A total of 247 patients were enrolled (NTG, n = 123; placebo, n = 124). The prespecified baseline observation carried forward (BOCF) analysis found no significant difference between groups; however, a last observation carried forward (LOCF) analysis showed a significant advantage for NTG. A post hoc analysis (LOCF/BOCF hybrid) demonstrated a significant adjusted mean difference of -7.0 mm in favor of NTG 0.4% (95% CI -13.6, -0.4; P = .038). Headache was the most common adverse event in the NTG (69.9%) and placebo (47.6%) groups.

Conclusions: This was the first placebo-controlled study that also controlled for the confounding effects of analgesics used to treat NTG-induced headache. In patients with moderate-to-severe CAF pain, NTG 0.4% ointment effectively reduced CAF pain compared with placebo.

Trial registration: ClinicalTrials.gov, NCT00522041.

Figures

Figure 1
Figure 1
Patient disposition. NTG, nitroglycerin; VAS, visual analog scale.
Figure 2
Figure 2
Treatment difference in VAS pain at each time point: Adjusted Mean With 95% CI (ITT Population). Includes all post-baseline VAS scores prior to withdrawal and up to (but excluding) the assessment made at the last visit day. Adjusted means and CIs were derived from a repeated measures ANCOVA model with an auto-regressive first-order structure, with treatment, time, country, gender, and treatment × time as factors and baseline VAS pain as a covariate. ANCOVA, analysis of covariance; ITT, intent-to-treat; NTG, nitroglycerin; VAS, visual analog scale.

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Source: PubMed

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