What are the oral medications for bleeding internal hemorrhoids?

From the Guidelines

For bleeding internal hemorrhoids, the most effective oral medication is phlethotropic agents, such as Daflon, containing micronized purified flavonoid fraction, which can help reduce bleeding by strengthening vein walls and improving circulation, as suggested by the World Journal of Emergency Surgery in 2021 1. The recommended dosage is 1000mg daily (two 500mg tablets) for acute episodes, typically for 4-7 days, then reduce to 500mg daily for maintenance. Some key points to consider when using oral medications for bleeding internal hemorrhoids include:

• Oral pain relievers such as acetaminophen (Tylenol) at 500-1000mg every 6 hours (not exceeding 4000mg daily) can help manage discomfort.
• Stool softeners like docusate sodium (100-300mg daily) prevent constipation that worsens hemorrhoids.
• These medications work best alongside increased fiber intake (25-30g daily), adequate hydration (8 glasses of water daily), and sitz baths (warm water soaks for 10-15 minutes, 2-3 times daily).
• If bleeding persists beyond a few days, becomes heavy, or is accompanied by severe pain, dizziness, or weakness, seek immediate medical attention as these medications only provide symptomatic relief and more serious conditions may require prescription medications or procedures. It's also important to note that the American Gastroenterological Association technical review on the diagnosis and treatment of hemorrhoids in 2004 1 and the World Journal of Emergency Surgery in 2021 1 suggest that medical and pharmacological therapies are the most widely adopted therapy for complicated hemorrhoids, and that flavonoids and phlebotonics have been extensively studied and shown to have a beneficial effect in the treatment of symptomatic hemorrhoids.

From the FDA Drug Label

Multiple studies involving several hundred patients have been reported These have routinely shown that diosmin reduces symptoms of discomfort, swelling, inflammation and time to resolution when compared to standard of care. In general, resolution time of acute flares is shortened from 8 days to 4-5 days. A double-blind, placebo-controlled study (n=120) showed statistically better management of pain, pruritis, discharge, edema, erythema, and bleeding on examination One study (n=351) compared the effacacy of combining infrared photocoagulation (IRP) and diosmin vs each therapy used alone on bleeding cessation in patients with grades I, II, and III acute internal hemorrhoids. The percentage of patients with no bleeding after 5 days of therapy was higher in the combined group (75%) compared with only diosmin (60%) or with IRP alone (56%) Patients experiencing an acute hemorrhoidal episodes for less then 48 h were enrolled in a randomized, double-blind, placebo-controlled study. One group received diosmin (n=49) and the other a placebo (n=41) During the 7 day administration, there was a significant difference in favor of diosmin in the dietary management of discomfort, edema and bleeding.

Diosmin is an effective oral medication for the management of bleeding internal hemorrhoids. The studies have shown that diosmin reduces symptoms of discomfort, swelling, inflammation, and time to resolution when compared to standard of care. Diosmin has been found to be effective in managing pain, pruritis, discharge, edema, erythema, and bleeding on examination. The resolution time of acute flares is shortened from 8 days to 4-5 days with diosmin treatment.

• Key benefits of diosmin include:
  • Reduction in symptoms of discomfort, swelling, and inflammation
  • Shortened resolution time of acute flares
  • Effective management of pain, pruritis, discharge, edema, erythema, and bleeding
  • Significant difference in favor of diosmin in the dietary management of discomfort, edema, and bleeding 2

From the Research

Oral Medications for Bleeding Internal Hemorrhoids

• Flavonoids, such as diosmin, are herbal medicines that can be used to treat hemorrhoids, including bleeding internal hemorrhoids 3
• These medications can help reduce venous stasis, suppress local inflammation, improve venous tone, and enhance lymphatic outflow 3
• A study comparing flavonoids with placebo in 1514 patients with hemorrhoids found that flavonoids were effective in reducing symptoms 3
• Another study found that a flavonoid mixture (diosmin, troxerutin, rutin, hesperidin, quercetin) was safe and effective in managing bleeding from hemorrhoidal disease 4

Treatment Options for Internal Hemorrhoids

• Medical management, including stool softeners, topical over-the-counter preparations, and topical nitroglycerine, is often the first line of treatment for internal hemorrhoids 5
• Dietary modifications, such as increased fiber and water intake, and behavioral therapies, such as sitz baths, can also be effective 5
• Office-based treatments, such as rubber band ligation, can be used for grades I-III internal hemorrhoids 5, 6
• Polidocanol sclerotherapy is a relatively new approach for treating symptomatic grade I-III internal hemorrhoids and may be associated with higher therapeutic success rates compared to rubber band ligation 6

Efficacy of Oral Medications

• A study found that diosmin, a flavonoid, was effective in reducing bleeding from internal hemorrhoids 3
• Another study found that a flavonoid mixture (diosmin, troxerutin, rutin, hesperidin, quercetin) improved bleeding in 79.5% of patients after 1 month and 70.5% after 6 months 4
• The use of flavonoids, such as diosmin, can be a safe and effective means of managing bleeding from hemorrhoidal disease, with minimal adverse events reported 4