Can diltiazem (calcium channel blocker) worsen a hemorrhoid?

Diltiazem and Hemorrhoids: Potential Effects and Considerations

Topical diltiazem is unlikely to worsen hemorrhoids and may actually help reduce hemorrhoidal pain by relaxing the internal anal sphincter and improving local blood flow. 1

Mechanism of Action and Effects on Hemorrhoids

Diltiazem is a calcium channel blocker (CCB) that works by:

• Blocking slow L-type calcium channels in vascular smooth muscle cells
• Reducing internal anal sphincter tone
• Promoting increased local blood flow
• Creating a "chemical sphincterotomy" effect 1

These properties make diltiazem beneficial rather than harmful for hemorrhoids in most cases. The 2021 World Journal of Emergency Surgery guidelines specifically recommend topical calcium channel blockers like diltiazem as sphincter muscle relaxers for anal fissures, which often coexist with hemorrhoids 1.

Evidence Supporting Beneficial Effects

Several studies demonstrate that topical diltiazem may actually help with hemorrhoid-related pain:

• A 2018 meta-analysis of randomized controlled trials found that topical diltiazem effectively relieves pain after hemorrhoidectomy with minimal side effects 2
• A 2021 study showed that application of diltiazem ointment at the perianal area considerably decreases pain after hemorrhoidectomy 3
• A 2023 randomized controlled trial found that combination lidocaine/diltiazem was associated with both improved analgesia and patient satisfaction after hemorrhoid banding 4

Potential Concerns and Contraindications

While diltiazem is generally beneficial for hemorrhoids, there are some considerations:

1. Systemic absorption: Though minimal with topical application, systemic effects could theoretically include:

   • Hypotension
   • Bradycardia
   • Headache

2. Specific patient populations: Caution may be needed in patients with:

   • Severe left ventricular dysfunction (relevant mainly for oral diltiazem) 1
   • Conduction disturbances
   • Concurrent use of medications affected by diltiazem's inhibition of P-glycoprotein and CYP3A4 1

Clinical Approach

For patients with hemorrhoids who are using or considering topical diltiazem:

1. Continue or initiate use: The evidence suggests diltiazem is more likely to help than harm hemorrhoids
2. Application method: Apply a small amount (typically 1g of 2% diltiazem ointment) to the perianal area 2-3 times daily 3, 5
3. Duration: Treatment for at least 5-7 days is common in studies showing benefit 4, 5
4. Monitoring: Watch for rare side effects like headache or local irritation

Conclusion

The scientific evidence strongly suggests that diltiazem, particularly when used topically, does not worsen hemorrhoids and is more likely to provide benefit through its sphincter-relaxing and vasodilatory properties. Any theoretical risk is outweighed by the documented benefits in reducing pain and improving healing in hemorrhoidal disease.