What is the best suppository for internal hemorrhoids?

Best Suppository for Internal Hemorrhoids

For internal hemorrhoids, 5-ASA suppositories at 1g daily are the first-line therapy, with hydrocortisone suppositories (5 mg) recommended for non-responders or those with refractory symptoms. 1

Treatment Algorithm for Internal Hemorrhoids

First-Line Treatment:

• 5-ASA suppositories (1g daily), typically administered at bedtime 1
• Continue for 4-8 weeks to evaluate response
• Combine with conservative management:
  • Increased fiber intake (25-30g daily)
  • Adequate hydration
  • Sitz baths 2-3 times daily
  • Avoiding straining during defecation
  • Avoiding prolonged sitting 1

Second-Line Treatment (for incomplete response after 4-8 weeks):

• Add or switch to hydrocortisone suppository (5 mg) once daily 1
• Optimal administration is typically in the morning
• For severe symptoms, consider combination therapy:
  • Morning hydrocortisone suppository
  • Evening 5-ASA suppository 1

Duration of Treatment:

• Hydrocortisone suppositories should be used for the shortest period necessary (typically 1-2 weeks) to minimize systemic absorption and side effects 1

Hemorrhoid Classification and Treatment Considerations

Internal hemorrhoids are classified into four degrees, which helps determine the appropriate treatment approach:

Degree	Description	Primary Treatment
First degree	Bleed but do not protrude	Medical therapy (suppositories)
Second degree	Protrude with defecation but reduce spontaneously	Medical therapy; consider office procedures if persistent
Third degree	Protrude and require manual reduction	Office procedures or surgical intervention
Fourth degree	Permanently prolapsed and cannot be reduced	Surgical intervention [1,2]

Office-Based Procedures for Persistent Symptoms

If symptoms persist despite optimal medical therapy with suppositories:

• Rubber band ligation is the first-line procedural treatment, resolving symptoms in 89% of patients 1, 2
• Sclerotherapy shows 70-85% short-term efficacy but only one-third achieve long-term remission 1
• Infrared coagulation yields 70-80% success in reducing bleeding and prolapse 2

Important Considerations and Cautions

• Anal pain is generally not associated with uncomplicated hemorrhoids and suggests other pathology (thrombosis, fissure, or abscess) 1
• Phlebotonics (flavonoids) can reduce bleeding, rectal pain, and swelling, but symptom recurrence reaches 80% within 3-6 months after treatment cessation 2
• Special populations require additional consideration:
  • Immunocompromised patients have higher infection risk with procedures 1
  • Pregnant women should prioritize conservative management 1
  • Patients with inflammatory bowel disease require extreme caution with surgical interventions 1

Monitoring Response

• Evaluate response to suppository therapy within 4-8 weeks 1
• If symptoms persist despite combination therapy, consider:
  • Oral prednisolone 40 mg daily with tapering over 6-8 weeks
  • Procedural interventions 1
• Perform careful anorectal examination, including external examination and anoscopy, to assess response and rule out other pathologies 1