What are the pharmacological treatment options for hemorrhoids?

Pharmacological Treatment of Hemorrhoids

Pharmacological treatment of hemorrhoids should focus on symptom relief while more definitive procedures are scheduled, as medications alone are not curative but can effectively manage symptoms and improve quality of life. 1

First-Line Pharmacological Options

• Flavonoids (micronized purified flavonoid fraction) are recommended to relieve hemorrhoidal symptoms by improving venous tone, with evidence showing effectiveness for controlling acute bleeding in all grades of hemorrhoids 2, 3

• Topical analgesics (such as lidocaine) provide symptomatic relief of local pain and itching, though data supporting their long-term efficacy are limited 2, 4

• Topical corticosteroid creams may ameliorate local perianal inflammation but should be used for no more than 7 days to avoid thinning of perianal and anal mucosa 2, 4

• Topical muscle relaxants are suggested for thrombosed or strangulated hemorrhoids to provide relief from pain associated with anal sphincter hypertonicity 2, 4

• Topical nifedipine (0.3%) with lidocaine (1.5%) applied every 12 hours for two weeks is highly effective for thrombosed external hemorrhoids by relaxing internal anal sphincter hypertonicity 4

Second-Line Pharmacological Options

• Topical nitrates have shown good results in relieving pain due to thrombosed external hemorrhoids, presumably by decreasing anal tone, though headaches may limit their use 2, 4

• Topical heparin treatment has been found to significantly improve healing and resolution of acute hemorrhoids, although evidence is limited due to small study sizes 4

• Calcium dobesilate (used in diabetic retinopathy and chronic venous insufficiency) has shown effectiveness and good tolerability in hemorrhoid treatment 1

Important Considerations and Limitations

• Pharmacological treatments should be considered adjunctive therapy rather than definitive treatment for hemorrhoids 1, 3

• The primary objective of drug therapy is to control acute symptoms (particularly bleeding) while awaiting more definitive treatment such as banding, sclerotherapy, or surgery 1

• Long-term use of high-potency corticosteroid creams is deleterious and should be avoided 2, 4

• Symptom recurrence can reach 80% within 3-6 months after cessation of phlebotonic treatments 3

• For thrombosed external hemorrhoids presenting after 72 hours, conservative management with stool softeners, oral and topical analgesics is preferred over surgical intervention 4, 3

Pharmacological Treatment Based on Hemorrhoid Classification

For Internal Hemorrhoids (Grades I-II)

• Flavonoids for bleeding control 2, 1
• Topical analgesics for discomfort 2, 4
• Consider drug-free topical products which have shown efficacy in improving clinical signs and symptoms 5

For External Hemorrhoids

• Topical nifedipine with lidocaine for pain relief 4
• Short-term topical corticosteroids for inflammation 2, 4
• Topical analgesics for pain management 4, 3

For Thrombosed External Hemorrhoids

• Topical muscle relaxants for pain relief 2, 4
• Topical nitrates if muscle relaxants are ineffective 2, 4
• Oral and topical analgesics if presenting >72 hours after onset 4, 3

Adjunctive Measures with Pharmacological Treatment

• Increased dietary fiber and water intake should always accompany pharmacological treatment 4, 3

• Avoidance of straining during defecation is essential to prevent exacerbation of symptoms 4, 3

• Sitz baths can provide symptomatic relief and should be recommended alongside pharmacological options 4

• For persistent symptoms despite pharmacological treatment, procedural interventions like rubber band ligation should be considered 2, 4, 3