Wow, I'm not overly confident in my lady. She's a physicians assistant to start with anyhow but it was the only way to get in to see this group as soon as I did. I see a real doc next Tuesday.
Anyhow, she called me back because I left a message about the re-tear I had late this past week and this morning's movement with pain, blood and since then constant spasm. She checked to see if she could move up my appointment with the real doc and she wasn't able to.
Then I asked her about diltiazem to help me out and she said "sure, I can prescribe that if you'd like" but didn't really know much about how often to use it, etc. and that the docs in her group don't prescribe it that often. Huh? So I asked her if nitro would be better and she said there would be more side effects and they didn't really have a ton of success with that. Huh again? So what do they do, prescribe a high fiber diet, stool softeners, hyrdocortisone suppositories and then if that doesn't work surgery?
She said diltiazem increases blood flow to the area but doesn't really help with pain or spasm, something like valium would be better for that. Is that true? She did say it promotes healing because of the added blood flow.
Looking forward to actually seeing the real doc next week. She called in the diltiazem to a compounding pharmacy because CVS (my pharmacy) doesn't do that, no clue how much it will cost or if I can get insurance to cover it. Anyone have any idea on cost of this stuff?
Apparently she looked it up and said to apply three times a day with gloves. My confidence is not soaring.

The ointments do have to be compounded. The typical concentrations are as follows:
2% diltiazem
0.2% nitroglycerin
0.2% nifedipine
The 2% for diltiazem is not a typo. Diltiazem is used at a higher concentration than the other two.
You do need a compounding pharmacy to make them most of the time, at least if you're in the US where pre-made commercial ointments for fissures aren't available. My local Walgreens will compound nitroglycerin and nifedipine but they won't compound diltiazem, so it all depends on the pharmacy. My local CVS doesn't compound anything. If you can get a chain like Walgreens to do it, it will be cheaper. How much it costs depends entirely on your health insurance, but it will for sure cost more than a standard prescription.
Strictly speaking, the stuff you get from a compounding pharmacy is usually better, because they (in most cases) use an ointment mill to do the compounding. Also, the inputs used by a compounding pharmacy can differ. For example, Walgreens may simply crush pills or mix an existing cream with some base to make the specified concentration. But a compounding pharmacy often has the drug in some other form, such as powder, which produces a nicer compound drug (more evenly distributed and more easily absorbable). Anyway, long story short, either way it's going to beat hydrocortisone alone. I used nitroglycerin compounded by Walgreens and it worked great. Just make sure the doctor specifies that it's for rectal use since pharmacies may use different bases depending on what area it's for.
I wouldn't worry about how to apply it. Once you get it, post back and lots of people here can share details. Everyone usually ends up figuring out what works best for them personally anyhow.
Some of us here have used valium for fissure spasms too. If they're willing to give you that, it's worth a try. Off the top of my head, members Fissulyna and Dee have both had good results from valium. I used it too and it did help with the spasms. I have my own other concerns with valium but I won't sound like a broken record by repeating them here. If you look at the literature, though, you'll find that nitroglycerin, nifidepine, and diltiazem are routinely mentioned for fissure treatment, whereas valium is only referred to sporadically here and there. Personally I'd consider the ointments combined with stool softeners to be the primary treatment (for healing purposes) with valium being secondary treatment (for relief of symptoms).

BTW sometimes pharmacies don't like billing insurance directly for compound drugs. If you run into one of these, just ask them for a claim form and send the claim to insurance yourself. I've had to do it a couple of times and have never had a problem, aside from the minor hassle of filling out the paperwork for insurance and what not. Definitely sounds like you're getting on the right track now!
Oh and finally, yes, nitroglycerin has the most initial side effects out of the three ointments for most people. It's famous for causing a bad throbbing headache. But you get tolerant of that very quickly. Different things work for different people, so don't limit yourself to just one therapy because of what one doctor believes. Are you in a big city? If so getting a second opinion isn't a bad idea. Lots of us here have seen a whole crapload of doctors since each one has their own beliefs and treatment plans.

There is simply no way I can improve on the great information and advice NG just gave...but as someone who used nefedipine, I found that while it did not eliminate my spasms, it really seemed to make them more tolerable. When I stopped using it, my pain increased.
And if increased blood flow helps it heal and loosens up your anal canal, that is ALWAYS an improvement!
In my prior research, I was able to gather that the success rates for nefedipine, diliatzem, and botox were all about the same, from 50-67% success. I cannot recall the nitro success rates.
I never healed and had to have surgery, BTW... :(

Oh, and it takes about 1 1/2 weeks for the nef or dil to kick in and start working..

Yeah, i'll second what Kim said, it does take a few weeks for the Diltiazem to start working, be cautious though, only use a pea size amount whereas I was prescribed the ointment with instructions to put a 2.5cm line of ointment onto the finger and then massage around the anus and some inside, this caused me to have a bad reaction and I scratched the living daylights out of my a$$ :( needless to say I discontinued use (temporarily), recently though i've been using just the pea-sized amount as and when required not religiously, and this seems to stop me getting the itch..

I was also told to use a pea-size amount and to get it upwards 1 cm. Too much of Diliatzem is not a good thing!!

Ha ha Steve -- I went "whole hog" when I was using it -- I tried to get large amounts as far up as possible. BUT, you know, I was in agonizing pain and just knew ( :oops: ) that was the way to go. I even used a syringe, which had come with the useless proctofoam, to inject it up high.
But I have come to see that you guys are right, it will be absorbed near the fissure (and the goal is to heal the fissure) if it's placed *near* the fissure, which should be close to the opening there...
But Steve, I was never given any instructions, in fact the surgeon I got it from had never used it, like many...

Kim I used the syringe from a pack of ProctoFoam for nitroglycerin/nifedipine/diltiazem application too :)
I was seeing an useless GP before I saw a CRS and the guy gave me every kind of hydrocortisone and pramoxine based product possible: hydrocortisone suppositories, super strong prescription-only hydrocortisone creams, ProctoFoam, and one other thing that I can't remember. Every time I told the guy it wasn't working, he'd just tell me I either had to eat more fiber or get surgery.
Turns out the only good thing from all of that was the freakin' syringe!

My syringe and I became very close, NG, LOL...