Ok, it hurts that I'm going back down this path but I need a little guidance. As many know I had Botox over 4 months ago and as I'm healing I'm still not healed. The Botox seems to be wearing off and at my last CRS appointment the doctor said I should go back on nifedipine, as long as the spasm don't come back, to try and finish this thing off.
As I have used both nifedipine and nitro early on with no success (see signature below) I was wondering if anyone knows the difference between the two outside of headache side effect from nitro?
Is it just pot luck as to which may be more effective? I'd be interest to hear from anyone with experience. As my Botox wears off I'm having more signs of an active fissure. I'm hoping it's just due to my BMS being off the last week (maybe subject of another thread).
I don't regret Botox, it's gotten me from hell to discomfort just worried the spasms may come back.
Thanks all...stay strong...in forum we trust

Hi Apes,
I tried nifedipine, then diltiazem then nitro.
Nifedipine and diltiazem are both calcium channel blockers. They work by preventing entry of calcium into the muscle, which blocks muscle contraction. Obviously they doesn't completely block muscle contraction, or your sphincter would be totally relaxed and you'd have no control. I think poor absorption plays a part in reducing the effect.

If your calcium channels are somewhat resistant to the drug, you won't get any benefit from it.

In my case, I seemed to be resistant to nifedipine, but susceptible to diltiazem, because dilt. did help me.

Nitroglycerine works differently. I forget the details, and I don't think its mode of action is fully understood, but it seems to be through the nitric oxide pathway. The idea is still to block muscle contraction, but by working on the myosin, not calcium channels. If you are resistant to nifedipine AND dilt, there is still a chance that nitro can help.

In my case, nitro did help, and gave me (I believe) many pain-free months. I still use it if I have a problem.

I believe (could be wrong) that the reason nitro gives people worse headaches is because it's extremely well absorbed. All three drugs are used to treat hypertension, by relaxing the smooth muscles in veins and arteries. All three can cause headaches by dilating blood vessels in the head.

Sorry if this is more than you wanted to know. I think the bottom line is that yes, it's pot luck what will work for you. If you haven't tried diltiazem, by all means try it. It does seem to cause allergic reactions more than the other two, but again, it's pot luck whether or not it will cause a reaction in you.

Have you tried heat? Because the mode of action is more or less the same - it relaxes the anal sphincter, enlarges the blood vessels and soothes the pain. There was a study done on using a heat pad to decrease the anal resting pressure. Here's the link: http://www.ncbi.nlm.nih.gov/pubmed/10496555. I would bet that heat in conjunction with the drug will increase absorption of the drug, by dilating the blood vessels.

I'm sorry you are going through this, and having to make the painful decision. I'm in a similar situation and am going back onto nitro. I'm not in any pain at the moment but my fissure is still open, and the nurse wants me to take nitro for another six weeks. Boooo!

Sorry to hear you are not healed yet Apes. Hopefully the ointment will take you that last distance.

Just thought I would chime in to say that I think I once read that the calcium channel blockers (Nifedipine and Diltiazem) dilate the arteries, whereas the Nitro dilates the veins. I think this was the basis for studies that have shown the calcium channel blockers to be superior to Nitro at healing fissures. Not by huge numbers though. Likely the difference is negligible and may even be attributed rather to patient adherence given the headaches is can cause. Given this I try the Nifedipine first myself. Although there is argument foe alternating them if both classes of drugs work for you in order to prevent developing a tolerance.

You are correct, Msimon, but there's a bit more to it.
"Although venous effects predominate, nitroglycerin produces, in a dose-related manner, dilation of both arterial and venous beds."

But all the drugs work not just on the muscle of the blood vessels, but also the anal sphincter muscle itself. So the drugs dilate the blood vessels and relax the sphincter which 1) reduces spasms and 2) allows increased blood flow.

Wow thats a lot of info, and never to much. I so much appreciate it. How cool would it be if an actual doctor gave you this description, rather then saying oh I just like this one better.
Scientist, back when my pain was a 12 on a scale of 1-10 i used both nitro for several weeks then nifedipine for several weeks, different doctors. All during that time I was taking warm baths, 3-6x a day. Initially when i went into the tube the spasm would ease but it didn't last even staying in the tub. Hope it doesn't get to that point again but i want to be prepared.

I hope it doesn't get to that point too, Apes.
What can I say? Try a hot water bottle. That way you don't have to be constantly in and out of the bath tub, getting dressed and undressed all day long. You can use a hot water bottle pretty much 24/7, as long as it's very warm, not hot. I used to keep one on my office chair, with a sweater casually draped over it so people wouldn't notice it. Every so often I'd nuke it in the office microwave! (carefully so as not to burst it!)

Ah yes Scientist. Good point about the muscle relaxation. In that sense it really should be individual preference.

Positive thinking Apes, it's not going to come to that again

"How cool would it be if an actual doctor gave you this description, rather then saying oh I just like this one better." I totally agree. Actually, my Doctor adamantly says that Nifedipine and Diltiazem are the same. I said "yes the same class of drug" and he was like, "no, they are the same." I thought to myself "whatever." It was irritating. Rant over ;)

msimon, I'm all about positive thinking, unless those dibilatating spasm that almost crushed me come back. i will never forget what I went through and dealing with my current discomfort and concerns pales in comparison.

I'm rooting for you Apes! Don't you just wish you could forget though? My body never forgets a pain, especially butt pain