| Formulary Chapter 12: Ear, nose and oropharynx - Full Chapter
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| Chapter Links... |
 BSPED Adrenal Insufficiency Consensus Guidelines |
| MHRA: Corticosteroids: rare risk of central serous chorioretinopathy with local as well as systemic administration |
| MHRA: Topical corticosteroids: information on the risk of topical steroid withdrawal reactions |
| MHRA: Topical steroids: introduction of new labelling and a reminder of the possibility of severe side effects, including Topical Steroid Withdrawal Reactions |
| NHSE: Steroid Emergency Card to support early recognition and treatment of adrenal crisis in adults |
| NICE NG79: Sinusitis (acute): antimicrobial prescribing |
| Details... |
| 12.01 |
Drugs acting on the ear |
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| 12.01.01 |
Astringent preparations |
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| 12.01.01 |
Anti-inflammatory preparations |
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Betamethasone (Betnesol ®)
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Formulary
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Ear/eye/nose drops betamethasone 0.1%
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Betamethasone with neomycin (Betnesol N®)
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Formulary
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Ear/eye/nose drops betamethasone 0.1% with Neomycin 0.5%
For use in nasal infection see section 12.02.03.
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MHRA: Aminoglycosides (gentamicin, amikacin, tobramycin, and neomycin): increased risk of deafness in patients with mitochondrial mutations
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Dexamethasone with framycetin sulfate and gramicidin (Sofradex®)
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Formulary
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Ear/eye drops dexamethasone (as sodium metasulphobenzoate) 0.05%, framycetin sulfate 0.5%, gramicidin 0.005%
Sofradex® is less suitable for prescribing.
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MHRA: Aminoglycosides (gentamicin, amikacin, tobramycin, and neomycin): increased risk of deafness in patients with mitochondrial mutations
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Dexamethasone with glacial acetic acid and neomycin sulfate
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Formulary
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Ear spray acetic acid glacial 2%, Dexamethasone 0.1%, Neomycin sulfate 0.5%
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MHRA: Aminoglycosides (gentamicin, amikacin, tobramycin, and neomycin): increased risk of deafness in patients with mitochondrial mutations
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Flumetasone pivalate with clioquinol
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Formulary
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Ear drops flumetasone 0.02% with clioquinol 1%
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Gentamicin with hydrocortisone
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Formulary
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Ear drops hydrocortisone acetate 1% with gentamicin 0.3%
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Medicines for children: Gentamicin and hydrocortisone ear drops for inflammatory ear infections
MHRA: Aminoglycosides (gentamicin, amikacin, tobramycin, and neomycin): increased risk of deafness in patients with mitochondrial mutations
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| 12.01.01 |
Anti-infective preparations |
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Ciprofloxacin with dexamethasone
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Formulary
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Ear drops ciprofloxacin 0.3% with dexamethasone 0.1%
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Clotrimazole (Canesten®)
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Formulary
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Solution 1%
Consider OTC/Self care.
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Gentamicin
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Formulary
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Ear/eye drops 0.3%
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MHRA: Aminoglycosides (gentamicin, amikacin, tobramycin, and neomycin): increased risk of deafness in patients with mitochondrial mutations
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Triamcinolone acetonide, nystatin, gramicidin, neomycin
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 Unlicensed
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Ointment 5g
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| 12.01.01 |
Other aural preparations |
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Acute otitis media is a self-limiting condition that mainly affects children. Symptoms usually resolve within 3 to 7 days without antibacterial drugs. Consult NG91 and BNF treatment summaries for more information. |
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Phenazone with lidocaine (Otigo ®)
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Formulary
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Ear drops lidocaine hydrochloride 10 mg per 1 gram, phenazone 40 mg per 1 gram
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| 12.01.03 |
Removal of ear wax |
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Olive Oil
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Formulary
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Ear drops
Consider OTC/Self care.
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Sodium Bicarbonate
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Formulary
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Ear drops 5%
Consider OTC/Self care.
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| 12.02 |
Drugs acting on the nose |
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| 12.02.01 |
Drugs used in nasal allergy |
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Azelastine hydrochloride
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Formulary
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Nasal spray 210 microgram per 1 actuation (Azelair®)
Nasal spray 140 microgram per 1 actuation (Rhinolast®)
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Fluticasone with azelastine
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Formulary
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Third line agent if monotherapy with either intranasal antihistamine or glucocorticoid is not considered sufficient.
Consider OTC/Self care.
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NICE: Allergic rhinitis
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Mometasone furoate with olopatadine (Ryaltris®)
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Formulary
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Adults and adolescents 12 years of age and older for the treatment of moderate to severe nasal symptoms associated with allergic rhinitis.
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Beclometasone Dipropionate
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First Choice
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Nasal spray 50micrograms/dose
Consider OTC/Self care.
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Fluticasone furoate (Avamys®)
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Second Choice
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Nasal spray 27.5micrograms/metered spray
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Mometasone Furoate
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Second Choice
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Nasal spray 50micrograms/metered spray
Consider OTC/Self care.
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Betamethasone (Betnesol®)
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Formulary
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Ear/eye/nose drops 0.1%
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Fluticasone Propionate
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Formulary
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Nasal spray 50microgram per dose
Consider OTC/Self care.
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Fluticasone Propionate
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Formulary
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Nasal drops 400micrograms/unit dose
For nasal polyps.
Consider alternative treatment if no improvement after 4–6 weeks.
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| 12.02.02 |
Topical nasal decongestants |
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| 12.02.02 |
Sympathomimetics |
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| 12.02.03 |
Nasal preparations for infection |
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| 12.02.03 |
Nasal Staphylococci |
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| 12.03 |
Drugs acting on the oropharynx |
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| 12.03.01 |
Drugs for oral ulceration and inflammation |
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Benzydamine
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Formulary
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Oral rinse 0.15%
Spray 0.15%
Consider OTC/Self care.
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Betamethasone
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Formulary
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Soluble tablets 500micrograms
Unlicensed use
For use as a mouthwash only, following oral surgery.
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Choline Salicylate (Bonjela® Adult)
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Formulary
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Oral gel 8.7%
For adults and children over 16.
Consider OTC/Self care.
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Gelclair®
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Formulary
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Sachets
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GelX®
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Formulary
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Oral spray
Oral mucositis.
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Hydrocortisone
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Formulary
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Muco-adhesive buccal tablets 2.5mg
Hydrocortisone mucoadhesive buccal tablets licensed for use in children (under 12 years—on medical advice only).
Consider OTC/Self care.
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MHRA: Hydrocortisone muco-adhesive buccal tablets: should not be used off-label for adrenal insufficiency in children due to serious risks
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Lidocaine
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Formulary
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Spray 10mg/dose
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| 12.03.02 |
Oropharyngeal anti-infective drugs |
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| 12.03.02 |
Oropharyngeal Fungal infections |
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| 12.03.02 |
Oropharyngeal Viral infections |
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| 12.03.03 |
Lozenges and sprays |
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| 12.03.04 |
Mouthwashes, gargles, and dentifrices |
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| 12.03.05 |
Treatment of dry mouth |
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| 12.03.05 |
Systemic treatment |
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| 12.04 |
Oral and Maxillofacial |
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Key |
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Restricted Drug |
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Unlicensed |
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Link to adult BNF
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Link to children's BNF
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Link to SPCs
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Scottish Medicines Consortium |
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Cytotoxic Drug |
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Controlled Drug |
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High Cost Medicine
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Cancer Drugs Fund
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Homecare |
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ICB commissioned |
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NHS England commissioned |
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Blueteq form needed |
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Low carbon footprint |
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Medium carbon footprint |
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High carbon footprint |
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| Status |
Description |
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Green:
Appropriate for initiation and ongoing prescribing in both primary and secondary care.
Generally, little or no routine drug monitoring is required. |
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Green (Restricted):
Appropriate for initiation and ongoing prescribing in both primary and secondary care provided:
Additional criteria specific to the medicine or device are met, or
The medicine or device is used following the failure of other therapies as defined by the relevant LSCMMG pathway.
Generally, little or no routine drug monitoring is required.
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Red medicines:
Medicine is supplied by the hospital for the duration of the treatment course.
Primary care initiation or continuation of treatment is not recommended unless exceptional circumstances such as specialist GP.
Red medicines are those where primary care prescribing is not recommended. These treatments should be initiated by specialists only and prescribing retained within secondary care. They require specialist knowledge, intensive monitoring, specific dose adjustments or further evaluation in use. If however, a primary care prescriber has particular specialist knowledge or experience of prescribing a particular drug for a particular patient it would not always be appropriate for them to expect to transfer that prescribing responsibility back to secondary care. There should be a specific reason and a specific risk agreement, protocol and service set up to support this.
Primary care prescribers may prescribe RED medicines in exceptional circumstances to patients to ensure continuity of supply while arrangements are made to obtain ongoing supplies from secondary care. |
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Amber level 0:
Suitable for prescribing in primary care following recommendation or initiation by a specialist.
Little or no specific monitoring required.
Patient may need a regular review, but this would not exceed that required for other medicines routinely prescribed in primary care.
Brief prescribing document or information sheet may be required.
Primary care prescribers must be familiar with the drug to take on prescribing responsibility or must get the required information.
When recommending or handing over care, specialists should ask primary care prescribers to take over prescribing responsibility, and should give enough information about the indication, dose, monitoring requirements, use outside product licence and any necessary dose adjustments to allow them to confidently prescribe. |
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Amber level 1 (with shared care):
Suitable for prescribing in primary care following recommendation or initiation by a specialist.
Minimal monitoring required.
Patient may need a regular review, but this would not exceed that required for other medicines routinely prescribed in primary care.
Full prior agreement about patient’s on-going care must be reached under the shared care agreement.
Primary care prescribers are advised not to take on prescribing of these medicines unless they have been adequately informed by letter of their responsibilities with regards monitoring, side effects and interactions and are happy to take on the prescribing responsibility. A copy of locally approved shared care guidelines should accompany this letter which outlines these responsibilities. Primary care prescribers should then tell secondary care of their intentions as soon as possible by letter so that arrangements can be made for the transfer of care. |
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Amber level 2 (with shared care and enhanced service):
Initiated by specialist and transferred to primary care following a successful initiation period.
Significant monitoring required on an on-going basis.
Full prior agreement about patient’s on-going care must be reached under the shared care agreement.
Suitable for enhanced service.
These medicines are considered suitable for GP prescribing following specialist initiation of therapy, as per shared care document which will be sent out with the request to prescribe, with on-going communication between the primary care prescriber and specialist. Amber Level 2 medicines require significant monitoring for which an enhanced service may be suitable. (Subject to local commissioning agreements). |
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Do not prescribe: NOT recommended for use by the NHS in Lancashire and South Cumbria.
Includes medicines that NICE has not recommended for use and terminated technology appraisals, unless there is a local need. |
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Grey medicines:
Medicines which have not yet been reviewed or are under the review process.
GPs and specialists are recommended not to prescribe these drugs.
This category includes drugs where funding has not yet been agreed.
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Refer to local guidance. |
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