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12.2 Nose

First line drugs Second line drugs Specialist drugs Secondary care drugs

Traffic light status (TLS) explained:

  • Green: Routine prescribing within licensed indication
  • Amber 1: specialist recommendation followed by GP initiation and continuation
  • Amber 2: specialist or GP initiation in line with local guideline after 1st line failure followed by GP continuation
  • Amber 3: specialist initiation and stabilisation followed by GP continuation
  • Amber SCG: specialist initiation and stabilisation followed by GP continuation in line with an agreed shared care guideline
  • Red: Hospital or specialist prescribing only
  • Double Red: These medicines have been evaluated and rejected by MKPAG and are NOT approved for use within MK. They are not recommended for use because of lack of clinical effectiveness, cost effectiveness or safety

 

 

Nasal congestion

 

Xylometazoline hydrochloride

  • Nasal drops 0.1%
  • Paediatric nasal drops 0.05%

Notes: 

  • Should not be prescribed in Primary Care or at Discharge
  • Advise patient to purchase, unless prescription is for long-term regular use

 

Ephedrine hydrochloride (Amber 2)

  • Nasal drops 0.5%, 1%      

Notes:

  • Topical nasal decongestants containing sympathomimetics, ephedrine and xyometazoline, can cause rebound congestion following prolonged use (more than 7 days) and are therefore of limited value.
  • Ephedrine nasal drops should be used with caution in infants under 3 months of age. There is no good evidence of value – if irritation occurs it might narrow the nasal passage.       

 

Sodium chloride

  • Nasal drops 0.9%          

Note: Sodium Chloride 0.9% given as nasal drops may help relieve nasal congestion by helping to liquefy mucous secretions.      

 

 

 

Nasal infection

 

Acute sinusitis

For treatment of acute sinusitis refer to ‘Antimicrobial Guidelines for Primary Care’ (Chapter 5)    

 

 

Nasal staphylococci      

Naseptin®

  • Nasal cream: chlorhexidine hydrochloride 0.1%, neomycin sulphate 0.5%  
  • Caution - contains arachis oil 

 

Mupirocin (Amber 1)

  • Bactroban® Nasal ointment 2%      

Notes:

  • Mupirocin (Bactroban®) should be kept in reserve for MRSA treatment to avoid resistance developing.
  • To avoid the development of resistance, the treatment course should not exceed 7 days and the course not repeated on more than one occasion.

 

Betnesol-N®

  • Drops: Betamethasone sodium phosphate 0.1%, neomycin sulphate 0.5%
  • Considered to be a "Drug of Limited Clinical value"

 

 

MRSA    

Five Day Treatment Protocol for MRSA

 

 

Epistaxis      

Bismuth and iodoform (BIPP) 

  • Paste Impregnated gauze
  • ENT only

 

 

Nasal inflammation, nasal polyps and rhinitis

 

Allergic Rhinitis

 

  • The 2017 BSACI guideline recommends that a combination of topical antihistamine (AH) and intranasal steroid (INS) should be used in patients when symtoms remain uncontrolled on AH  or INS monotherapy or on a combination of oral AH plus INS

 

  • Dymista® is currently the only available combination spray containing topical AH and INS

 

  Beclometasone

  • Beconase® Aqueous nasal spray, 50 micrograms per spray         

Notes: 

  • Patients aged over 18 should not be prescribed in Primary Care or at Discharge
  • Advise patient to purchase, unless prescription is for long-term regular use

 

Betamethasone sodium phosphate

  • Drops 0.1%

Notes:

  • There are no published studies showing that any one nasal steroid is more effective than any other. Aqueous sprays tend to cause less irritation.    
  • GPs should prescribe Beconase as the first-line choice therapy for allergic rhinitis and ensure the patient knows how to use their nasal spray effectively.
  • Beclomethasone nasal spray is considered as first line therapy. It is relatively cheap, effective and well tolerated, requiring twice daily administration.
  • Systemic absorption may follow on from any nasal steroid particularly if the doses are high and prolonged.
  • CSM recommends that when children are receiving prolonged treatment with nasal corticosteroids the height of the child should be monitored. If growth is slowed then paediatric referral should be considered.

 

Fluticasone furoate (Amber 2)

  • Avamys® Nasal spray, 27.5 micrograms per spray  

Notes:

  • Avamys to be used for allergic rhinitis.

 

Fluticasone propionate (Amber 2)

  • Flixonase® Nasal spray, 50 micrograms per spray  

Notes: 

  • Flixonase to be used for perennial rhinitis.

 

Fluticasone propionate (Amber 1)

  • Flixonase® Nasule Drops ,400 micrograms (1 mg/ml), nasal drops suspension.

Notes:

  • for the treatment of nasal polyps only.

 

  Triamcinolone (Amber 2)    

  • Nasacort® Nasal spray, 55 micrograms per spray

 

Fluticasone propionate with azelastine hydrochloride (Amber 2)  

  • Dymista® Nasal spray

Notes: 

  • 2nd line to oral antihistamine and Avamys® nasal spray following at least a month’s trial of topical corticosteroid

 

Antimuscarinic  

    

Ipratropium bromide (Amber 2) 

  • Rinatec®  Nasal spray 0.03%          

Notes: 

  • Ipratropium may be useful to treat non-allergic watery rhinorrhoea. It does not act directly to reduce blood flow to the nose but reduces watery secretions.

 

Traffic light status (TLS) explained:

  • Green: Routine prescribing within licensed indication
  • Amber 1: specialist recommendation followed by GP initiation and continuation
  • Amber 2: specialist or GP initiation in line with local guideline after 1st line failure followed by GP continuation
  • Amber 3: specialist initiation and stabilisation followed by GP continuation
  • Amber SCG: specialist initiation and stabilisation followed by GP continuation in line with an agreed shared care guideline
  • Red: Hospital or specialist prescribing only
  • Double Red: These medicines have been evaluated and rejected by MKPAG and are NOT approved for use within MK. They are not recommended for use because of lack of clinical effectiveness, cost effectiveness or safety

 

 

Return to Chapter: 12. Ear, Nose and Oropharynx

Last updated by: Sheila Wood on 08-08-2019 12:10