NHS Borders Joint Prescribing Formulary Ear, nose, and oral cavity Black Text Drugs which may be prescribed by all prescribers Drugs which are either for specialist only prescription or for specialist Pink Text initiation, with prescribing transfer to GP Important Information: In addition to the disclaimer on NHS Borders website the following information is included confirming that the information contained in NHS Borders Joint Prescribing formulary is drawn from several sources, including BNF & BNF for children, product SPCs, local and national guidelines, local expert opinion, Lothian Joint Formulary and these are all gratefully acknowledged here. NHS Borders has done its utmost to ensure the information in the BJF is accurate and reliable, but NHS Borders cannot guarantee that the information is complete and accurate. Prescribers are referred to the SPCs, BNF and BNF for children to confirm prescribing information. June 2021 Contents Page Table of Contents 12.1 Drugs acting on the ear ................................................................................................ 3 Otitis externa ................................................................................................................ 3 Otitis media .................................................................................................................. 3 Removal of ear wax ..................................................................................................... 3 12.2 Drugs acting on the nose ............................................................................................. 4 Drugs used in nasal allergy .......................................................................................... 4 Topical nasal decongestants ........................................................................................ 5 Nasal preparations for infection .................................................................................... 5 12.3 Drugs acting on the oral cavity ..................................................................................... 6 Drugs for oral ulceration and inflammation ................................................................... 6 Oral cavity anti-infective drugs ..................................................................................... 6 Mouthwashes, gargles and dentifrices ......................................................................... 7 Treatment of dry mouth ................................................................................................ 7 Ear, nose, and oral cavity Page 2 of 8 Contents Page 12.1 Drugs acting on the ear Otitis externa First choice Betamethasone Ear drops Dose: apply 2 or 3 drops every three – four hours, reducing frequency as condition responds Second choice Otomize Ear spray Dexamethasone 0.1%, neomycin sulphate 3250 units/ml, glacial acetic acid 2% Dose: One metered spray to the affected ear(s) three times a day Alternative preparations • Cilodex Ear Drops Ciprofloxacin3mg/ml +dexamethasone 1mg/ml are specialist initiation. • Flumetasone pivalate 0.02%, clioquinol 1% (previously Locorten- Vioform) may be used if a perforated ear drum is suspected. Dose is 2-3 drops into ear twice daily for 7-10 days. • Clotrimazole 1% solution, applied 2 or 3 times daily, is an appropriate choice if a fungal infection is suspected. Treatment should be continued for at least 14 days after disappearance of the infection Otitis media • Topical treatment of acute otitis media is ineffective • Simple analgesia resolves most uncomplicated cases • Refer to BJF chapter 5 Infections for detail of antibiotic treatment when this is appropriate Removal of ear wax • Proprietary preparations may have constituents which irritate the meatal skin, and offer no advantage over simple products like almond oil Olive oil Ear drops Dose: apply twice daily for up to 2 weeks. Ear syringing may not always be necessary after this preparation. • Oil should be warmed before application, and a generous amount of oil applied, with the patient lying with affected ear uppermost for 5-10 minutes after application. Ear, nose, and oral cavity Page 3 of 8 Contents Page 12.2 Drugs acting on the nose Drugs used in nasal allergy • Systemic antihistamines may be used alone or with topical nasal corticosteroids to control symptoms of mild allergic rhinitis • Short term use of topical nasal decongestants may relieve congestion and facilitate penetration of topical nasal corticosteroid • Treatment of seasonal allergic rhinitis is commenced two or three weeks before the pollen season is likely to start, and is continued through the season • Sodium chloride 0.9% solution can be used as a nasal douche. NeilMed Sinus Rinse kit is an appropriate device with nasal irrigation sachets which may be purchased for this purpose. First choice Beclometasone Nasal spray 50 micrograms/spray Dose: 2 sprays into both nostrils twice daily. The dose can be reduced to one spray into each nostril twice daily when symptoms are controlled. Maximum dose is 8 sprays daily • Consider a 2 month trial of beclometasone before switching to mometasone Second choice Mometasone Furoate Nasal Spray 50 micrograms/spray or Dose: 2 sprays into each nostril once daily, increased to 4 sprays into each nostril once daily, if necessary Fluticasone Furoate 27.5 micrograms/ actuation nasal spray (Avamys) Dose: The recommended starting dose is two spray actuations (27.5micrograms of fluticasone furoate per spray actuation) in each nostril once daily (total daily dose, 110micrograms). Once adequate control of symptoms is achieved, dose reduction to one spray actuation in each nostril (total daily dose 55micrograms) may be effective for maintenance. Alternative preparations Fluticasone with Nasal spray azelastine Dose: 1 spray twice daily to each nostril • Specialist initiation for severe allergic rhinitis, if monotherapy with antihistamine or corticosteroid is inadequate Fluticasone Propionate Nasules 400 micrograms/unit dose Ear, nose, and oral cavity Page 4 of 8 Contents Page Dose: apply 200 micrograms (approximately 6 drops) into each nostril once or twice daily • Initiated after clear diagnosis, for treatment of nasal polyps • Treatment is reviewed after 4-6 weeks • Fluticasone nasules may be prescribed in conjunction with an extended course of oral clarithromycin 250mg twice daily for treatment of chronic sinusitis. As this is off-license use, treatment should be prescribed by an ENT consultant and dispensed by BGH pharmacy. The risks and benefits associated with withholding atorvastain/simvastatin while treating with clarithromycin (there is a potentially serious interaction between both simvastatin and atorvastatin with clarithromycin) should be considered when prescribing clarithromycin. • A two week course of oral prednisolone 25mg in the morning for 2 weeks for severe symptoms associated with nasal polyps, may be indicated prior to treatment with topical steroid nasal spray. Topical nasal decongestants • Inhalation of moist warm air can be useful in treating symptoms of acute infective conditions. The addition of menthol or eucalyptus oil may improve the efficacy of the inhalation Ephedrine Nasal drops 0.5% ,1% Dose: instil one or two drops into each nostril up to four times daily when required • Use should be limited to a maximum of 7 days, as sympathomimetics are associated with causing rebound congestion • Ipratropium bromide 21 micrograms/spray may be effective for the treatment of non-allergic watery rhinorrhoea Nasal preparations for infection Naseptin Cream. Chlorhexidine hydrochloride 0.1%, neomycin sulphate 0.5%. Dose: Apply to nostrils 4 times daily for 10 days (eradication of staphylococci). Apply to nostrils twice daily (for prevention of nasal carriage of staphylococci) • Mupirocin is reserved for use in eradication of nasal carriage of staphylococci in MRSA Ear, nose, and oral cavity Page 5 of 8 Contents Page 12.3 Drugs acting on the oral cavity Drugs for oral ulceration and inflammation Local treatment aims to: • Protect the ulcerated area • Relieve pain • Reduce inflammation • Control secondary infection First choice Benzydamine Oral rinse 0.15%. Dose: 15ml every one and a half to three hours as required • Treatment duration does not normally exceed 7 days • Dilute 1:1 with water if stinging occurs • Use 10 minutes before food to relieve pain in patients with aphthous ulcers • Indicated for painful inflammatory conditions of the oropharynx Spray 0.15% Dose: 4-8 sprays every one and a half to three hours Second choice Hydrocortisone Sodium succinate Oromucosal tablets 2.5mg Dose: 1 oromucosal tablet dissolved slowly in mouth in contact with the ulcer four times daily Third choice - Specialist use Betamethasone Tablets soluble 500 microgram Dose: Dissolve 1 tablet in 20mls water and hold in mouth for several minutes before spitting out. Avoid food & drink for 30 minutes. Repeat four times daily for one week • Specialist commencement for ulcerated sore mouth resistant to other treatment Oral cavity anti-infective drugs • Refer to BJF Infections chapter Ear, nose, and oral cavity Page 6 of 8 Contents Page Mouthwashes, gargles and dentifrices Chlorhexidine Gluconate Mouthwash 0.2% Dose: rinse mouth with 10ml, twice daily, for one minute • Indicated for oral hygiene and inhibition of plaque • In dental stomatitis, cleanse and soak dentures in mouthwash solution for 15 minutes twice daily Dental gel 1%. Dose: brush onto teeth once or twice daily • Indicated for oral hygiene, plaque inhibition and gingivitis.