| Formulary Chapter 12: Ear, nose and oropharynx - Full Chapter
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 North of Tyne, Gateshead and North Cumbria - Newcastle upon Tyne ENT GP Referral Guidelines |
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| 12.01 |
Drugs acting on the ear |
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| 12.01.01 |
Otitis externa |
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Boric acid (insufflation)
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Formulary
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| 12.01.01 |
Astringent preparations |
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Acetic Acid 2% spray (Earcalm ®)
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Formulary
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| 12.01.01 |
Anti-inflammatory preparations |
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Betamethasone 0.1% ear/eye/nose drops
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Formulary
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- First choice corticosteroid ear drops.
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Betamethasone 0.1% with neomycin 0.5% ear drops (Betnesol N®)
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Formulary
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- Alternative choice compound antibacterial/corticosteroid ear drop.
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Chloramphenicol
(5% & 10% drops)
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Formulary
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Dexamethasone 0.05% with framycetin 0.5% ear drops (Sofradex®)
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Formulary
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- Alternative choice compound antibacterial/corticosteroid ear drop.
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Dexamethasone 0.1% with neomycin 0.5% spray (Otomize®)
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Formulary
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- Alternative choice compound antibacterial/corticosteroid ear drop.
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Flumetasone 0.02% with Clioquinol 1% ear drops
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Formulary
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- Alternative choice compound antibacterial/corticosteroid ear drop.
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Hydrocortisone 1% Neomycin 0.439% & Polymixin B sulphate 10,000iu/ml ear drops (Otosporin®)
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Formulary
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- Alternative choice compound antibacterial/corticosteroid ear drop.
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Hydrocortisone Acetate 1% with Gentamicin 0.3% (Gentisone® HC)
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Formulary
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- First choice compound antibacterial/corticosteroid ear drop.
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Prednisolone 0.5% ear/eye drops
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Formulary
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- Second choice corticosteroid ear drops.
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Triamcinolone with neomycin, gramicidin and nystatin (Kenacomb Otic®)
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Formulary
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- Triamcinolone acetonide 1mg, neomycin sulphate 2.5mg, gramicidin 0.25mg & nystatin 100,000iu/5g ointment
 unlicensed
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Betamethasone 0.1% (Betnovate® Scalp Application)
(As EAR DROPS for eczema)
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 Restricted
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 unlicensed
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| 12.01.01 |
Anti-infective preparations |
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Chloramphenicol 5% and 10% ear drops
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Formulary
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Ciprofloxacin 0.2% ear drops
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Formulary
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- 2mg/ml (0.2%) ear drops (0.25ml unit dose)
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Ciprofloxacin & dexamethasone (Ciprodex®)
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Formulary
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- Ciprofloxacin 0.3% and dexamethasone 0.1% ear drops
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Clotrimazole 1% solution
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Formulary
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Gentamicin 0.3% ear/eye drops
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Formulary
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| 12.01.01 |
Other aural preparations |
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| 12.01.02 |
Otitis media |
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Phenazone with lidocaine (Otigo®)
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Formulary
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- Phenazone 40mg/1g & lidocaine hydrochloride 10mg/1g ear drops
- Approved for the treatment of Acute otitis media & Barotraumatic otitis in line NICE
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| 12.01.03 |
Removal of ear wax |
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Sodium Bicarbonate ear drops
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Formulary
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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 and fluticasone (Dymista®)
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Formulary
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Betamethasone Sodium Phosphate 0.1% eye/ear/nose drops
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Formulary
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| 12.02.01 |
Antihistamines |
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Azelastine Hydrochloride 140microgram nasal spray (Rhinolast®)
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Formulary
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| 12.02.01 |
Corticosteroids |
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Beclometasone Dipropionate 50 microgram nasal spray
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First Choice
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Betamethasone 0.1% eye/ear/nose drops
(ear)
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Alternatives
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Fluticasone furoate 27.5microgram/dose nasal spray (Avamys®)
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Alternatives
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- Note: take care to avoid confusion with fluticasone propionate.
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Fluticasone Propionate 400microgram/dose nasal drops (Flixonase Nasule®)
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Alternatives
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- Note: take care to avoid confusion with fluticasone furoate.
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Fluticasone Propionate 50microgram/dose nasal spray (Nasofan®)
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Alternatives
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- Note: take care to avoid confusion with fluticasone furoate.
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Mometasone Furoate 50microgram/metered dose nasal spray
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Alternatives
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Triamcinolone Acetonide 55microgram metered dose nasal spray (Nasacort®)
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Alternatives
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| 12.02.01 |
Cromoglicate |
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| 12.02.02 |
Topical nasal decongestants |
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Sodium Chloride 0.9%
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Formulary
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| 12.02.02 |
Sympathomimetics |
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Xylometazoline (Otrivine®)
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First Choice
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- 0.05% and 0.1% nasal drops.
- 0.1% nasal spray.
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Ephedrine
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Alternatives
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| 12.02.02 |
Antimuscarinic |
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Ipratropium Bromide 21 microgram/puff nasal spray (Rinatec®)
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Formulary
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| 12.02.03 |
Nasal preparations for infection |
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Boric Acid & Povidone Iodine
(Insufflation)
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Formulary
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Lidocaine and Phenylephrine Nasal spray
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Formulary
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| 12.02.03 |
Nasal Staphylococci |
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Chlorhexidine Hydrochloride 0.1%, Neomycin Suphate 0.5% (Naseptin®)
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Formulary
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Mupirocin 2% (Bactroban Nasal®)
(nasal)
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Formulary
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- First choice the treatment of MRSA
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Bismuth Subnitrate and Iodoform (B.I.P.P.)
(Paste)
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Formulary
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1.25cm x 100cm & 2.5cm x 100cm impregnated gauze
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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 Mouthwash & Spray (Difflam®)
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Formulary
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Betamethasone
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Formulary
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- Soluble tablets 500 micrograms
- Used as mouth gargle
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Caphosol®
(liquid)
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Formulary
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- For limited use in patients having chemo-radiotherapy or radiotherapy to malignancies of the oral cavity, hypopharynx and oro-pharynx.
- Trusts encouraged to prescribe enough between chemotherapy and radiotherapy appointments in secondary care in anticipation of mucositis developing.
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Choline Salicylate (Bonjela® Adult)
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Formulary
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Doxycycline 20mg tablets
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Formulary
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- Treatment of periodontitis.
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Gelclair®
(Gel)
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Formulary
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- Trusts encouraged to prescribe enough between chemotherapy and radiotherapy appointments in secondary care in anticipation of mucositis developing.
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Hyaluronan
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Formulary
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- 0.2% gel and 0.025% mouthwash.
- For limited second-line use on specialist advice in the treatment of
orofacial granulomatosis, severe oral ulceration and mucositis secondary
to immunosuppression where conventional treatments are unsuitable or
have failed.
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Hydrocortisone 2.5mg Lozenges
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Formulary
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 MHRA Drug Safety Update (Dec 2018): Hydrocortisone muco- adhesive buccal tablets: should not be used off-label for adrenal insufficiency in children due to serious risks.
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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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Miconazole 24mg/ml sugar-free oral gel (Daktarin®)
(20mg/g)
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Formulary
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MHRA Drug Safety Update (June 2016): Topical miconazole, including oral gel: reminder of potential for serious interactions with warfarin
MHRA Drug Safety Update (Sept 2017): Miconazole (Daktarin): over-the-counter oral gel contraindicated in patients taking warfarin
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Miconazole 50mg muco-adhesive buccal tablets (Loramyc®)
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Formulary
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- Restricted to use in immunocompromised patients with severe oropharyngeal candidiasis, where the use of other antifungal agents e. g. nystatin, fluconazole is not appropriate and for use on the advice of microbiologists.
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Nystatin 1000,000units/ml suspension (Nystan®)
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Formulary
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| 12.03.02 |
Oropharyngeal Viral infections |
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Aciclovir tablets and suspension
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Formulary
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see section 05.03.02
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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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Chlorhexidine
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Formulary
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- 0.2% mouthwash.
- 0.2% mint flavoured spray.
- 1% dental gel.
- Dental products should only be prescribed by dentists and GPs should not accept requests to prescribe medicines that the dentist could reasonably prescribe themselves, nor accept requests from patients to issue FP10 prescriptions for items prescribed on a private prescription by their dentist.
- 2% oral gel unlicensed
- For hospital use in the prevention of ventilator-associated pneumonia in adult patients who are ventilated (for >48 hours).
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MHRA Drug Safety Update (November 2012): Chlorhexidine: reminder of potential for hypersensitivity
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Hexetidine 0.1% mouthwash
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Formulary
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Tranexamic Acid Mouthwash
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Formulary
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| 12.03.05 |
Treatment of dry mouth |
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Artificial Saliva
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Formulary
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- Use cheapest
- Available products include
- AS Saliva Orthana®
- Biotene Oralbalance® gel
- BioXtra® Glandosane® spray
- Malic acid Salivix®
- Oralieve® Moisturising Spray & Gel
- Patients should be advised of self-care measures and signposted to purchase over the counter remedies where appropriate.
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| 12.03.05 |
Local Treatment |
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Pilocarpine 5mg tablets
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Alternatives
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- Treatment to be initiated with specialist advice.
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| 12.03.05 |
Systemic treatment |
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| 12.04 |
Miscellaneous |
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Carnoy’s solution
(Treatment of Keratocystic odontogenic tumours)
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Restricted
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- Unlicensed
- 10ml bottle
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Cocaine 5% Nasal Spray
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Unlicensed
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| Non Formulary Items |
Olive Oil Ear Drops
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Non Formulary
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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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Cytotoxic Drug |
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Controlled Drug |
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High Cost Medicine |
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NHS England |
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Homecare |
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ICB |
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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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Drugs for hospital use only. The responsibility for initiation and monitoring treatment should rest with an appropriate hospital clinician and the drug should be supplied through the hospital throughout the duration of treatment. In some very exceptional circumstances (e.g. due to distance from the hospital, storage, supply or mobility/transport problems) it may be appropriate for the GP to be asked to prescribe a Red drug. This should be negotiated on an individual patient basis and should only be done with the GP’s prior informed agreement where the roles of the GP and hospital services are clearly defined and agreed. The GP should not feel under pressure to prescribe in these circumstances. For all RED drugs automatically added to the formulary in response to a positive NICE TA: Prescribers need to ensure that local Trust new drug governance procedures and pharmacy processes are followed before any prescribing. |
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Drugs initiated by hospital specialist, but where continuing treatment by GPs may be appropriate under a shared care arrangement. These medicines are considered suitable for primary care prescribing following specialist initiation of therapy and stabilisation, with ongoing communication between the primary care prescriber and specialist as set out in the associated shared care guideline (SCG). Shared care should be initiated by the specialist, which includes consultant, suitably trained specialist non-medical prescriber or GPwER within a secondary, tertiary, or primary care clinic.
The specialist should send the primary care prescriber a copy of the NENC Clinical Effectiveness and Governance (CEG) Subcommittee approved SCG to sign. The primary care prescriber should sign the SCG or indicate reasons why they are unable to accept the agreement and return a copy back to the specialist, as soon as possible.
SCGs are available or are being developed for most of the drugs listed as AMBER. |
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Drugs normally recommended or initiated by a hospital specialist who is a prescriber, a GP with an extended role [GPwER], or a specialist within primary care which can be safely maintained in primary care and monitored in primary care. In some cases, a further restriction for use may be defined. The primary care prescriber must be familiar with the drug to take on prescribing responsibility or must obtain the required information from the specialist. Therefore, provision of additional information, or an information leaflet, may be appropriate in some cases to facilitate continuing treatment by primary care prescriber or provide information re stopping criteria.
These are considered suitable for primary care prescribing following specialist assessment and recommendation of therapy, with ongoing communication between the primary care prescriber and specialist, if necessary.
In some case these drugs require specialist initiation and short to medium term monitoring of efficacy or toxicity until the patient’s dose is stable. Following specialist review the patient may be transferred to primary care for ongoing prescribing. Ongoing prescribing by primary care can include, if required, additional dose titrations and assessment of efficacy, with ongoing communication between the primary care prescriber and specialist, if necessary.
If the drug requires urgent initiation, it is expected that the specialist undertakes the initial prescribing responsibility for an appropriate period of time, usually a minimum of 28 days. A GREEN+ drug can only be recommended to primary care for initiation if does not need to be initiated within 28 days. |
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Medicines suitable for initiation, ongoing prescribing and discontinuation in all care settings, subject to appropriate communication between those responsible. |
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UNDER REVIEW: drugs whose current formulary status or RAG status is currently under review. |
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Drugs that have been considered by the NENC Clinical Effectiveness and Governance (CEG) Subcommittee (or other approved body) and are not approved for prescribing within the North East and North Cumbria ICS. These may also include all medicines with a “not NHS” or “DLCV” classification in the BNF, those agents as included within the NICE “Do not do” list, and those agents included with the NHS England: Items which should not routinely be prescribed in primary care. |
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