netFormulary South East London Joint Medicines Formulary NHS
Guy's and St Thomas' NHS Foundation Trust
Kings College Hospital NHS Foundation Trust
Lewisham and Greenwich NHS Trust
 
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 Formulary Chapter 12: Ear, nose and oropharynx - Full Chapter
Notes:

Where a formulary entry does not detail a medicine’s indications for use, the medicine can be assumed to be approved for all licensed indications.

Formulary approved "off-label" use is detailed separately.

 Details...
12.01  Expand sub section  Drugs acting on the ear
12.01.01  Expand sub section  Otitis externa
12.01.01  Expand sub section  Astringent preparations
Acetic acid 2% ear spray
View adult BNF View SPC online
Formulary  
   
12.01.01  Expand sub section  Anti-inflammatory preparations
Otomize® ear spray
View adult BNF View SPC online
Formulary Contains:
  • Dexamethasone 0.1%
  • Neomycin sulphate 3250 units/mL
  • Glacial acetic acid 2% 
  •    
    Betamethasone 0.1% & neomycin 0.5% drops
    View adult BNF View SPC online
    Formulary  
       
    Betamethasone drops 0.1%
    View adult BNF View SPC online
    Formulary  
       
    Gentisone HC® ear drops
    View adult BNF View SPC online
    Formulary Contains:
  • Hydrocortisone acetate 1%
  • Gentamicin sulphate 0.03% 
  •    
    Locorten-Vioform® ear drops
    View adult BNF View SPC online
    Formulary Contains:
  • Flumetasone pivalate 0.02%
  • Clipquinol 1% 
  •    
    Prednisolone 0.5% & neomycin sulphate 0.5% ear drops
    View adult BNF View SPC online
    Formulary  
       
    Prednisolone ear drops 0.5%
    View adult BNF View SPC online
    Formulary  
       
    Sofradex® drops
    View adult BNF View SPC online
    Formulary Contains:
  • Dexamethasone 0.05%
  • Framycetin sulphate 0.5%
  • Gramicidin 0.005% 
  •    
    12.01.01  Expand sub section  Anti-infective preparations to top
    Chloramphenicol ear drops 10%
    View adult BNF View SPC online
    Formulary

     
       
    Clotrimazole topical solution 1%
    View adult BNF View SPC online
    Formulary  
       
    Gentamicin drops 0.3% (Ear)
    View adult BNF View SPC online
    Formulary  
       
    Ofloxacin ophthalmic solution 0.3%
    View adult BNF View SPC online
    Formulary

    Recognised off-label use in the ear:

    Twice a day or three times a day administration

     
       
    Ciprofloxacin unit dose ear drops 0.2%
    View adult BNF View SPC online
    Formulary
    Green

     
       
    12.01.02  Expand sub section  Otitis media
    12.01.03  Expand sub section  Removal of ear wax
    Olive Oil ear drops
    View adult BNF
    Formulary  
       
    Sodium bicarbonate ear drops 5%
    View adult BNF
    Formulary  
       
    Waxsol® ear drops (Docusate sodium)
    View adult BNF View SPC online
    Formulary  
       
    12.02  Expand sub section  Drugs acting on the nose
    12.02.01  Expand sub section  Drugs used in nasal allergy
    12.02.01  Expand sub section  Antihistamines to top
    Azelastine aqueous nasal spray (Rhinolast®)
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    Formulary  
       
    12.02.01  Expand sub section  Corticosteroids
    Betamethasone 0.1% drops
    View adult BNF View SPC online
    Formulary  
       
    Fluticasone furoate 27.5 micrograms nasal spray
    View adult BNF View SPC online
    Formulary  
       
    Fluticasone propionate 400 micrograms nasal drops (nasules) (nasal polyps)
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    Formulary
    Green

    Approved for the management of nasal polyps and associated symptoms of nasal obstruction

    Approved off-label use:

    • For treatment of chronic sinusitis after functional endoscopic sinus surgery (FESS) surgery for polyps.  One nasule (400 micrograms) added to saline nasal irrigation, used twice a day.
     
       
    Fluticasone propionate 50 micrograms and azelastine 137 micrograms nasal spray (Dymista®)
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    Formulary
    Green

    Approved in adults and children from 12 years for moderate to severe seasonal and perennial allergic rhinitis

    Restricted to use where a combination of oral antihistamines and nasal corticosteroids have failed (step 4 of SE London Allergic Rhinitis Pathway - see above for link)

     
    Link  SE London APC Recommendation: Fluticasone propionate and azelastine combination nasal spray (Dymista) for
       
    Fluticasone propionate 50 micrograms nasal spray
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    Formulary  
       
    Mometasone 50 micrograms nasal spray
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    Formulary  
       
    Beclometasone dipropionate 50 micrograms nasal spray
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    Restricted Drug Restricted

    Beclomethasone nasal spray is reserved for use when a nasal corticosteroid less dependent on CYP3A metabolism is required, e.g. patients taking cobicistat or ritonavir (see MHRA alert below)

    Mometasone, fluticasone propionate and fluticasone furoate are preferred intranasal cotricosteroid sprays for prescribing in SE London.

    See APC allergic rhinitis integrated guideline (link above)

     
    Link  MHRA Dec 2016:Cobicistat, ritonavir and coadministration with a steroid: risk of systemic corticosteroid adverse effects
       
    12.02.01  Expand sub section  Cromoglicate
    Sodium cromoglicate 4% nasal spray
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    Formulary  
       
    12.02.02  Expand sub section  Topical nasal decongestants
    NeilMed® Sinus Rinse Isotonic
    Formulary
    Red
    Hospital prescribing only 
       
    Sodium chloride nose drops 0.9%
    View adult BNF View SPC online
    Formulary  
       
    12.02.02  Expand sub section  Sympathomimetics
    Ephedrine nasal drops 0.5%, 1%
    View adult BNF View SPC online
    Formulary  
       
    Xylometazoline nasal spray 0.1% & nasal drops 0.1%
    View adult BNF View SPC online
    Formulary  
       
    12.02.02  Expand sub section  Antimuscarinic to top
    Ipratropium 21 micrograms nasal spray
    (Rinatec®)
    View adult BNF View SPC online
    Formulary  
       
    12.02.03  Expand sub section  Nasal preparations for infection
    12.02.03  Expand sub section  Nasal Staphylococci
    Bismuth subnitrate & iodoform gauze
    Formulary  
       
    Chloramphenicol 1% eye ointment  (ENT and plastics post surgical use - off-label)
    View adult BNF View SPC online
    Formulary

    Approved off-label indication:

    Topical use post ENT surgery or plastic surgery (to wound)

    Applied twice or three times daily for a short course (usually 5 days) post-procedure for prevention of infection

     
       
    Mupirocin 2% nasal ointment
    View adult BNF View SPC online
    Formulary USE ON MICROBIOLOGY/VIROLOGY ADVICE 
       
    Naseptin® cream
    View adult BNF View SPC online
    Formulary

    USE ON MICROBIOLOGY/VIROLOGY ADVICE Contains:

    • Chlorhexidine hydrochloride 0.1%
    • Neomycin sulphate 0.5%

    Caution: also contains arachis oil (peanut oil)

     
       
    Octenidine nasal gel
    Formulary
    Red
    USE ON MICROBIOLOGY/VIROLOGY ADVICE 
       
    Polyfax ® eye ointment
    View adult BNF
    Restricted Drug Restricted

    USE ON MICROBIOLOGY/VIROLOGY ADVICE only - for eradication of nasal carriage of MRSA

    Contains:

    • Polymixin B sulphate 10 000units/g
    • Bacitaricin zinc 500 units/g

    Instructions:

    • Eye ointment is used in the nose
    • A matchhead size portion to be applied into each nostril
    • Close nostrils to spread the ointment throughout the nares
    • Dose = 2-3 times daily
    • Continue treatment for 5-7 days
     
       
    Alkaline nasal douche
    Unlicensed Drug Unlicensed

    Powder containing:

    • Sodium bicarbonate 20g
    • Sodium chloride 20g
    • Borax 20g

    Indications:

    • Post-operatively after nasal surgery and functional endoscopic sinus surgery.
    • For any condition causing crusting of nasal cavities

    Instructions for use:

    • 5 mL spoonful of powder added to a tumblerful of warm water and mixed well.
    • Small aliquots of the solution are sniffed.
    • Any solution that goes into the throat should not be swallowed
    • Dose = three times daily
     
       
    12.03  Expand sub section  Drugs acting on the oropharynx
    12.03.01  Expand sub section  Drugs for oral ulceration and inflammation
    Benzydamine hydrochloride 0.15% spray (Difflam®)
    View adult BNF View SPC online
    Formulary  
       
    Benzydamine oral rinse 0.15%
    View adult BNF View SPC online
    Formulary  
       
    Cetalkonium & choline salicylate gel (Bonjela®)
    View SPC online
    Formulary  
       
    Hydrocortisone buccal tablets
    View adult BNF View SPC online
    Formulary  
    Link  MHRA Dec 18: Hydrocortisone muco-adhesive buccal tablets: should not be used off-label for adrenal insufficiency in children due to serious risks
       
    Betamethasone soluble tabs 500 micrograms (oral ulceration and inflammation)
    View adult BNF View SPC online
    Formulary

    Approved off-label use:

    Oral ulceration and inflammation

    • Dose = 1 tablet dissolved in water used as a mouthwash up to four times a day
    • Refer to APC information sheet on off-label medicines in the Oral Medicine Clinic for further information (link below at end of section)
     
       
    Prednisolone tablets (oral ulceration and inflammation - off-label [mouthwash])
    View adult BNF View SPC online
    Formulary
    Amber 2

    Approved off-label indication:

    Oral ulceration and inflammation

    • Dose = 5mg, crushed and dispersed in 10mL of water and used as a mouthwash up to four times a day
    • Oral medicine clinic initiation only
    • Refer to APC information sheet on off-label medicines in the Oral Medicine Clinic for further information (link below at end of section)
     
       
    Fluticasone 400 microgram nasules (oral ulceration and inflammation - off-label [mouthwash])
    View adult BNF View SPC online
    Formulary
    Amber 2

    Approved off-label indication:

    Oral ulceration and inflammation

    • Dose = one nasule diluted in 10mL of water and used as a mouthwash up to four times a day
    • Oral medicine clinic initiation only
    • Refer to APC information sheet on off-label medicines in the Oral Medicine Clinic for further information (link below at end of section)
     
       
    Mometasone nasal spray (oral ulceration and inflammation - off-label [oral use])
    View adult BNF View SPC online
    Formulary
    Amber 2

    Approved off-label indication:

    Oral ulceration and inflammation

    • Dose = one or two sprays to the lesion up to three times a day
    • Oral medicine clinic initiation only
    • Refer to APC information sheet on off-label medicines in the Oral Medicine Clinic for further information (link below at end of section)
     
       
    Beclomethasone 50 or 100 microgram aerosol inhaler (oral ulceration and inflammation - off-label [oral use])
    View adult BNF View SPC online
    Formulary
    Amber 2

    Approved off-label indication:

    Oral ulceration and inflammation

    • Dose = spray one or two puffs to the lesion up to three times a day
    • Oral medicine clinic initiation only
    • Refer to APC information sheet on off-label medicines in the Oral Medicine Clinic for further information (link below at end of section)
     
       
    Fluticasone 50 or 125 microgram aerosol inhaler (oral ulceration and inflammation - off-label [oral use])
    View adult BNF View SPC online
    Formulary
    Amber 2

    Approved off-label indication:

    Oral ulceration and inflammation

    • Dose = spray one or two puffs to the lesion up to three times a day
    • Oral medicine clinic initiation only
    • Refer to APC information sheet on off-label medicines in the Oral Medicine Clinic for further information (link below at end of section)
     
       
    Betamethasone valerate 0.1% ointment (oral ulceration and inflammation - off-label [oral use - mixed with orabase])
    View adult BNF View SPC online
    Formulary
    Amber 2

    Approved off-label indication:

    Oral ulceration and inflammation

    • Dose = pea sized volume mixed with an equal amount of orabase ointment (using a clean plastic measure and cotton bud for each dose) and applied to the lesion once daily
    • Oral medicine clinic initiation only
    • Refer to APC information sheet on off-label medicines in the Oral Medicine Clinic for further information (link below at end of section)
     
       
    Clobetasol propionate 0.05% ointment (oral ulceration and inflammation - off-label [oral use - mixed with orabase])
    View adult BNF View SPC online
    Formulary
    Amber 2

    Approved off-label indication:

    Oral ulceration and inflammation

    • Dose = pea sized volume mixed with an equal amount of orabase ointment (using a clean plastic measure and cotton bud for each dose) and applied to the lesion once daily
    • Oral medicine clinic initiation only
    • Refer to APC information sheet on off-label medicines in the Oral Medicine Clinic for further information (link below at end of section)
     
       
    Doxycyline 100 mg soluble tablets (oral ulceration and inflammation - off-label [mouthwash])
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    Formulary
    Amber 2

    Approved off-label indication:

    Oral ulceration and inflammation

    • Dose = 100mg, dispersed in 10mL of water and used as a mouthwash up to four times a day
    • Oral medicine clinic initiation only
    • Usual course length = 2 weeks, though for severe recalcitrant disease up to 6-8 weeks may be required
    • Refer to APC information sheet on off-label medicines in the Oral Medicine Clinic for further information (link below at end of section)
     
       
    Tacrolimus 0.1% and 0.03% ointment (orofacial granulomatosis - off-label [oral use])
    View adult BNF View SPC online
    Formulary
    Amber 2

    Approved off-label indication:

    Orofacial granulomatosis

    • Apply a thin layer to the lesions once daily at bedtime
    • Usual course length 6-8 weeks
    • Oral medicine clinic initiation only
    • Refer to APC information sheet on off-label medicines in the Oral Medicine Clinic for further information (link below at end of section)
     
       
    Colchicine tablets (oral ulceration and inflammation - off-label)
    View adult BNF View SPC online
    Formulary
    Amber 2

    Approved off-label indication:

    Oral ulceration and inflammation

    • Dose = 0.5 mg to 1.5 mg total daily dose
    • Oral medicine clinic initiation only
     
       
    Thalidomide caps (intractable oral ulcers - off-label)
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    Formulary
    Red

    Approved off-label indication:

    Intractable recurrent oral ulcers

    • Oral Medicine use only
    • Restricted to third line use where topical steroids and colchicine have been ineffective
     
       
    Carbenoxolone sodium 1% mouthwash granules  (Bioplex®)
    Formulary  
       
    Lidocaine 5% ointment
    View adult BNF View SPC online
    Formulary  
       
    Orabase® protective paste
    Formulary Contains:
  • Carmellose sodium 16.7%
  • Pectin 16.7%
  • Gelatin 16.7% 
  •    
    Orahesive® powder
    Formulary Contains equal parts of:
  • Carmellose sodium
  • Pectin
  • Gelatine 
  •    
    Betnovate® (betamethasone valerate 0.05%) ointment 50% in Orabase® (oral ulceration and inflammation)
    View adult BNF View SPC online
    Unlicensed Drug Unlicensed
    Red

    Approved for use in oral ulceration and inflammation

    • Dose = apply to the lesion once daily
    • Oral medicine clinic prescribing only
    • Restricted to use in patients unable to follow the administration instructions for use of separate supplies of steroid and orabase ointments
     
       
    Dermovate® (clobetasol propionate 0.05%) ointment 50% in Orabase® (oral ulceration and inflammation)
    View adult BNF View SPC online
    Unlicensed Drug Unlicensed
    Red

    Approved for use in oral ulceration and inflammation

    • Dose = apply to the lesion once daily
    • Oral medicine clinic prescribing only
    • Restricted to use in patients unable to follow the administration instructions for use of separate supplies of steroid and orabase ointments
     
       
    Ledermix dental paste
    Unlicensed Drug Unlicensed Antiflammatory agent used following dental procedures  
       
    Oxetacaine and antacid suspension
    Unlicensed Drug Unlicensed

    Mucositis pain after radiation therapy only

    Use in accordance with the GSTFT guidelines for the management of radiation induced acute effects in the head and neck region

    To be used as a mouthwash and then swallowed.

     
       
    Sodium chloride mouthwash 0.9%
    Unlicensed Drug Unlicensed

    Mucositis pain after radiation therapy only

    Use in accordance with the GSTFT guidelines for the management of radiation induced acute effects in the head and neck region

    To be used as a mouthwash and then swallowed.

     
       
    12.03.02  Expand sub section  Oropharyngeal anti-infective drugs to top
    12.03.02  Expand sub section  Oropharyngeal Fungal infections
    Miconazole oral gel
    View adult BNF View SPC online
    Formulary  
    Link  MHRA Sep 17: Miconazole (Daktarin): over-the-counter oral gel contraindicated in patients taking warfarin
       
    Nystatin oral suspension 100 000 units/mL
    View adult BNF View SPC online
    Formulary  
       
    12.03.02  Expand sub section  Oropharyngeal Viral infections
    12.03.03  Expand sub section  Lozenges and sprays
    Dequacaine® lozenges
    View adult BNF View SPC online
    Formulary Contains:
  • Benzocaine
  • Dequalinium  
  •    
    12.03.04  Expand sub section  Mouthwashes, gargles, and dentifrices
    Chlorhexidine gluconate mouthwash 0.2%
    View adult BNF View SPC online
    Formulary  
       
    Hydrogen peroxide mouth wash BP
    View adult BNF View SPC online
    Formulary Strengths avaialble:
  • 3% (10 volume)
  • 6% (20 volume) 
  •    
    Sodium chloride mouthwash, compound BP
    View adult BNF View SPC online
    Formulary Contains:
  • Sodium bicarbonate 1%
  • Sodium choride 1.5% 
  •    
    Thymol Mouthwash Solution-tablets
    View adult BNF View SPC online
    Formulary  
       
    OM1 antimicrobial soution
    Unlicensed Drug Unlicensed
    Red

    To be used under the supervision of a Consultant in Oral Microbiology or Oral Medicine only

    Treatment of the following conditions where coliforms and other microorganism counts are high and the patient is symptomatic:

    • Exfoliative cheilitis chronic mucocutaneous candidiasis (CMCC)
    • Oral infections caused by Gram negative rods e.g. E. coli & proteus spp.

    PIL available on GTi

     
       
    12.03.05  Expand sub section  Treatment of dry mouth to top
    Minocycline periodontal gel
    Unlicensed Drug Unlicensed Gum disease  
       
    Tetracycline capsules 250mg (unlicensed product for aphthae ulcers)
    Unlicensed Drug Unlicensed

    Aphthae ulcers Mix contents of one capsule in 10 ml of warm water and use as a mouthwash four times a day

     
       
    12.03.05  Expand sub section  Local Treatment
    Artificial saliva spray
    View adult BNF
    Formulary The brand in use at each site will depend on local contracts. Contact the pharmacy department for information if required.
  • Glandosane spray
  • Xerotin spray
  • Saliveze spray
  • AS Saliva Orthana  
  •    
    Biotene Oralbalance® saliva replacement gel
    View adult BNF
    Formulary

     
       
    Oralieve® moisturising mouth gel
    View adult BNF
    Formulary

     
       
    BioXtra® gel
    View adult BNF
    Formulary

    For Oncology and Palliative Care use only

     
       
    Gelclair® oral rinse gel
    Restricted Drug Restricted

    For Oncology and Palliative Care use only

     
       
    12.03.05  Expand sub section  Systemic treatment
    Pilocarpine eye drops 4% (dry mouth - off-label)
    View adult BNF View SPC online
    Restricted Drug Restricted
    Red

    Approved off-label indication:

    • For symptoms of dry mouth in patients with Sjögren's syndrome or following irradiation for head and neck cancer (alternative when there are supply issues with pilocarpine tabs) Given orally.

    Starting dose = 3 drops of 4% (6mg) three times a day

     
       
    Pilocarpine tabs
    View adult BNF View SPC online
    Restricted Drug Restricted For symptoms of dry mouth and dry eyes in patients with Sjögren's syndrome 
       
    12.04  Expand sub section  Miscellaneous
    Carnoy’s solution (ethanol 60%, chloroform 30%, glacial acetic acid 10%)
    View adult BNF View SPC online
    Unlicensed Drug Unlicensed
    Red

    Topical adjuvant for procedures for odontogenic keratocysts

     
       
     ....
     Non Formulary Items
    Budesonide 64 micrograms nasal spray

    View adult BNF View SPC online
    Non Formulary
    Grey
    Mometasone, fluticasone propionate and fluticasone furoate are preferred intranasal cotricosteroid sprays for prescribing in SE London. See APC allergic rhinitis integrated guideline (link above)
     
      
    Key
    note Notes
    Section Title Section Title (top level)
    Section Title Section Title (sub level)
    First Choice Item First Choice item
    Non Formulary Item Non Formulary section
    Restricted Drug
    Restricted Drug
    Unlicensed Drug
    Unlicensed
    Track Changes
    Display tracking information
    click to search medicines.org.uk
    Link to adult BNF
    click to search medicines.org.uk
    Link to SPCs
    SMC
    Scottish Medicines Consortium
    Cytotoxic Drug
    Cytotoxic Drug
    CD
    Controlled Drug
    High Cost Medicine
    High Cost Medicine
    Cancer Drugs Fund
    Cancer Drugs Fund
    NHSE
    NHS England
    Homecare
    Homecare
    CCG
    CCG

    Traffic Light Status Information

    Status Description

    Red

    Specialist or hospital prescribing only. The responsibility for prescribing, monitoring, dose adjustment and review should remain with the specialist or hospital. In very exceptional circumstances a specialist may discuss individual patient need for a RED drug to be prescribed by a GP and the GP should consider informing the Medicines Management team before a decision is made to prescribe for individual patients.   

    Amber 1

    Treatment can be initiated in primary care after a recommendation from an appropriate specialist  

    Amber 2

    Specialist initiation followed by maintenance prescribing in primary care  

    Amber 3

    Specialist initiation with ongoing monitoring required. After dose stabilisation GPs can be requested to take over prescribing responsibilities using the approved APC shared care documentation  

    Green

    Specialist and non-specialist initiation  

    Grey

    Not recommended for prescribing  

    netFormulary