Topical nasal decongestants MOMETASONE FUROATE

12.2.2 Topical nasal decongestants MOMETASONE FUROATE

Indications see preparations The nasal mucosa is sensitive to changes in atmospheric Cautions see notes above

temperature and humidity and these alone may cause Side-effects see notes above

slight nasal congestion. The nose and nasal sinuses produce a litre of mucus in 24 hours and much of this Nasonex c (Schering-Plough) A finds its way silently into the stomach via the nasophar-

Nasal spray , mometasone furoate 50 micrograms/ ynx. Slight changes in the nasal airway, accompanied by metered spray. Net price 140-spray unit = £7.83

an awareness of mucus passing along the nasopharynx

Excipients include benzalkonium chloride, polysorbate 80

causes some patients to be inaccurately diagnosed as Dose prophylaxis and treatment of allergic rhinitis, ADULT and

suffering from chronic sinusitis. These symptoms are CHILD over 12 years, 100 micrograms (2 sprays) into each nostril

particularly noticeable in the later stages of the common once daily, increased if necessary to max. 200 micrograms (4 sprays) into each nostril once daily; when control achieved reduce

cold. Sodium chloride 0.9% given as nasal drops may to 50 micrograms (1 spray) into each nostril once daily; CHILD 6–

relieve nasal congestion by helping to liquefy mucous 11 years, 50 micrograms (1 spray) into each nostril once daily

secretions.

Nasal polyps, ADULT over 18 years, 100 micrograms (2 sprays) into each nostril once daily, increased if necessary after 5–6 weeks to

Inhalation of warm moist air is useful in the treatment 100 micrograms (2 sprays) into each nostril twice daily (consider

of symptoms of acute infective conditions. The addition

rynx

alternative treatment if no improvement after further 5–6 weeks); of volatile substances such as menthol and eucalyptus reduce to the lowest effective dose when control achieved

may encourage the use of warm moist air (section 3.8).

opha or Symptoms of nasal congestion associated with vaso-

motor rhinitis and the common cold can be relieved by

and TRIAMCINOLONE ACETONIDE

the short-term use (usually not longer than 7 days) of Indications

e, decongestant nasal drops and sprays. These all contain

prophylaxis and treatment of allergic sympathomimetic drugs which exert their effect by

nos

, vasoconstriction of the mucosal blood vessels which

rhinitis

Cautions see notes above in turn reduces oedema of the nasal mucosa. They are of Ear Side-effects see notes above

limited value because they can give rise to a rebound

c congestion (rhinitis medicamentosa) on withdrawal, due

12 Nasacort (Aventis Pharma) A Aqueous nasal spray to a secondary vasodilation with a subsequent tempor- , triamcinolone acetonide ary increase in nasal congestion. This in turn tempts the

55 micrograms/metered spray. Net price 120-spray further use of the decongestant, leading to a vicious unit = £7.39 Excipients include benzalkonium chloride, disodium edetate, polysor-

cycle of events. Ephedrine nasal drops is the safest

sympathomimetic preparation and can give relief for Dose ADULT and CHILD over 12 years 110 micrograms (2 sprays)

several hours. The more potent sympathomimetic drugs into each nostril once daily; when control achieved, reduce to

bate 80

oxymetazoline, and xylometazoline are more likely to 55 micrograms (1 spray) into each nostril once daily; CHILD 6–12

cause a rebound effect. All of these preparations may years, 55 micrograms (1 spray) into each nostril once daily Note

cause a hypertensive crisis if used during treatment with Preparations of triamcinolone acetonide can be sold to the public for nasal administration as a non-pressurised nasal

a monoamine-oxidase inhibitor including moclobemide. spray if supplied for the symptomatic treatment of seasonal

The CHM/MHRA has stated that non-prescription allergic rhinitis in adults over 18 years, subject to max. daily dose of 110 micrograms per nostril for max. 3 months, and a

cough and cold medicines containing ephedrine, oxy- pack size of 3.575 mg

metazoline, or xylometazoline should not be used in children under 2 years of age (section 3.9.1). However, in special circumstances, some specialists prescribe nasal drops containing ephedrine or xylometazoline in

Cromoglicate

children under 2 years of age for the short-term treat- ment of severe nasal obstruction that has not responded to sodium chloride 0.9% nose drops and inhalation of

SODIUM CROMOGLICATE

warm moist air.

(Sodium Cromoglycate) Non-allergic watery rhinorrhoea often responds well to Indications prophylaxis of allergic rhinitis

treatment with the antimuscarinic ipratropium Side-effects local irritation; rarely transient broncho-

bromide.

spasm Systemic nasal decongestants—see section 3.10.

BNF 57

12.2.3 Nasal preparations for infection 607

Sinusitis and oral pain Sinusitis affecting the max- Nasal spray , xylometazoline hydrochloride 0.1%, net illary antrum can cause pain in the upper jaw. Where

price 10 mL = £1.91 this is associated with blockage of the opening from the

1 spray into each nostril 2–3 times daily when required; sinus into the nasal cavity, it may be helpful to relieve

Dose

max. duration 7 days; not recommended for children under 12 the congestion with inhalation of warm moist air (sec-

years

tion 3.8) or with ephedrine nasal drops (see above). Brands include Otraspray , Otrivine D For antibacterial treatment of sinusitis, see Table 1,

section 5.1.

Antimuscarinic

Sympathomimetics IPRATROPIUM BROMIDE

Indications rhinorrhoea associated with allergic and

EPHEDRINE HYDROCHLORIDE non-allergic rhinitis

Cautions see section 3.1.2; avoid spraying near eyes Indications nasal congestion

Side-effects epistaxis, nasal dryness, and irritation; Cautions see notes above; also avoid excessive or

less frequently nausea, headache, and pharyngitis; prolonged use; caution in infants under 3 months (no

very rarely antimuscarinic effects such as gastro- good evidence of value—if irritation occurs might

intestinal motility disturbances, palpitations, and narrow nasal passage); interactions: Appendix 1

urinary retention

(sympathomimetics)

Dose

Side-effects local irritation, nausea, headache; after . ADULT and CHILD over 12 years, 42 micrograms (2 excessive use tolerance with diminished effect,

sprays) into each nostril 2–3 times daily rebound congestion; cardiovascular effects also

reported c Rinatec (Boehringer Ingelheim) A , ipratropium bromide 21 micr-

Dose Nasal spray 0.03%

ograms/metered spray. Net price 180-dose unit = . See below

£4.55 Excipients include benzalkonium chloride, disodium edetate

1 Ephedrine (Non-proprietary) Nasal drops , ephedrine hydrochloride 0.5%, net price

10 mL = £1.25; 1%, 10 mL = £1.31 Note The BP directs that if no strength is specified 0.5% drops

12.2.3 Nasal preparations for

should be supplied Dose 1–2 drops into each nostril up to 3 or 4 times daily when

infection

required; CHILD 3 months–12 years (on a specialist’s advice only for CHILD

3 months–2 years), 1–2 drops of 0.5% solution into each nostril 3–4 times daily; max. duration 7 days

There is no evidence that topical anti-infective nasal Dental prescribing on NHS Ephedrine nasal drops may be pre-

preparations have any therapeutic value in rhinitis or scribed

sinusitis; for elimination of nasal staphylococci, see

1. Can be sold to the public provided no more than 180 mg of

below.

ephedrine base (or salts) are supplied at one time, and pseudoephedrine salts are not supplied at the same time; for

Systemic treatment of sinusitis—see Table 1 section 5.1 details see Medicines, Ethics and Practice, No. 32, London

Pharmaceutical Press, 2008 (and subsequent editions as Betnesol-N (UCB Pharma) AU

available) Drops (for ear, eye, or nose), betamethasone sodium phosphate 0.1%, neomycin sulphate 0.5%. Net price

10 mL = £2.39

Ear XYLOMETAZOLINE HYDROCHLORIDE

Excipients include benzalkonium chloride, disodium edetate Dose nose , 2–3 drops into each nostril 2–3 times daily; eye ,

section 11.4.1; ear , section 12.1.1

nose, ,

Indications nasal congestion Vistamethasone N c (Martindale) AU Cautions see under Ephedrine Hydrochloride and

Drops (for ear, eye, or nose), betamethasone sodium notes above

phosphate 0.1%, neomycin sulphate 0.5%. Net price

and

Side-effects see under Ephedrine Hydrochloride and

5 mL = £1.09, 10 mL = £1.20

include thiomersal Dose nose , 2–3 drops into each nostril twice daily; eye , section

Excipients

or

notes above

opharynx

Dose 11.4.1; ear , section 12.1.1 . See below

Xylometazoline (Non-proprietary)

Nasal staphylococci

Nasal drops , xylometazoline hydrochloride 0.1%, net price 10 mL = £1.91

Elimination of organisms such as staphylococci from the Dose 2–3 drops into each nostril 2–3 times daily when required;

nasal vestibule can be achieved by the use of a cream max. duration 7 days; not recommended for children under 12

containing chlorhexidine and neomycin (Naseptin c ), years

but re-colonisation frequently occurs. Coagulase-posi- Brands include Otradrops , Otrivine D tive staphylococci are present in the noses of 40% of the

Paediatric nasal drops , xylometazoline hydro-

population.

chloride 0.05%, net price 10 mL = £1.59 Dose CHILD 2–12 years 1–2 drops into each nostril 1–2 times

A nasal ointment containing mupirocin is also avail- daily when required (on a specialist’s advice only for CHILD 3 able; it should probably be held in reserve for resistant months–2 years); max. duration 7 days

cases. In hospital or in care establishments, mupirocin Brands include Otradrops , Otrivine

D, Tixycolds

nasal ointment should be reserved for the eradication

12.3 Drugs acting on the oropharynx BNF 57 (in both patients and staff) of nasal carriage of meticillin-

Antiseptic mouthwashes Secondary bacterial infec- resistant Staphylococcus aureus (MRSA). The ointment

tion may be a feature of any mucosal ulceration; it can should be applied 3 times daily for 5 days and a sample

increase discomfort and delay healing. Use of chlor- taken 2 days after treatment to confirm eradication. The

hexidine mouthwash (section 12.3.4) is often beneficial course may be repeated if the sample is positive (and the

and may accelerate healing of recurrent aphthae. throat is not colonised). To avoid the development of resistance, the treatment course should not exceed 7