Drugs Acting on the Nose

NHSL Medicines Guidance
NHS Lanarkshire

General Notes

Mild allergic rhinitis can be controlled by oralantihistamines (for formulary options refer to Chapter 3. Respiratory System: Antihistamines, Hyposensitisation and Allergic Emergencies)or topicalnasal corticosteroids; systemic nasal decongestants are of doubtful value. Topical nasal decongestants can be used fora short periodto relieve congestion and allow penetration of a topical nasal corticosteroid.

More persistent symptoms and nasal congestion can be relieved by topical nasalcorticosteroids;sodium cromoglicateis an alternative, but may be less effective.

Topical antihistamines are considered less effectivethan topical corticosteroids but probably more effective than cromoglicate. In seasonal allergic rhinitis (e.g. hay fever), treatment should begin 2 to 3 weeks before the season commences and may have to be continued for several months; continuous treatment may be required for years in perennial rhinitis.

Corticosteroids

Preferred list (P)

MOMETASONE FUROATE 50 microgram/dose nasal spray

BECLOMETASONE 50 microgram/dose nasal spray

Total list (T)

BETAMETHASONE 0.1% eye/ear/nose drops (Vistamethasone®)

  • Restriction: Short term use only - maximum 6 weeks to avoid side effects.

FLUTICASONE FUROATE 27.5 microgram/dose nasal spray (Avamys®)

  • Restriction: Treatment of allergic rhinitis where mometasone and beclomethasone have been ineffective or not tolerated.

Specialist initiation (S1)

FLUTICASONE WITH AZELASTINE nasal spray (Dymista®)

  • Fluticasone propionate 50 microgram and azelastine 137 microgram/dose

  • Restriction: Only for use in patients who require both a nasal steroid and nasal antihistamine when compliance is considered to be an issue.

Prescribing Notes:

  • Systemic absorption of corticosteroids may follow nasal administration particularly if high doses are used or if treatment is prolonged; therefore consider the cautions and side-effects of systemic corticosteroids before prescribing and review patients regularly.
  • The risk of systemic effects may be greater with nasal drops than with nasal sprays; drops are often administered incorrectly more so than sprays. Therefore counsel on correct use of drops and do not use beyond 6 weeks.

Intranasal Antihistamines

Preferred list (P)

AZELASTINE HYDROCHLORIDE 0.1%/dose nasal spray (Rhinolast®)

  • Topical azelastine is useful for controlling breakthrough symptoms in allergic rhinitis.

Intranasal Antimuscarinics

Specialist initiation (S1)

IPRATROPIUM BROMIDE 21 microgram/dose nasal spray (Rinatec®)

  • Ipratropium may be useful in non-allergic rhinitis with watery rhinorrhoea.

Topical Nasal Decongestants

Preferred list (P)

EPHEDRINE 0.5% nasal drops

SODIUM CHLORIDE 0.9% nasal drops

  • Sterimar brand is non-formulary in NHSL. Available as generic.
  • Sodium chloride may relieve nasal congestion by helping to liquefy mucous secretions.

Total list (T)

XYLOMETAZOLINE 0.1% nasal spray/drops

Prescribing Notes:

Rebound congestion

Sympathomimetic drugs are of limited value in the treatment of nasal congestion because they can, following prolonged use (more than 7 days), give rise to a rebound congestion (rhinitis medicamentosa) on withdrawal, due to a secondary vasodilatation with a subsequent temporary increase in nasal congestion. This in turn tempts the further use of the decongestant, leading to a vicious cycle of events.

Anti-Infective Nasal Preparations

Preferred list (P)

CHLORHEXIDINE WITH NEOMYCIN (Naseptin nasal cream®)

  • Chlorhexidine 0.1% with neomycin 0.5%
  • Excipient arachis (peanut) oil removed, therefore no longer contra-indicated in peanut/soya allergy.

Total list (T)

MUPIROCIN 2% nasal ointment (Bactroban Nasal®)

NHSL Joint Adult Formulary Key

To indicate the category of a formulary medicine, updated sections adopt the following key:

Preferred list (P): First-line formulary choices.

Total list (T): Alternative choices when preferred list options not effective/not tolerated, or not indicated.

Specialist initiation (S1): Specialist initiation, or on the advice of a Consultant or Specialist Practitioner in this therapeutic area. Continuation in primary care is acceptable.

Specialist use only (S2): Supply via hospital, Homecare Service or a hospital based prescription (HBP) for dispensing by community pharmacy. Not prescribed in primary care setting.

Editorial Information

Last reviewed: 31/01/2022

Next review date: 31/01/2025

Author(s): NHSL.

Version: Please refer to the introduction section for an explanation of the review dates above.

Approved By: ADTC

Reviewer name(s): ADTC.