Analgesics

Paracetamol or ibuprofen (if suitable for the patient) can be used for acute sinusitis.

Saline irrigation & steam inhalation

A randomised controlled trial found that steam inhalations had little effect in sinusitis but saline nasal irrigation (also called nasal douching) improved symptoms. Patients were more likely to feel they could manage the problem themselves and used less OTC medication.

Pharmacists can recommend a short video showing patients how to use saline nasal irrigation, such as the method used by NHS Southampton Hospitals on YouTube. NHS Health A-Z also gives guidance on how to clean the nose with a homemade salt water solution.

Nasal saline irrigation may cause minor adverse effects, such as irritation. Patients sometimes experience ear discomfort while rinsing and may experience drainage of left-over solution from the nose, sometimes many minutes or hours after use.

High-dose nasal corticosteroids (fluticasone or mometasone)

These POMs can be supplied for sinusitis through a PGD. The use of high-dose nasal corticosteroid is off-label in sinusitis and is based on the NICE review of relevant clinical trials. NICE concluded that there is evidence that high-dose nasal corticosteroid (equivalent to mometasone 400mcg a day) for 14 to 21 days produced a statistically significant improvement in symptoms in adults and children aged 12 years and over compared with placebo.

The following side-effects are listed in the product SPC or BNF as very common or common with intranasal fluticasone (or other intranasal steroids), but as use is ‘off label’ these may not reflect all side-effects when used for sinusitis: epistaxis; headache; throat irritation; nasal ulceration; dyspnoea; altered smell; altered taste.

The steroid burden of nasal corticosteroids needs to be considered in people already taking oral or inhaled corticosteroids, particularly in children, due to systemic effects.

Antibiotics

NICE advises that even bacterial sinusitis is usually self-limiting and does not routinely need antibiotics. A recent Cochrane Review indicated only a small benefit from antibiotics even in acute sinusitis that had lasted for longer than seven days. The NNT was 15 for one additional person with acute sinusitis to be ‘cured’ with antibiotics, based on a meta-analysis.

NICE says that antibiotics may be used if sinusitis symptoms persist for more than 10 days or are severe with fever (>38°C), severe local pain, discoloured or purulent nasal discharge or marked deterioration.

NICE states that: “An immediate antibiotic prescription is not recommended unless people are systemically very unwell, have symptoms and signs of a more serious illness, or are at high risk of serious complications because of pre-existing comorbidity.”

Where an antibiotic is to be recommended, NICE advises penicillin first-line unless there is a reported penicillin allergy via the NHS National Care Record or stated by the patient/carer.

Under the Pharmacy First scheme, antibiotics via a PGD can be provided by pharmacists where there are still persistent symptoms despite the use of high-dose nasal corticosteroid for 14 days, or if high-dose nasal corticosteroids are unsuitable. The antibiotics available to pharmacists to provide are penicillin-V (first-line), with clarithromycin or doxycycline, or erythromycin in pregnancy, if penicillin allergy is a concern.

The main contraindication is allergy/hypersensitivity to an antibiotic – usually penicillin. Those with a known allergy to phenoxymethylpenicillin (penicillin-V), or any penicillin, or a history of severe immediate allergic reaction (e.g. anaphylaxis) to another beta-lactam antibiotic (e.g. cephalosporin, carbapenem or monobactam) must not be prescribed penicillin-V.

Acceptable sources of allergy information include individual/carer/parent/guardian or the National Care Record (but bear in mind these sources are not always accurate or reliable).