NHS England (NHSE) has published new prescribing guidance for various common conditions for which over the counter (OTC) items should not be routinely prescribed in primary care (quick reference guide). These conditions include mild to moderate hay fever/seasonal allergic rhinitis.

Products such as sodium cromoglicate eye drops are cheap to buy and are readily available OTC along with advice from pharmacies. Some self-care medicines are available from shops and supermarkets. Please click here for further information, exceptions, and a patient leaflet.

Iatrogenic allergy should be discounted for any allergic conjunctivitis. Common offenders are neomycin, framycetin, atropine, chloramphenicol, fusidic acid and benzalkonium chloride (preservative).

Sodium cromoglicate

• Aqueous eye drops 2% (£2.50 = 13.5ml)
• Preservative-free multidose bottle eye drops 2% (£3.80 = 10mls) (see note 3)
• Preservative-free eye drops 2%, 0.3ml unit dose (£11.70 = 30 units)

Indications

• Allergic conjunctivitis
• Seasonal keratoconjunctivitis

Dose

• Apply 4 times daily

Notes

1. Sodium cromoglicate is a cheap, effective (particularly as a prophylactic) mast cell stabiliser. It should be instilled four times a day and may take a couple of days for maximal effect.
2. There may be differences between the licensed indications of products.
3. If preservative-free drops are required, consider the cost and volume of plastic associated with prescribing single unit dose eye drops.
   1. Sodium cromoglicate preservative-free multidose bottles and ketotifen unit dose eye drops (see below) are both less expensive than sodium cromoglicate unit dose eye drops.
   2. Ketotifen unit dose eye drops (see below) are less expensive than sodium cromoglicate preservative-free multidose bottles if intermittent use is expected i.e. if treatment is not required for more than a total of 7 days or 14 doses every 28 days. Each unit dose is sufficient for both eyes.

Ketotifen

• Preservative-free eye drops 250micrograms/ml (£6.95 = 30 units x 0.4ml unit dose)

Indications

• Seasonal allergic conjunctivitis

Dose

• Apply twice daily.

Notes

1. Ketotifen has both mast cell stabilising and antihistamine properties.

Olopatadine

• Eye drops 1mg/ml (£5.64 = 5ml)

Indications

• Seasonal allergic conjunctivitis

Dose

• Apply twice daily, maximum duration of treatment 4 months

Notes

1. Olopatadine has both mast cell stabilising and antihistamine properties. 

Ikervis

(Ciclosporin)

• Eye drops emulsion 0.1% (£72.00 = 30 units x 0.3ml unit dose)

Indication and dose

• Treatment of severe keratitis in adult patients with dry eye disease, which has not improved despite treatment with tear substitutes
  • Ikervis eye drops should be applied once daily to the affected eye(s) at bedtime

Notes

1. Prescribe by brand to avoid confusion.
2. Ikervis treatment must be initiated by an ophthalmologist, including first prescription.
3. Response to treatment with Ikervis should be reassessed at least every 6 months by specialist, and where appropriate repeat prescribing may be performed by primary care on specialist advice.
4. NICE TA369: Ciclosporin (Ikervis) 1mg/ml 0.3ml single use eye drops are recommended as an option for treating severe keratitis in adults with dry eye disease that has not improved despite treatment with tear substitutes (December 2015).

Verkazia

(Ciclosporin)

• Eye drops emulsion 0.1% (£288.00 = 120 units x 0.3ml unit dose)

Indications and dose:

• Treatment of severe vernal keratoconjunctivitis (VKC) in children from 4 years of age and adolescents

• Verkazia eye drops should be applied four times daily (morning, noon, afternoon and evening) to the affected eye(s) during the VKC season.
• If signs and symptoms persist after end of season, maintain at recommended dose or decrease dose once adequate control is achieved.
• Treatment should be discontinued after signs and symptoms are resolved, and reinitiated upon their recurrence.

Notes

1. Prescribe by brand to avoid confusion.
2. Verkazia treatment must be initiated by an ophthalmologist, including first prescription.
3. Response to treatment with Verkazia should be reassessed at least every 3 months by specialist, and where appropriate repeat prescribing may be performed by primary care on specialist advice.
4. Efficacy and safety of Verkazia has not been studied beyond 12 months. Regular examination of the eye(s) is recommended every 3 to 6 months by specialist when Verkazia is used for more than 12 months.
5. If more than one topical ophthalmic product is being used, these must be administered at least 15 minutes apart. Verkazia should be administered last.

Ciclosporin

• Eye drops 0.05% preservative-free (unlicensed preparation)
• Eye drops 0.06% preservative-free (unlicensed preparation supplied from Moorfields)
• Eye ointment 0.2% (unlicensed preparation)