Items which should not routinely be prescribed in primary care - rubefacients, benzydamine, mucopolysaccharide and cooling products by all Sub-ICB Locations

Why it matters:

NHS England guidance states:

Rubefacients are topical preparations that cause irritation and reddening of the skin due to increased blood flow. They are believed to relieve pain in various musculoskeletal conditions and are available on prescription and in OTC remedies. They may contain nicotinate compounds, salicylate compounds, essential oils and camphor.

The BNF states: “The evidence available does not support the use of topical rubefacients in acute or chronic musculoskeletal pain”.

NICE has issued the following ‘do not do’ recommendation: Do not offer rubefacients for treating osteoarthritis.

Due to limited evidence and NICE recommendations, the joint clinical working group considered rubefacients (excluding topical NSAIDs) suitable for inclusion in this guidance.

Other miscellaneous topical analgesics containing benzydamine, mucopolysaccharide polysulphate or cooling ingredients fall under this category. Benzydamine and mucopolysaccharide are weak prostaglandin inhibitors and are therefore pharmacologically different from those routinely referred to as NSAIDs in current practice (such as ibuprofen and diclofenac), so it cannot be presumed that the clinical evidence relating to NSAIDs can be extrapolated to benzydamine or mucopolysaccharide polysulphate containing products (Rubefacients and miscellaneous topical analgesics, PrescQIPP, July 2021).

The Clinical Knowledge Summary on sprains and strains (NICE, 2020) does not specifically discuss cooling sprays and gels, but does suggest ice is used for self-management strategies in the first 48-72 hours after injury.

Due to limited evidence and the NICE recommendations, the joint clinical working group considered these additional products suitable for inclusion in this category.

NHS England recommend that GPs:

Description: Cost of rubefacients per 1000 patients

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Tagged as: Cost Saving, Efficacy, NHS England - items which should not routinely be prescribed in primary care, Pain (or browse all measures)

Sub-ICB Locations are ordered by mean percentile over the past six months. Each chart shows the results for the individual Sub-ICB Location, plus deciles across all Sub-ICB Locations in the NHS in England.

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