Items which should not routinely be prescribed in primary care - rubefacients, benzydamine, mucopolysaccharide and cooling products

Below are the database queries which are used to create this measure. These are run against a copy of the BSA prescribing data which we store in Google BigQuery. We're working on making our BigQuery tables publicly available at which point it will be possible to run and modify these queries yourself. But even where code and database queries are not directly useable by others we believe it is always preferable to make them public.

Description Cost of rubefacients per 1000 patients
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.

For guidance on when prescribing may be appropriate in some exceptional circumstances, please see the full NHS England guidance document.
Tags Cost Saving, Efficacy, NHS England - items which should not routinely be prescribed in primary care, Pain
Implies cost savings Yes
Authored by richard.croker
Checked by christopher.wood
Last reviewed 2024-09-17
Next review due 2026-09-17
History View change history on GitHub →

Numerator SQL

SELECT
     CAST(month AS DATE) AS month,
     practice AS practice_id,
     SUM(actual_cost) AS numerator
 FROM hscic.normalised_prescribing
 WHERE bnf_code IN ("100302000BBBXA0", "1003020AEAAAAAA", "1003020AEBBAAAA", "1003020F0AAAAAA", "1003020F0BBAAAA", "1003020F0BBABAA", "1003020I0AAAAAA", "1003020I0BBAAAA", "1003020N0AAABAB", "1003020N0AAATAT", "1003020N0AABABA", "1003020N0BDAAAK", "1003020N0BFACA0", "1003020N0BFAFAY", "1003020N0BIAAAT", "1003020N0BIADA0", "1003020N0BIAHBA", "1003020N0BIAIA0", "1003020N0BIAJA0", "1003020N0BUABA0", "1003020T0BBAAAA", "1003020T0BBABAF", "1003020Y0AAACAC", "1003020Y0AAADAD", "1003020Y0BDAAAB", "1003020Y0BDABAC", "1003020Y0BDACAD")
 GROUP BY month, practice_id

Denominator SQL

SELECT
     CAST(month AS DATE) AS month,
     practice AS practice_id,
     SUM(total_list_size / 1000.0) AS denominator
 FROM hscic.practice_statistics
 GROUP BY month, practice_id
Feedback