General measures

As well as individual patient variations (e.g. whether person is at high-risk of having an acute attack for any reason, how much of the preparation is likely to be swallowed), factors to take into account include the safety of each of the active ingredients, and the extent to which each of the ingredients will be absorbed through the oral mucosa (membrane that lines the inside of the mouth).

Fasting and stress (emotional and physical) can also trigger attacks in people with acute forms of porphyria. Minimise stress by using adequate pain relief and treating infection promptly. Encourage patients to maintain adequate calorie intake.

Topical preparations

All topical preparations are considered safe in people with acute porphyria, when applied to intact skin or mucosa. In this context, ‘topical preparations’ include skin creams, ointments and local anaesthetics in small amounts. Where damage to the oral mucosa is known or suspected, take into account that there may be higher systemic exposure.

Mouth ulcer preparations

Many mouth ulcer preparations contain more than one active ingredient, check the medicine packet carefully. At the time of writing, the safety in porphyria of cetalkonium chloride, cetylpyridinium chloride, chlorocresol, menthol and eucalyptus, and aminoacridine could not be determined. Be cautious, especially with anyone who has high risk symptoms.

Local anaesthetics

In the UK, local anaesthetics that are commonly used in primary care dentistry are lidocaine, articaine, mepivacaine and prilocaine. These are all safe to use when used locally for dental procedures. Many of these preparations also contain adrenaline (epinephrine) or felypressin. Adrenaline/felypressin are used to prolong the effect of the local anaesthetic and increase tolerance. Both adrenaline and felypressin are considered safe options.

Medicines to treat/prevent infections

Safe

Aciclovir (cream or tablet/suspension)
Amoxicillin
Azithromycin
Cefalexin
Cefradine
Chlorhexidine (gel, mouthwash, spray)
Co-amoxiclav
Doxycycline
Metronidazole
Nystatin
Phenoxymethylpenicillin
Sodium chloride mouthwash
Sodium fusidate ointment

Likely safe

These include medicines where the safety may be less well known or where they may be used topically as a mouthwash, oral gel or spray, but should not be used systemically such as a tablet/capsule or injection.

Demeclocycline oral paste
Hydrogen peroxide mouthwash – encourage patients not to swallow
Miconazole (cream, gel, ointment) – caution in anyone with high risk symptoms, consider an alternative product. Oral/intravenous imidazole antifungals should be avoided in porphyria.

Unsafe (avoid)

Clarithromycin
Clindamycin
Erythromycin when given systemically
Fluconazole when given systemically
Oxytetracycline – safety unknown – use alternative or seek specialist advice

Analgesics

Safe

Aspirin
Dihydrocodeine
Ibuprofen
Paracetamol

Likely safe

Benzydamine (mouthwash, oromucosal spray)
Choline salicylate dental gel – safety unknown, use alternative where possible, avoid in anyone with high risk symptoms
Diclofenac – use only where ibuprofen not an option

Unsafe (avoid)

Carbamazepine

Steroids

Beclomethasone inhaler
Betamethasone
Hydrocortisone (cream or tablet)
Triamcinolone oral paste

Saliva substitutes

Several saliva substitute preparations are available, but not all can be prescribed on a dental NHS prescription (see Q&A on What should be considered when choosing or prescribing saliva substitutes for further information on prescribing issues). Although sodium fluoride, potassium chloride, calcium chloride and potassium phosphate are known to be safe in porphyria, the safety in porphyria of all the ingredients in each of the listed preparations is not known.

Antihistamines and sedatives

Safe

Cetirizine
Chlorphenamine
Diazepam
Loratadine
Promethazine
Temazepam

Other

Safe

Ephedrine nasal drops
Lansoprazole
Omeprazole
Sodium fluoride (mouthwash, drops, toothpaste, tablets)

Useful links

• A list of medicines that are safe in the acute porphyrias is produced by the UK Porphyria Medicines Information Service (UKPMIS) they can also be contacted for specialist porphyria advice on choosing medicines on telephone 029 21842251. This service is available to healthcare professionals and people with porphyria in the UK.
• British and Irish Porphyria Network (BIPNET)
• British Porphyria Association (BPA)