A sore throat is one of the most common conditions encountered in general practice. Pharyngitis is inflammation of the mucous membranes that line the back of the throat, or pharynx. This inflammation can cause discomfort, dryness and difficulty swallowing. 

Benzydamine’s main anti-inflammatory activity results from its inhibition of the production of pro-inflammatory cytokines

The main symptom of pharyngitis is a sore, dry, or itchy throat. Additional symptoms may appear depending on the type of infection, such as cold or flu symptoms.  

Acute pharyngitis is characterised by the rapid onset of sore throat and pharyngeal inflammation (with or without exudate). The absence of cough, nasal congestion and nasal discharge suggests a bacterial, rather than viral aetiology. Acute pharyngitis can be caused by a variety of viral and bacterial pathogens, including group A Streptococcus (GAS), as well as fungal pathogens (Candida). Bacterial pharyngitis is more common in winter (or early spring), while the enteroviral infection is more common in the summer and fall. Acute pharyngitis is generally a self-limited condition with resolution within two weeks.  

Quality of life in patients with acute pharyngitis or tonsillitis is significantly lower than in healthy persons, and it should be taken into account when the efficacy of new therapeutic options is investigated.   

Benzydamine hydrochloride is a non-steroidal anti-inflammatory molecule with local anaesthetic and analgesic activity, that delivers targeted relief from inflammatory conditions in the mouth and throat. Its unique chemical nature and mechanism of action makes benzydamine unique.  

Chemical nature of benzydamine vs other NSAIDs  

Unlike other NSAIDs, which are aspirin-like and therefore acidic chemical molecules, benzydamine is a base. This explains its tendency to preferentially concentrate in inflamed tissues. Once at the site of inflammation, benzydamine acts on a number of inflammatory mechanisms to relieve pain, redness and swelling.   

Benzydamine’s mechanisms of action  

Cytokines are cell-signalling proteins that have a specific effect on the interactions and communications between cells and immune responses and stimulate the movement of cells towards sites of inflammation. Benzydamine’s main anti-inflammatory activity results from its inhibition of the production of pro-inflammatory cytokines, mainly tumour necrosis factor-alpha (TNF-α) and Interleukin-1 beta (IL-1β), a major driver of inflammation, and monocyte chemotactic protein-1 (MCP1). These are common pro-inflammatory cytokines. So although it is classified as an NSAID, it works as a CSAID (cytokine-suppressive anti-inflammatory drug).  

Benzydamine acts as a modulator of cytokines, ensuring it does not inhibit anti-inflammatory cytokines: Interleukin-10 (IL-10) Interleukin-1ra (IL-1ra).   

Benzydamine also elicits supportive anti-inflammatory activity, through cell membrane stabilisation, reducing both capillary vasodilation and the release of pro-inflammatory substances. Benzydamine’s local anaesthetic effect may be related to its capability for inhibiting the release of inflammatory mediators such as substance P, which causes the release of histamine from mast cells. The prevention of substance P release further contributes to an anti-inflammatory effect.  

Benzydamine’s safety profile  

Benzydamine’s chemical structure makes it highly lipid-soluble, with low plasma protein binding capacity. This promotes its absorption and selective binding into inflamed tissues, where it accumulates, reducing the possibility of systemic side effects. Benzydamine’s targeted activity makes it ideal for topical application and it has no known drug interactions. Benzydamine is only a weak inhibitor of prostaglandin synthesis, even following oral application, meaning it is an efficacious, more gastro-friendly anti-inflammatory choice. It is a well-established molecule with over 50 years of clinical experience. Its unique triple action provides anti-inflammatory, analgesic and local anaesthetic relief for your patients with inflammatory conditions of the mouth and throat.   

Effects of chlorhexidine/benzydamine mouth spray on pain and quality of life in acute viral pharyngitis  

Cingi et al conducted a prospective, randomised, double-blind, placebo-controlled, multicentre study to assess the efficacy of chlorhexidine gluconate/benzydamine hydrochloride mouth spray for reducing pain and improving quality of life in patients with acute viral pharyngitis.   

Chlorhexidine belongs to the antimicrobial class of drugs. It works by decreasing the amount of bacteria in the mouth, providing a broad spectrum antiseptic activity, killing or inhibiting the growth of bacteria, viruses and fungi.  

Prior to treatment, patients rated the intensity of their pain on a visual analogue scale and evaluated their quality of life on the 36-Item, Short-Form Health Survey. Patients were then randomised to receive either paracetamol plus chlorhexidine/benzydamine or paracetamol plus placebo for seven days. On days three and seven of treatment, the participants again rated the intensity of their pain, and on day seven, they again rated their quality of life.   

A total of 164 patients were evaluable at study’s end-80 in the chlorhexidine/benzydamine group and 84 in the control group. A comparison of self-evaluations revealed that the active treatment group reported less pain on both day three (p <0.001) and day seven (p = 0.002). Likewise, the chlorhexidine/benzydamine group reported a significantly better quality of life on day seven (p < 0.001). Chlorhexidine/benzydamine was well tolerated, and no serious adverse events were observed. 

The same study author assessed the effect of chlorhexidine gluconate and benzydamine hydrochloride mouth spray, used in conjunction with antibiotic treatment, on the intensity of clinical signs and quality of life of patients with group A streptococcal tonsillopharyngitis. 

Methods:Patients (n = 147) with streptococcal tonsillopharyngitis were recruited and randomly allocated to either the treatment group (penicillin plus chlorhexidine and benzydamine; n = 72) or control group (penicillin plus placebo; n = 75). Blinded assessments were conducted before and after 10 days’ treatment, using an intensity rating scale for clinical sign severity, a visual analogue scale for subjective health state, the Short Form 36 Health Questionnaire for quality of life, and a customised questionnaire for side effects. 

Results:The treatment group showed a statistically significant reduction in the intensity of clinical signs, compared with the control group. On treatment day seven, there was no significant difference in quality of life between the treatment and control groups. The treatment drugs were well tolerated, and no serious adverse events were observed. 

Conclusion:Chlorhexidine gluconate and benzydamine hydrochloride combination mouth spray, added to standard antibiotic treatment, significantly alleviate the intensity of clinical signs in patients with streptococcal pharyngitis. Further research is needed using larger sample sizes or alternative control groups. 

Persistent sore throat 

In cases of persistent sore throat, it is important to reconsider the initial diagnosis. Consider an alternative diagnosis or further investigation if the individual has not responded to a course of antibiotics. Consider a neoplasm if the sore throat is persistent, especially if there is a neck mass. 

Indications for urgent referral include: 

  • An unexplained persistent sore or painful throat −‘persistent’ refers to a time frame of three-four weeks 
  • Red, or red and white patches, or ulceration or swelling of the oral/pharyngeal mucosa for more than three weeks 
  • Odynophagia or dysphagia for more than three weeks 
  • Unexplained hoarseness accompanied by a persistent sore throat. 

Consider non-infectious causes of sore throat (eg gastro-oesophageal reflux disease, chronic irritation from cigarette smoke, alcohol or hay fever). 

Conclusion 

Clinical studies show that benzydamine/chlorhexidine sprays significantly reduce the pain of a viral sore throat without causing any serious side effects, while in Strep throat the combination has shown to alleviate the intensity of clinical signs when used alongside standard antibiotic treatment.  

REFERENCES:   

References available on request.