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10. Musculoskeletal and Joint Diseases

CD&D APC Patient Decision Aids Resource available at: http://medicines.necsu.nhs.uk/guidelines/durham-darlington/

CD&D APC “Do Not Prescribe List” and “Grey List – drugs prescribed under limited circumstances” available at: http://medicines.necsu.nhs.uk/guidelines/durham-darlington/

NSAIDs and cardiovascular events
All NSAID use (including cyclo-oxygenase-2 selective inhibitors) can, to varying degrees, be associated with a small increased risk of thrombotic events (e.g. myocardial infarction and stroke) independent of baseline cardiovascular risk factors or duration of NSAID use; however, the greatest risk may be in those receiving high doses long term. Cyclo-oxygenase-2 selective inhibitors , diclofenac (150 mg daily) and ibuprofen (2.4 g daily) are associated with an increased risk of thrombotic events. The increased risk for diclofenac is similar to that of licensed doses of etoricoxib . Naproxen (1 g daily) is associated with a lower thrombotic risk, and low doses of ibuprofen (1.2 g daily or less) have not been associated with an increased risk of myocardial infarction.
The lowest effective dose of NSAID should be prescribed for the shortest period of time to control symptoms and the need for long-term treatment should be reviewed
periodically. (from BNF 66.)

The following NSAIDs should be the preferred choices for those starting treatement. Existing patients on alternate NSAIDs should be reviewed as appropriate, but can remain on a non-formulary NSAID if deemed appropriate.

Preferred Drugs
Long Term use: Ibuprofen low dose – First line treatment
Naproxen low dose – Second line treatment
Naproxen high dose – Third line treatment

Ibuprofen
BNF | BNFC | SPC

200mg, 400mg & 600mg tablets
100mg in 5ml sugar-free suspension

MHRA Drug Safety Update (June 2015): High-dose ibuprofen (≥2400mg/day): small increase in cardiovascular risk.

Naproxen
BNF | BNFC | SPC

250mg & 500mg tablets

Diclofenac
BNF | BNFC | SPC

25mg & 50mg e/c tablets; 50mg dispersible tablets
75mg & 100mg m/r tablets or capsules
75mg in 2ml injection (Dyloject) - mainly for use in postoperative analgesia
12.5mg, 25mg, 50mg & 100mg suppositories

MHRA Drug Safety Update (June 2013): Diclofenac: new contraindications and warnings

The use of diclofenac is restricted to existing patients in CDDFT – see memo issued in May 2013 available via the CDDFT Intranet

Celecoxib
BNF | BNFC | SPC

100mg & 200mg capsules

Indometacin
BNF | BNFC | SPC

25mg & 50mg capsules; 75mg m/r capsules
25mg in 5ml suspension; 100mg suppositories

Meloxicam
BNF | BNFC | SPC

7.5mg & 15mg tablets

Diclofenac + Misoprostol
BNF | BNFC | SPC
Naproxen + Esomeprazole
BNF | BNFC | SPC
Methylprednisolone Acetate
BNF | BNFC | SPC

Injection - 40mg/ml (Depo-medrone)

Methylprednisolone Acetate 40mg/ml & Lidocaine
BNF | BNFC | SPC

1ml injection - methylprednisolone acet. 40mg + lidocaine 1%
2ml injection - methylprednisolone acet. 80mg + lidocaine 1%

Triamcinolone Acetonide
BNF | BNFC | SPC

40mg in 1ml & 80mg in 2ml intramuscular/ intra-articular injections
10mg in 1ml & 50mg in 5ml intradermal/intra-articular injections

Hydrocortisone Acetate
BNF | BNFC | SPC

25mg in 1ml injection

Prednisolone Acetate
BNF | BNFC | SPC

25mg in 1ml depot injection

Triamcinolone Hexacetonide
BNF | BNFC | SPC

20mg in 1ml intra-articular injectionu – Paediatric use only

Shared care guidelines for DMARDs can be found here:

Area Prescribing Committee website

CDDFT Intranet

Azathioprine
BNF | BNFC | SPC

25mg & 50mg tablets;

50mg in 5ml suspension

For non Cancer indications

 

Shared care guidelines for DMARDs can be found here:

Area Prescribing Committee website

CDDFT Intranet

Ciclosporin
BNF | BNFC | SPC

10mg, 25mg, 50mg & 100mg capsules

Prescribe by brand name to ensure continuity

Shared care guidelines for DMARDs can be found here:

Area Prescribing Committee website

CDDFT Intranet

Hydroxychloroquine
BNF | BNFC | SPC

Tablets - 200mg

Shared care guidelines for DMARDs can be found here:

Area Prescribing Committee website

CDDFT Intranet

Leflunomide
BNF | BNFC | SPC

Tablets - 10mg, 20mg, 100mg

Shared care guidelines for DMARDs can be found here:

Area Prescribing Committee website

CDDFT Intranet

Methotrexate ONCE WEEKLY DOSE
BNF | BNFC | SPC

Tablets - 2.5mg

Injection – for non cancer indications

Shared care guidelines for DMARDs can be found here:

Area Prescribing Committee website

CDDFT Intranet

Mycophenolate mofetil
BNF | BNFC | SPC

250mg capsules; 500mg tablets

Shared care guidelines for DMARDs can be found here:

Area Prescribing Committee website

CDDFT Intranet

MHRA Drug Safety Update (Jan 2015): Mycophenolate mofetil (CellCept) and mycophenolic acid: risk of hypogammaglobulinaemia and risk of bronchiectasis

MHRA Drug Safety Update (Dec 2015): Mycophenolate mofetil, mycophenolic acid: new pregnancy-prevention advice for women and men

Penicillamine
BNF | BNFC | SPC

Tablets - 125mg, 250mg

Shared care guidelines for DMARDs can be found here:

Area Prescribing Committee website

CDDFT Intranet

Sodium Aurothiomalate
BNF | BNFC | SPC

10mg, 20mg & 50mg in 0.5ml injections

Shared care guidelines for DMARDs can be found here:

Area Prescribing Committee website

CDDFT Intranet

Sulfasalazine
BNF | BNFC | SPC

500mg e/c tablets

Shared care guidelines for DMARDs can be found here: APC Website CDDFT Intranet

MHRA Drug Safety Update (April 2014): Tumour necrosis factor alpha inhibitors ): risk of tuberculosis—screen all patients before starting treatment and monitor them closel.

 

NTAG September 2015: The Northern (NHS) Treatment Advisory Group recommends that the sequential use of TNF inhibitors can be considered in the case of failure due to inefficacy or adverse effects (AEs) and if the patient still has

active disease.  Sequential use must be assessed and reviewed by a multidisciplinary team within the Trust and patients must continue to fulfil the NICE ‘start-stop’ criteria when prescribing a TNF inhibitor for psoriatic arthritis.

Abatacept
BNF | BNFC | SPC

250mg injection

125mg injection (prefilled syringe)

Commissioner: CCGs – Adults NICE TA234, NICE TA375

Commissioner: NHS England – Paediatrics Only NICE TA195, NICE TA280, NICE TA373

Drug protocol: abatacept (CDDFT intranet access only)

Adalimumab
BNF | BNFC | SPC

40mg injection (prefilled syringe)

Commissioner: CCGs – Adults NICE TA199, NICE TA187, NICE TA383, NICE TA130 NICE TA375

Commissioner: NHS England – Paediatrics Only NICE TA130, NICE TA143, NICE TA199, NICE TA187, NICE TA146, NICE TA373

NHS England: Not routinely commissioned - Uveitis in Paediatric

Anakinra
BNF | BNFC | SPC

100mg injection (prefilled syringe)

The APC approved anakinra for acute refractory or difficult gout requiring hospitalisation.  It was noted this is an UNLICENSED INDICATION, supported by the APC.

NHS England: Not routinely commissioned - Adult indications - Paediatric indications

NHS England - Cryopyrin Associated Periodic Syndrome – only via specialised services commissioned by NHS England.

Apremilast
BNF | BNFC | SPC

10mg, 20mg and 30mg tablets

MHRA Drug Safety Update (Jan 2017): Apremilast (Otezla ▼): risk of suicidal thoughts and behaviour

Apremilast for treating active psoriatic arthritis (NICE TA433)

Barcitinib
BNF | BNFC | SPC

2mg and 4mg tablets

Baricitinib for moderate to severe rheumatoid arthritis  - See NICE TA466

Belimumab▼
BNF | BNFC | SPC

120mg and 400mg IV infusion

Belimumab for treating active autoantibody-positive systemic lupus erythematosus see NICE TA397

Certolizumab Pegol
BNF | BNFC | SPC

Each pre-filled syringe contains 200 mg certolizumab pegol in one ml

NHS England – Not routinely commissioned - Paediatric indications

NICE TA186

NTAG September 2015: The Northern (NHS) Treatment Advisory Group recommends the use of certolizumab  pegol  as  an  option  in  those  patients  who  fulfil  NICE criteria for use of TNF Inhibitor therapy in psoriatic arthritis.

However  other  more  established,  NICE  approved  treatment  options would remain first line choices in this patient group.

Commissioner: CCGs – Adults NICE TA375 NICE TA415 NICE TA445

Etanercept▼
BNF | BNFC | SPC

10mg (Enbrel®), 25mg injection (Enbrel® & Benapali®)

Commissioner: NHS England – Paediatrics Only  NICE TA199, NICE TA383, NICE TA130, NICE TA103, NICE TA373

Commissioner: NHS England – Juvenile arthritis - NICE TA35

Commissioner: CCGs – Adults NICE TA199, NICE TA143, NICE TA130, NICE TA375

Tertiary Centre Only: NICE TA35

NTAG April 2016: The Northern (NHS) Treatment Advisory Group recommends the use of etanercept biosimilar Benepali® as an option for use in adults where the originator product (Enbrel®) would normally be prescribed.

Golimumab
BNF | BNFC | SPC

50mg injection (prefilled pen & syringe)

Commissioner: CCGs - Adults NICE TA233, NICE TA225, NICE TA220 NICE TA375

Commissioner: NHS England – Paediatrics Only - NICE TA220, NICE TA383

Infliximab
BNF | BNFC | SPC

100mg injection (Remicade® , Inflectra® & Remsima®)

Commissioner: CCGs – Adults  NICE TA199, NICE TA187, NICE TA143, NICE TA130  NICE TA375

Commissioner: NHS England – Paediatrics Only NICE TA130, NICE TA134, NICE TA140, NICE TA383, NICE TA163, NICE TA199

Commissioner: NHS England – Crohn’s disease in children - NICE TA187

NHS England: Not routinely commissioned for - Connective tissue disease-interstital lung disease – Renal - Sarcoidosis - Uveitis in Paediatric

Drug protocol: infliximab – rheumatology (CDDFT intranet access only)

NTAG September 2015: The Northern (NHS) Treatment Advisory Group recommends the use of infliximab biosimilars as an option where the originator product (Remicade®) would normally be prescribed.

Rituximab
BNF | BNFC | SPC

100mg in 10ml & 500mg in 50ml concentrate for IV infusion

Commissioner: NHS England – Paediatrics Only - TA195, NHS England Policy

Commissioner: NHS England – ANCA-positive vasculitis - Policy - A13/P/a

Commissioner: NHS England – SLE - Policy - A13/PS/a

NHS England: Not routinely commissioned for - Connective tissue disease–interstitial lung disease - Haemophilia – Nephritis

NTAG recommendation: Recommends rituximab in combination with methotrexate
as first-line biological therapy in cases where there is an absolute contraindication to tumour necrosis factor inhibitor

NTAG June 2017: The Northern (NHS) Treatment Advisory Group recommends the use of
rituximab biosimilars as an option for use in adults where the originator
product (MabThera®) would normally be prescribed. 

Drug protocol: rituximab – rheumatology (CDDFT intranet access only)

 

Secukinumab▼
BNF | BNFC | SPC

150mg/ml injection

Secukinumab is recommended, within its marketing authorisation, as an option for treating active ankylosing spondylitis in adults whose disease has responded inadequately to conventional therapy (non-steroidal anti-inflammatory drugs or TNF‑alpha inhibitors). NICE TA407

 For treating active psoriatic arthritis after inadequate response to DMARDs  – see NICE TA445

Tocilizumab
BNF | BNFC | SPC

80mg in 4ml, 200mg in 10ml & 400mg in 20ml concentrate for IV infusion

Tertiary Centre Only: NICE TA247, NICE TA238

Commissioner: NHS England – Paediatrics Only - NICE TA247

Commissioner: NHS England – Juvenile arthritis - NICE TA238, NICE TA373

Commissioner: CCGs – Adults  NICE TA375

NTAG recommendation: Recommended as an alternative treatment to anakinra for systemic onset juvenile idiopathic arthritis. Not recommended for polyarticular juvenile idiopathic arthritis.  (Tertiary centres)

Drug protocol: tocilizumab – rheumatology (CDDFT intranet access only)

Ustekinumab
BNF | BNFC | SPC

45mg vial

Ustekinumab (Stelara®) is recommended as a possible treatment, alone or with a drug called methotrexate, for adults with active psoriatic arthritis when treatment with non-biological disease-modifying antirheumatic drugs (or DMARDS) has not worked well enough if:

•treatment with tumour necrosis factor (TNF) alpha inhibitors is not suitable for them, or

•the person has had a TNF alpha inhibitor before.

NICE TA340

 

Colchicine
BNF | BNFC | SPC

Tablets - 500microgram

Allopurinol
BNF | BNFC | SPC

Tablets - 100mg, 300mg

Febuxostat
BNF | BNFC | SPC

Tablets - 80mg , 120mg

For use in accordance with NICE guidance in patients where allopurinol is not tolerated or contraindicated (SPC)

NICE TA164

Probenecid
BNF | BNFC | SPC

500mg tablets u

Rasburicase
BNF | BNFC | SPC

1.5mg & 7.5mg vials

Prophylactic use for hyperuricaemia associated with cytotoxic drugs in high risk patients only.

Glucosamine (+/- chondroitin)
BNF | BNFC | SPC

Acute Attacks
NSAIDs
– see section 10.1.1
Colchicine

Long-term Control of Gout
First Choice = Allopurinol

Alternatives =
Febuxostat
For use in accordance with NICE guidance in patients where allopurinol is not tolerated or contraindicated (SPC)
NICE TA164
Probenecid u

Hyperuricaemia Associated with Cytotoxic Drugs
First Choice = 
Allopurinol

Alternative =
• Rasburicase
Prophylactic use in high risk patients only
Commissioner: NHS England

Anticholinesterases
Edrophonium
Neostigmine
Pyridostigmine


LEMS
Amifampridine Phosphate ▼
Commissioner: NHS England – not routinely commissioned see Policy - D04/PS/a


Multiple Sclerosis
Fampridine ▼
Commissioner: NHS England - not routinely commissioned see Policy - D04/PS/d

Edrophonium
BNF | BNFC | SPC

10mg injection

Neostigmine
BNF | BNFC | SPC

15mg tablets; 2.5mg injection

Pyridostigmine
BNF | BNFC | SPC

60mg tablets & 60mg/5ml suspension

Amifampridine Phosphate▼
BNF | BNFC | SPC
Fampridine▼
BNF | BNFC | SPC
Baclofen
BNF | BNFC | SPC

Tablets - 10mg

Syrup - 5mg/5ml

Dantrolene
BNF | BNFC | SPC

Capsules - 25mg, 100mg

Diazepam
BNF | BNFC | SPC

See section 4.1.2

N.B. Diazepam 10mg tablets are no longer included in the formulary

Tizanidine
BNF | BNFC | SPC

Tablets - 2mg

For use on advice from neurologists when other treatments are unsuitable.

Cannabis Extract (Sativex)
BNF | BNFC | SPC
Methocarbamol
BNF | BNFC | SPC
Quinine Sulphate
BNF | BNFC | SPC

200mg tablets


MHRA advice now states that quinine should not be used routinely in the treatment of nocturnal leg cramps, and should only be considered when cramps cause regular disruption of sleep. After a period of 4 weeks, treatment should be discontinued if no benefit is gained.

Ataluren▼
BNF | BNFC | SPC

Ataluren approved in line with NICE recommendation https://www.nice.org.uk/guidance/hst3

Hyaluronidase
BNF | BNFC | SPC

For use on advice from specialist.

Collagenase▼
BNF | BNFC | SPC

900 microgram injection (Xiapex)

Collagenase approved in line with NICE TA459 

Ibuprofen
BNF | BNFC | SPC

Gel - 5%

Algesal may be considered as an alternative product that may be purchased in the community cheaper than topical NSAIDs.

Piroxicam
BNF | BNFC | SPC

Gel - 0.5%

Algesal may be considered as an alternative product that may be purchased in the community cheaper than topical NSAIDs.

Capsaicin
BNF | BNFC | SPC

0.075% cream
For use with specialist advice in post-herpetic neuralgia & severe neuropathic pain mainly in diabetes patients.


0.025% cream
For symptomatic relief in osteoarthritis.

PR Freeze Spray
BNF | BNFC | SPC
Topical Rubefacients
BNF | BNFC | SPC
Hyaluronic acid
BNF | BNFC | SPC

For intra-articular injection into the knee