| Formulary Chapter 10: Musculoskeletal and joint diseases - Full Chapter
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| Notes: |
This chapter of the formulary is under continual development, please let the team know if you have any comments about the contents: mlcsu.lscformulary@nhs.net.
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| Chapter Links... |
 LSCMMG: Gout Management Summary Guidelines |
| LSCMMG: Psoriatic Arthritis Pathway |
| LSCMMG: Radiographic (Ankylosing Spondylitis) and Non-radiographic Axial Spondyloarthritis (ASp) Pathway |
| LSCMMG: Rheumatoid Arthritis Pathway |
| Details... |
| 10.01 |
Drugs used in rheumatic diseases and gout |
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Belimumab (Benlysta® )
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Formulary
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Concentrate for solution for infusion 120mg, 400mg
 RAG for NICE TA806: TA806 Belimumab for treating lupus nephritis (terminated appraisal)
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 MHRA: Belimumab (Benlysta▼): increased risk of serious psychiatric events seen in clinical trials
NICE TA752:Belimumab for treating active autoantibody-positive systemic lupus erythematosus
NICE TA806: Belimumab for treating lupus nephritis (terminated appraisal)
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| 10.01 |
Rheumatoid arthritis and other inflammatory disorders |
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| 10.01 |
Osteoarthritis and soft-tissue disorders |
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| 10.01.01 |
Non-steroidal anti-inflammatory drugs |
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Ibuprofen
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First Choice
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Tablets 200mg, 400mg, 600mg
M/R tablets 800mg
Liquid 100mg/5mL
Solution for infusion 400mg/100mL
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LSCMMG: Over the Counter Items that Should not be Routinely Prescribed in Primary Care Policy
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Naproxen
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First Choice
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Tablets 250mg, 500mg
Effervescent tablets 250mg
Evidence suggests that naproxen is aassociated with a lower cardiovascular risk than COX-2 inhibitors, diclofenac or high dose ibuprofen.
naproxen is the preferred option for patients requiring long-term treatment with a more potent NSAID than ibuprofen
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Celecoxib (Celebrex®)
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Formulary
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Capsules 100mg & 200mg
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Etoricoxib (Arcoxia®)
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Formulary
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Tablets 60mg, 90mg, 120mg
Rheumatology initiation only
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MHRA: Etoricoxib (Arcoxia): revised dose recommendation for rheumatoid arthritis and ankylosing spondylitis
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Indometacin
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Formulary
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Capsules 25mg
M/R capsules 75mg
Suppositories 100mg
Indometacin is usually only recommended for gout
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Meloxicam
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Formulary
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Tablets 7.5mg, 15mg
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Phenylbutazone
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Formulary
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Tablets 100mg
Consultant rheumatologist only.
Reserved for ankylosing spondylitis not responsive to other NSAIDs
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Diclofenac
(Rectal route)
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 Restricted
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Suppositories 12.5mg, 25mg, 50mg, 100mg
For short term treatment of post-op pain, renal colic and lithotripsy only
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MHRA: Diclofenac: new contraindications and warnings
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Diclofenac
(Oral route)
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Restricted
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Tablets e/c 25mg, 50mg
Dispersible tablets 50mg
For short term use in breastfeeding mothers only
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MHRA: Diclofenac: new contraindications and warnings
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Diclofenac (Akis®)
(parenteral route)
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Restricted
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For short term treatment of post-op pain (Akis®)
Injection 75mg/1mL
Morecambe bay only
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MHRA: https://www.gov.uk/drug-safety-update/diclofenac-new-contraindications-and-warnings
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| 10.01.01 |
Aspirin |
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| 10.01.02 |
Corticosteroids |
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| 10.01.02.01 |
Systemic corticosteroids |
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| 10.01.02.02 |
Local corticosteroids injections |
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Methylprednisolone Acetate (Depo-Medrone®)
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Formulary
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Injection 80mg/2mL, 120mg/3ml, 40mg/ml
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Methylprednisolone Acetate with Lidocaine (Depo-Medrone®)
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Formulary
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Injection
(Methylprednisolone 80mg/2mL with lidocaine 20mg/2mL)
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Triamcinolone Acetonide (Adcortyl®)
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Formulary
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Injection 10mg/1mL
Intra-articular/intra-dermal injection
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Triamcinolone Acetonide (Kenalog®)
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Formulary
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Injection 40mg/1mL
Intra-articular/intramuscular injection
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Triamcinolone hexacetonide
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Formulary
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Injection 20mg/mL
Second line to Kenalog®
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| 10.01.03 |
Drugs which suppress the rheumatic disease process |
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Bimekizumab (Bimzelx®)
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Formulary
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Pre-filled syringe/pen 160mg
ICB Commissioned
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NICE TA916: Bimekizumab for treating active psoriatic arthritis
NICE TA918: Bimekizumab for treating axial spondyloarthritis
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Sarilumab (Kevzara®)
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Formulary
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Pre-filled pen 150mg. 200mg
Pre-filled syringe 150mg, 200mg
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NICE TA485: Sarilumab for moderate to severe rheumatoid arthritis
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| 10.01.03 |
Gold |
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| 10.01.03 |
Penicillamine |
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Penicillamine
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Formulary
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Tablets 125mg
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LSCMMG: Shared care guideline - Penicillamine
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| 10.01.03 |
Antimalarials |
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Hydroxychloroquine
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Formulary
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Tablets 200mg, 300mg
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LSCMMG: Hydroxychloroquine information sheet
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| 10.01.03 |
Drugs affecting the immune response |
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Abatacept (Orencia®)
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Formulary
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Intravenous infusion 250mg
S/C injection 125mg prefilled syringe pre-filled pen
Usually supplied to patients by a home delivery company
REQUIRES BLUETEQ APPROVAL
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NICE TA373: Abatacept, adalimumab, etanercept and tocilizumab for treating juvenile idiopathic arthritis
NICE TA375: Adalimumab, etanercept, infliximab, certolizumab pegol, golimumab, tocilizumab and abatacept for rheumatoid arthritis not previously treated with DMARDs or after conventional DMARDs only have failed
NICE TA715: Adalimumab, etanercept, infliximab and abatacept for treating moderate rheumatoid arthritis after conventional DMARDs have failed
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Adalimumab (Biosimilars avaliable)
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Formulary
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S/C injection 40mg prefilled syringe and pen
Usually supplied to patients by a home delivery company
REQUIRES BLUETEQ APPROVAL
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MHRA: Tumour necrosis factor alpha inhibitors
NICE TA195:Adalimumab, etanercept, infliximab, rituximab and abatacept for the treatment of rheumatoid arthritis after the failure of a TNF inhibitor
NICE TA199: Etanercept, infliximab and adalimumab for the treatment of psoriatic arthritis
NICE TA373: Abatacept, adalimumab, etanercept and tocilizumab for treating juvenile idiopathic arthritis
NICE TA375: Adalimumab, etanercept, infliximab, certolizumab pegol, golimumab, tocilizumab and abatacept for rheumatoid arthritis not previously treated with DMARDs or after conventional DMARDs only have failed
NICE TA383: TNF-alpha inhibitors for ankylosing spondylitis and non-radiographic axial spondyloarthritis
NICE TA715: Adalimumab, etanercept, infliximab and abatacept for treating moderate rheumatoid arthritis after conventional DMARDs have failed
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Anakinra (Kineret®)
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Formulary
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Solution for injection pre-filled syringes 100mg/0.67mL
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NICE TA685: Anakinra for treating Still’s disease
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Apremilast
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Formulary
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Tablets 10mg, 20mg, 30mg
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MHRA: Apremilast (Otezla ▼): risk of suicidal thoughts and behaviour
NICE TA433: Apremilast for treating active psoriatic arthritis
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Azathioprine
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Formulary
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Tablets 25mg, 50mg
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LSCMMG: Shared care guideline - Azathioprine
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Certolizumab Pegol (Cimzia®)
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Formulary
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S/C injection 200mg prefilled syringe pre-filled pen
Usually supplied to patients by a home delivery company
REQUIRES BLUETEQ APPROVAL
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MHRA: Tumour necrosis factor alpha inhibitors
NICE TA375: Adalimumab, etanercept, infliximab, certolizumab pegol, golimumab, tocilizumab and abatacept for rheumatoid arthritis not previously treated with DMARDs or after conventional DMARDs only have failed
NICE TA415: Certolizumab pegol for treating rheumatoid arthritis after inadequate response to a TNF-alpha inhibitor
NICE TA445: Certolizumab pegol and secukinumab for treating active psoriatic arthritis after inadequate response to DMARDs
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Ciclosporin
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Formulary
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Capsules 25mg, 50mg, 100mg
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LSCMMG: Shared care guideline - Ciclosporin
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Cyclophosphamide
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Formulary
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Tablets 50mg
Injection 200mg, 500mg, 1g
 unlicensed use
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Etanercept (Biosimilars avaliable)
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Formulary
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S/C injection 25mg, 50mg vial with diluent and prefilled syringe pre-filled pen
usually supplied to patients by a home delivery company
REQUIRES BLUETEQ APPROVAL
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MHRA: Tumour necrosis factor alpha inhibitors
NICE TA195:Adalimumab, etanercept, infliximab, rituximab and abatacept for the treatment of rheumatoid arthritis after the failure of a TNF inhibitor
NICE TA199: Etanercept, infliximab and adalimumab for the treatment of psoriatic arthritis
NICE TA373: Abatacept, adalimumab, etanercept and tocilizumab for treating juvenile idiopathic arthritis
NICE TA375: Adalimumab, etanercept, infliximab, certolizumab pegol, golimumab, tocilizumab and abatacept for rheumatoid arthritis not previously treated with DMARDs or after conventional DMARDs only have failed
NICE TA383: TNF-alpha inhibitors for ankylosing spondylitis and non-radiographic axial spondyloarthritis
NICE TA715: Adalimumab, etanercept, infliximab and abatacept for treating moderate rheumatoid arthritis after conventional DMARDs have failed
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Golimumab (Simponi®)
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Formulary
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S/C injection 50mg, 100mg, prefilled syringe pre-filled pen
Usually supplied to patients by a home delivery company
REQUIRES BLUETEQ APPROVAL
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MHRA: Tumour necrosis factor alpha inhibitors
NICE TA220: Golimumab for the treatment of psoriatic arthritis
NICE TA225: Golimumab for the treatment of rheumatoid arthritis after the failure of previous disease-modifying anti-rheumatic drugs
NICE TA375: Adalimumab, etanercept, infliximab, certolizumab pegol, golimumab, tocilizumab and abatacept for rheumatoid arthritis not previously treated with DMARDs or after conventional DMARDs only have failed
NICE TA383: TNF-alpha inhibitors for ankylosing spondylitis and non-radiographic axial spondyloarthritis
NICE TA497: Golimumab for treating non-radiographic axial spondyloarthritis
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Guselkumab (Tremfya®)
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Formulary
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Solution for injection in pre-filled pen 100mg/1ml
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NICE TA815: Guselkumab for treating active psoriatic arthritis after inadequate response to DMARDs
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Infliximab (Biosimilars avaliable)
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Formulary
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Intravenous infusion 100mg, 120mg/ml pre-filled pen
REQUIRES BLUETEQ APPROVAL
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MHRA: Tumour necrosis factor alpha inhibitors
NICE TA195:Adalimumab, etanercept, infliximab, rituximab and abatacept for the treatment of rheumatoid arthritis after the failure of a TNF inhibitor
NICE TA199: Etanercept, infliximab and adalimumab for the treatment of psoriatic arthritis
NICE TA375: Adalimumab, etanercept, infliximab, certolizumab pegol, golimumab, tocilizumab and abatacept for rheumatoid arthritis not previously treated with DMARDs or after conventional DMARDs only have failed
NICE TA383: TNF-alpha inhibitors for ankylosing spondylitis and non-radiographic axial spondyloarthritis
NICE TA715: Adalimumab, etanercept, infliximab and abatacept for treating moderate rheumatoid arthritis after conventional DMARDs have failed
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Ixekizumab
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Formulary
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80mg solution for injection prefilled syringe; prefilled pen
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NICE TA537: Ixekizumab for treating active psoriatic arthritis after inadequate response to DMARDs
NICE TA718: Ixekizumab for treating axial spondyloarthritis
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Leflunomide
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Formulary
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Tablets 10mg, 20mg
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LSCMMG: Shared care guideline - Leflunomide
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Methotrexate (check local policy - branded generic available )
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Formulary
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Tablets 2.5mg
S/C 5mg, 7.5mg, 10mg, 12.5mg, 15mg, 17.5mg, 20mg, 22.5mg, 25mg and 30mg
Methotrexate should be prescribed once weekly as a single dose on the same day each week.
If oral methotrexate is prescribed only use the 2.5 mg strength.
See hospital policy for prescribing and supply of oral methotrexate
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LSCMMG: Shared care guideline - Methotrexate
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Risankizumab (Skyrizi®)
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Formulary
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solution for injection pre-filled syringes, solution for injection pre-filled pen 150mg/mL
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NICE TA803: Risankizumab for treating active psoriatic arthritis after inadequate response to DMARDs
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Rituximab (rheumatology) (Biosimilars avaliable)
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Formulary
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Concentrate for intravenous infusion 500mg/50mL
REQUIRES BLUETEQ APPROVAL
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NICE TA195:Adalimumab, etanercept, infliximab, rituximab and abatacept for the treatment of rheumatoid arthritis after the failure of a TNF inhibitor
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Secukinumab
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Formulary
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150mg/ml pre-filled pens/syringes
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NICE TA407: Secukinumab for active ankylosing spondylitis after treatment with non-steroidal anti-inflammatory drugs or TNF-alpha inhibitors
NICE TA445: Certolizumab pegol and secukinumab for treating active psoriatic arthritis after inadequate response to DMARDs
NICE TA719: Secukinumab for treating non-radiographic axial spondyloarthritis
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Tocilizumab (Biosimilars avaliable)
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Formulary
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Concentrate for intravenous infusion (20mg/mL) 80mg, 200mg, 400mg vials
Soution for injection in pre-filled syringe 162mg
Solution for injection in pre-filled pen 162mg
Usually supplied to patients by a home delivery company
REQUIRES BLUETEQ APPROVAL
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MHRA: Tocilizumab (RoActemra): rare risk of serious liver injury including cases requiring transplantation
NICE TA373: Abatacept, adalimumab, etanercept and tocilizumab for treating juvenile idiopathic arthritis
NICE TA375: Adalimumab, etanercept, infliximab, certolizumab pegol, golimumab, tocilizumab and abatacept for rheumatoid arthritis not previously treated with DMARDs or after conventional DMARDs only have failed
NICE TA518: Tocilizumab for treating giant cell arteritis
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Ustekinumab
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Formulary
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Subcutaneous injection 45mg, 90mg prefilled syringes and 45mg/0.5ml vials
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NICE TA340: Ustekinumab for treating active psoriatic arthritis
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| 10.01.03 |
Cytokine modulators |
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Consultant Rheumatologist initiation only
Only to be prescribed in accordance with NICE Guidelines |
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Baricitinib (Olumiant®)
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Formulary
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Tablets 2mg, 4mg
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Baricitinib (Olumiant▼): risk of venous thromboembolism
MHRA: Baricitinib (Olumiant▼): increased risk of diverticulitis, particularly in patients with risk factors
NICE TA466: Baricitinib for moderate to severe rheumatoid arthritis
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Filgotinib (Jyseleca®)
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Formulary
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Tablets 100mg, 200mg
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NICE TA676: Filgotinib for treating moderate to severe rheumatoid arthritis
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Tofacitinib (Xeljanz®)
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Formulary
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Tablets 5mg
MR Tablets 11mg
CCG commissioned for TA547
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LSCMMG: Tofacitinib (Xeljanz▼): new measures to minimise risk of major adverse cardiovascular events and malignancies
LSCMMG: Tofacitinib (Xeljanz▼): new measures to minimise risk of venous thromboembolism and of serious and fatal infections
LSCMMG: Tofacitinib (Xeljanz▼): restriction of 10 mg twice-daily dose in patients at high risk of pulmonary embolism while safety review is ongoing
NICE TA480: Tofacitinib for moderate to severe rheumatoid arthritis
NICE TA543: Tofacitinib for treating active psoriatic arthritis after inadequate response to DMARDs
NICE TA547: Tofacitinib for moderately to severely active ulcerative colitis
NICE TA735: Tofacitinib for treating juvenile idiopathic arthritis
NICE TA920: Tofacitinib for treating active ankylosing spondylitis
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Upadacitinib (Rinvoq ®)
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Formulary
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Prolonged release tablets 15mg
For NICE TA665: upadacitinib for treating severe rheumatoid arthritis - see link below
For NICE TA768: Upadacitinib for treating active psoriatic arthritis after inadequate response to DMARDs - see link below
For NICE TA829: Upadacitinib for treating active ankylosing spondylitis - see link below
For NICE TA861 Upadacitinib for treating active non-radiographic axial spondyloarthritis - see link below
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NICE TA665: Upadacitinib for treating severe rheumatoid arthritis
NICE TA744: Upadacitinib for treating moderate rheumatoid arthritis
NICE TA768: Upadacitinib for treating active psoriatic arthritis after inadequate response to DMARDs
NICE TA829: Upadacitinib for treating active ankylosing spondylitis
NICE TA861: Upadacitinib for treating active non-radiographic axial spondyloarthritis
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| 10.01.03 |
Sulfasalazine |
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Sulfasalazine EC (Salazopyrin EN-Tabs®)
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Formulary
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E/C tablets 500mg
Other dose forms of sulfasalazine - see section 1.5, non e/c tablets and liquid are not licensed for rheumatoid arthritis
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LSCMMG: Shared care guideline - Sulfasalazine
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| 10.01.04 |
Gout and cytotoxic-induced hyperuricaemia |
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Lumasiran (Oxlumo ®)
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Formulary
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Solution for injection 94.5mg/0.5mL
Tertiary Centre only for NICE HST25 Lumasiran for treating primary hyperoxaluria type 1 - See link below
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NICE: Lumasiran for treating primary hyperoxaluria type 1
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| 10.01.04 |
Acute attacks of gout |
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Colchicine
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Formulary
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Tablets 500 micrograms
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LSCMMG: Gout Management Summary Guidelines
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| 10.01.04 |
Long-term control of gout |
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Allopurinol
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First Choice
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Tablets 100mg, 300mg
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LSCMMG: Gout Management Summary Guidelines
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Febuxostat (Adenuric® )
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Second Choice
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Tablets f/c 80mg, 120mg
For patients who are intolerant of allopurinol or for whom allopurinol is contraindicated
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LSCMMG: Gout Management Summary Guidelines
MHRA: Febuxostat (Adenuric): increased risk of cardiovascular death and all-cause mortality in clinical trial in patients with a history of major cardiovascular disease
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| 10.01.04 |
Hyperuricaemia associated with cytotoxic drugs |
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Rasburicase (Fasturtec®)
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Formulary
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Intravenous infusion 7.5mg
Consultant haematologist only
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| 10.01.05 |
Other drugs for rheumatic diseases |
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| .... |
| Non Formulary Items |
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Key |
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Cytotoxic Drug
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Controlled Drug
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High Cost Medicine
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Cancer Drugs Fund
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NHS England |
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Homecare |
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CCG |
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Low carbon footprint |
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Medium carbon footprint |
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High carbon footprint |
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Traffic Light Status Information
| Status |
Description |
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Green:
Appropriate for initiation and ongoing prescribing in both primary and secondary care.
Generally, little or no routine drug monitoring is required. |
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Green (Restricted):
Appropriate for initiation and ongoing prescribing in both primary and secondary care provided:
Additional criteria specific to the medicine or device are met, or
The medicine or device is used following the failure of other therapies as defined by the relevant LSCMMG pathway.
Generally, little or no routine drug monitoring is required.
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Red medicines:
Medicine is supplied by the hospital for the duration of the treatment course.
Primary care initiation or continuation of treatment is not recommended unless exceptional circumstances such as specialist GP.
Red medicines are those where primary care prescribing is not recommended. These treatments should be initiated by specialists only and prescribing retained within secondary care. They require specialist knowledge, intensive monitoring, specific dose adjustments or further evaluation in use. If however, a primary care prescriber has particular specialist knowledge or experience of prescribing a particular drug for a particular patient it would not always be appropriate for them to expect to transfer that prescribing responsibility back to secondary care. There should be a specific reason and a specific risk agreement, protocol and service set up to support this.
Primary care prescribers may prescribe RED medicines in exceptional circumstances to patients to ensure continuity of supply while arrangements are made to obtain ongoing supplies from secondary care. |
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Amber level 0:
Suitable for prescribing in primary care following recommendation or initiation by a specialist.
Little or no specific monitoring required.
Patient may need a regular review, but this would not exceed that required for other medicines routinely prescribed in primary care.
Brief prescribing document or information sheet may be required.
Primary care prescribers must be familiar with the drug to take on prescribing responsibility or must get the required information.
When recommending or handing over care, specialists should ask primary care prescribers to take over prescribing responsibility, and should give enough information about the indication, dose, monitoring requirements, use outside product licence and any necessary dose adjustments to allow them to confidently prescribe. |
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Amber level 1 (with shared care):
Suitable for prescribing in primary care following recommendation or initiation by a specialist.
Minimal monitoring required.
Patient may need a regular review, but this would not exceed that required for other medicines routinely prescribed in primary care.
Full prior agreement about patient’s on-going care must be reached under the shared care agreement.
Primary care prescribers are advised not to take on prescribing of these medicines unless they have been adequately informed by letter of their responsibilities with regards monitoring, side effects and interactions and are happy to take on the prescribing responsibility. A copy of locally approved shared care guidelines should accompany this letter which outlines these responsibilities. Primary care prescribers should then tell secondary care of their intentions as soon as possible by letter so that arrangements can be made for the transfer of care. |
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Amber level 2 (with shared care and enhanced service):
Initiated by specialist and transferred to primary care following a successful initiation period.
Significant monitoring required on an on-going basis.
Full prior agreement about patient’s on-going care must be reached under the shared care agreement.
Suitable for enhanced service.
These medicines are considered suitable for GP prescribing following specialist initiation of therapy, as per shared care document which will be sent out with the request to prescribe, with on-going communication between the primary care prescriber and specialist. Amber Level 2 medicines require significant monitoring for which an enhanced service may be suitable. (Subject to local commissioning agreements). |
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Do not prescribe: NOT recommended for use by the NHS in Lancashire and South Cumbria.
Includes medicines that NICE has not recommended for use and terminated technology appraisals, unless there is a local need. |
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Grey medicines:
Medicines which have not yet been reviewed or are under the review process.
GPs and specialists are recommended not to prescribe these drugs.
This category includes drugs where funding has not yet been agreed.
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Refer to local guidance. |
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