| 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... |
| 10.02 |
Drugs used in neuromuscular disorders |
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Ataluren (Translarna ®)
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Formulary
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Granules for oral suspension 1000mg, 125mg, 250mg
Ataluren for treating Duchenne muscular dystrphy with a nonsense mutation in the dystrophin gene (replaces HST3) - likely to be tertiary centre only
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 NICE:Ataluren for treating Duchenne muscular dystrophy with a nonsense mutation in the dystrophin gene
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Nusinersen (Spinraza®)
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Formulary
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Solution for injection vials 12mg/5ml
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NICE TA588: Nusinersen for treating spinal muscular atrophy
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Onasemnogene abeparvovec (Zolgensma® )
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Formulary
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2 × 1013 vector genomes/mL solution for infusion
Tertiary centre
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NICE: Onasemnogene abeparvovec for treating presymptomatic spinal muscular atrophy
NICE: Onasemnogene abeparvovec for treating spinal muscular atrophy
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Risdiplam (Evrysdi®)
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Formulary
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Powder for oral solution 0.75mg/mL
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NICE TA755: Risdiplam for treating spinal muscular atrophy
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| 10.02.01 |
Drugs which enhance neuromuscular transmission |
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| 10.02.01 |
Anticholinesterases |
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Edrophonium Chloride
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Formulary
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Injection 10mg/1mL
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Pyridostigmine Bromide
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Formulary
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Tablets 60mg
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| 10.02.01 |
Immunosuppressant therapy |
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| 10.02.01 |
Acetylcholine-release enhancers |
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| 10.02.02 |
Skeletal muscle relaxants |
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Baclofen
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Formulary
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Tablets 10mg
Liquid 5mg/5mL
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Cannabis extract (Sativex®)
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Formulary
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Restricted to an initial 4-week trial for treatment of moderate to severe spasticity in adults with multiple sclerosis in line with NICE NG144. Treatment may be continued after the 4-week trial as long as the patient has had at least a 20% reduction in spasticity-related symptoms
 for Refractory neuropathic pain
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NICE NG144: Cannabis-based medicinal products
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Dantrolene
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Formulary
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Capsules 25mg
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Diazepam
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Formulary
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Tablets 2mg, 5mg, 10mg
Syrup 2mg/5mL
Injection 5mg/mL (2mL ampoules)
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Mexiletine hydrochloride (Namuscla ® )
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Formulary
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Capsules 167mg
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NICE TA748: Mexiletine for treating the symptoms of myotonia in non-dystrophic myotonic disorders
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Tizanidine (Zanaflex®)
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Formulary
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Tablets 2mg, 4mg
Consultant initiation only
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| 10.02.02 |
Other muscle relaxants |
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| 10.02.02 |
Nocturnal leg cramps |
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Quinine
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Formulary
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Tablets 200mg, 300mg
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MHRA: Quinine: reminder of dose-dependent QT-prolonging effects; updated medicine interactions
Quinine for muscle cramps
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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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