| 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: Axial Spondyloarthritis: High Cost Drugs Commissioning Pathway |
| LSCMMG: Gout Management Summary Guidelines |
| LSCMMG: Juvenile Idiopathic Arthritis in adult patients: Position statement for biological agents |
| LSCMMG: Psoriatic Arthritis: High Cost Drugs Commissioning Pathway |
| LSCMMG: Rheumatoid Arthritis: High Cost Drugs Commissioning Pathway |
| NHS England high cost drugs commissioning list |
| NICE CG124: Hip fracture: management |
| NICE NG100: Rheumatoid arthritis in adults: management |
| NICE NG193: Chronic pain (primary and secondary) in over 16s: assessment of all chronic pain and management of chronic primary pain |
| NICE NG219: Gout: diagnosis and management |
| NICE NG226: Osteoarthritis in over 16s: diagnosis and management |
| NICE NG38: Fractures (non-complex): assessment and management |
| NICE NG59: Low back pain and sciatica in over 16s: assessment and management |
| NICE NG65: Spondyloarthritis in over 16s: diagnosis and management |
| Details... |
| 10.01 |
Drugs used in rheumatic diseases and gout |
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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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Systemic as well as local effects of NSAIDs contribute to gastro–intestinal damage; taking oral formulations with milk or food, or using enteric-coated formulations, or changing the route of administration may only partially reduce symptoms such as dyspepsia. |
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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
 MHRA: High-dose ibuprofen (≥2400mg/day): small increase in cardiovascular risk
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Naproxen
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First Choice
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Tablets 250mg, 500mg
Naproxen is one of the first choices because it combines good efficacy with a low incidence of side-effects (but more than ibuprofen).
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LSCMMG: Over the Counter Items that Should not be Routinely Prescribed in Primary Care Policy
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Diclofenac
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Formulary
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Tablets e/c 25mg, 50mg
 For short term use in breastfeeding mothers only.
 Rheumatology initiation ONLY. When other NSAIDs have been shown to be clinically ineffective.
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MHRA: Diclofenac: new contraindications and warnings
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Celecoxib
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Formulary
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Capsules 100mg, 200mg
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Etoricoxib
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Formulary
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Tablets 30mg, 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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Mefenamic acid
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Formulary
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Tablets and capsules 500mg
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Meloxicam
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Formulary
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Tablets 7.5mg, 15mg
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Diclofenac
(Rectal route)
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 Restricted
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Suppositories 12.5mg, 25mg, 50mg, 100mg
Short-term use only.
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MHRA: 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 40mg/ml, 80mg/2mL, 120mg/3ml
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Methylprednisolone Acetate with Lidocaine (Depo-Medrone® with lidocaine)
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Formulary
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Suspension for injection lidocaine hydrochloride 10mg per 1ml, Methylprednisolone acetate 40mg per 1ml
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| 10.01.03 |
Drugs which suppress the rheumatic disease process |
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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, 250mg
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LSCMMG: Penicillamine shared care guideline
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| 10.01.03 |
Antimalarials |
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Hydroxychloroquine
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Formulary
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Tablets 200mg
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LSCMMG: Hydroxychloroquine information sheet
MHRA: Hydroxychloroquine, chloroquine: increased risk of cardiovascular events when used with macrolide antibiotics; reminder of psychiatric reactions
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| 10.01.03 |
Drugs affecting the immune response |
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Azathioprine
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Formulary
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Tablets 25mg, 50mg
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LSCMMG: Azathioprine and Mercaptopurine shared care guideline
MHRA: Thiopurines and intrahepatic cholestasis of pregnancy
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Ciclosporin
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Formulary
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Capsules 25mg, 50mg, 100mg
Patients should be stabilised on a particular brand of oral ciclosporin because switching between formulations without close monitoring may lead to clinically important changes in blood-ciclosporin concentration.
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LSCMMG: Ciclosporin shared care guideline
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Cyclophosphamide
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Formulary
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Tablets 50mg
Injection 500mg, 1g, 2g
Not licensed for rheumatoid arthritis with severe systemic manifestations.
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Leflunomide
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Formulary
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Tablets 10mg, 20mg
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LSCMMG: Leflunomide shared care guideline
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Methotrexate
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Formulary
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Tablets 2.5mg
Prefilled syringes and pens (various strengths)
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.
Methotrexate subcutaneous injection is supplied through a homecare arrangement in ELHT.
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LSCMMG: Methotrexate shared care guideline
MHRA: Methotrexate once-weekly for autoimmune diseases: new measures to reduce risk of fatal overdose due to inadvertent daily instead of weekly dosing
MHRA: Methotrexate: advise patients to take precautions in the sun to avoid photosensitivity reactions
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Mycophenolate Mofetil
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Formulary
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Tablets 500mg
Capsules 250mg
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LSCMMG: Shared care guideline: Mycophenolate Mofetil
MHRA: Mycophenolate mofetil, mycophenolic acid: new pregnancy-prevention advice for women and men
MHRA: Mycophenolate mofetil, mycophenolic acid: updated contraception advice for male patients
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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.
Commissioned by NHS England for paediatric indications where an adult NICE TA is in place. |
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Abatacept (Orencia®)
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Formulary
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Solution for infusion 250mg
solution for injection pre-filled syringes 125mg/1ml
Solution for injection pre-filled pens 125mg/1ml
Commissioned in accordance with LSCMMG biologics pathways.
 NHSE commissioned for some indications.
Consult chapter links for more details.
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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
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
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Formulary
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S/C injection 40mg prefilled syringe and pen
Commissioned in accordance with LSCMMG biologics pathways.
NHSE commissioned for some indications.
Consult chapter links for more details.
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MHRA: Tumour necrosis factor alpha inhibitors
NHSE: Clinical commissioning policy: Etanercept and adalimumab for the treatment of deficiency of adenosine deaminase type 2 (aged 5 years and older) [2319]
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
NICE does not recommend Anakinra for the treatment of rheumatoid arthritis.
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NICE TA685: Anakinra for treating Still’s disease
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Apremilast (Otezla®)
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Formulary
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Tablets 10mg, 20mg, 30mg
Commissioned in accordance with LSCMMG biologics pathways.
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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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Baricitinib
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Formulary
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Tablets 2mg, 4mg
Commissioned in accordance with LSCMMG biologics pathways.
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Baricitinib (Olumiant▼): risk of venous thromboembolism
MHRA: Baricitinib (Olumiant▼): increased risk of diverticulitis, particularly in patients with risk factors
MHRA: Janus kinase (JAK) inhibitors: new measures to reduce risks of major cardiovascular events, malignancy, venous thromboembolism, serious infections and increased mortality
NICE TA466: Baricitinib for moderate to severe rheumatoid arthritis
NICE TA982: Baricitinib for treating juvenile idiopathic arthritis in people 2 years and over (terminated appraisal)
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Belimumab (Benlysta® )
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Formulary
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Concentrate for solution for infusion 120mg, 400mg
Solution for injection pre-filled pen 200mg
 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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Bimekizumab (Bimzelx®)
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Formulary
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Pre-filled syringe/pen 160mg/ml, 320mg/2ml
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NICE TA916: Bimekizumab for treating active psoriatic arthritis
NICE TA918: Bimekizumab for treating axial spondyloarthritis
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Certolizumab Pegol (Cimzia®)
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Formulary
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Solution for injection pre-filled pens 200mg/1ml
Solution for injection pre-filled syringes 200mg/1ml
Solution for injection in a dose-dispenser cartridge 200mg/1ml
Commissioned in accordance with LSCMMG biologics pathways.
Consult chapter links for more details.
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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 TA383: TNF-alpha inhibitors for ankylosing spondylitis and non-radiographic axial spondyloarthritis
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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Etanercept
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Formulary
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Solution for injection pre-filled syringe 25mg, 50mg
Solution for injection pre-filled pen 25mg, 50mg
Powder and solvent for solution for injection 10mg, 25mg
Commissioned in accordance with LSCMMG biologics pathways.
NHSE commissioned for some indications.
Consult chapter links for more details.
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MHRA: Tumour necrosis factor alpha inhibitors
NHSE: Clinical commissioning policy: Etanercept and adalimumab for the treatment of deficiency of adenosine deaminase type 2 (aged 5 years and older) [2319]
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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Filgotinib (Jyseleca®)
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Formulary
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Tablets 100mg, 200mg
Commissioned in accordance with LSCMMG biologics pathways.
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MHRA: Janus kinase (JAK) inhibitors: new measures to reduce risks of major cardiovascular events, malignancy, venous thromboembolism, serious infections and increased mortality
NICE TA676: Filgotinib for treating moderate to severe rheumatoid arthritis
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Golimumab (Simponi®)
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Formulary
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Solution for injection pre-filled pen 50mg, 100mg
Solution for injection pre-filled syringe 50mg
Commissioned in accordance with LSCMMG biologics pathways.
Consult chapter links for more details.
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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
Commissioned in accordance with LSCMMG biologics pathways.
Consult chapter links for more details.
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NICE TA815: Guselkumab for treating active psoriatic arthritis after inadequate response to DMARDs
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Infliximab
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Formulary
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Solution for injection pre-filled pen 120mg/1ml
Powder for concentrate for solution for infusion 100mg
Adequate resuscitation facilities must be available when infliximab is used.
Commissioned in accordance with LSCMMG biologics pathways.
NHSE commissioned for some indications.
Consult chapter links for more details.
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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 (Taltz®)
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Formulary
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Solution for injection pre-filled pen 80mg/1ml
Solution for injection pre-filled syringe 80mg/1ml
Commissioned in accordance with LSCMMG biologics pathways.
Consult chapter links for more details.
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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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Risankizumab (Skyrizi®)
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Formulary
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Solution for injection pre-filled pen 150mg/1ml
Solution for injection pre-filled syringe 150mg/1ml
Commissioned in accordance with LSCMMG biologics pathways.
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NICE TA803: Risankizumab for treating active psoriatic arthritis after inadequate response to DMARDs
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Rituximab (Biosimilars avaliable)
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Formulary
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Concentrate for intravenous infusion 500mg/50mL
All anti-lymphocyte monoclonal antibodies should be given under the supervision of an experienced specialist, in an environment where full resuscitation facilities are immediately available.
Commissioned in accordance with LSCMMG biologics pathways.
NHSE commissioned for some indications.
Consult chapter links for more details.
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MHRA: Rituximab: screen for hepatitis B virus before treatment
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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Sarilumab (Kevzara®)
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Formulary
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Solution for injection pre-filled pen 150mg, 200mg
Solution for injection syringe 200mg
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NICE TA485: Sarilumab for moderate to severe rheumatoid arthritis
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Secukinumab (Cosentyx®)
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Formulary
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Solution for injection pre-filled pen 150mg/1ml, 300mg/2ml
Solution for injection pre-filled syringe 75mg/0.5ml, 150mg/1ml
Commissioned in accordance with LSCMMG biologics pathways.
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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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Solution for injection pre-filled pen 162mg/0.9ml
Solution for injection pre-filled syringe 162mg/0.9ml
Concentrate for solution for infusion 80mg, 200mg, 400mg
Commissioned in accordance with LSCMMG biologics pathways.
NHSE commissioned for some indications.
Consult chapter links for more details.
|
MHRA: Tocilizumab (RoActemra): rare risk of serious liver injury including cases requiring transplantation
NICE TA247: Tocilizumab for the treatment of rheumatoid 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 TA518: Tocilizumab for treating giant cell arteritis
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Tofacitinib (Xeljanz®)
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Formulary
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Tablets 5mg, 10mg
Modified-release tablets 11mg
Commissioned in accordance with LSCMMG biologics pathways.
NHSE commissioned for some indications.
Consult chapter links for more details.
|
MHRA: Janus kinase (JAK) inhibitors: new measures to reduce risks of major cardiovascular events, malignancy, venous thromboembolism, serious infections and increased mortality
MHRA: Tofacitinib (Xeljanz▼): new measures to minimise risk of major adverse cardiovascular events and malignancies
MHRA: Tofacitinib (Xeljanz▼): new measures to minimise risk of venous thromboembolism and of serious and fatal infections
MHRA: 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 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
|
Modified-release tablets 15mg, 30mg, 45mg
Commissioned in accordance with LSCMMG biologics pathways.
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MHRA: Janus kinase (JAK) inhibitors: new measures to reduce risks of major cardiovascular events, malignancy, venous thromboembolism, serious infections and increased mortality
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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Ustekinumab
|
Formulary
|
Solution for injection pre-filled syringe 45mg/0.5ml, 90mg/1ml
Solution for injection pre-filled pen 45mg/0.5ml, 90mg/1ml
Solution for injection vial 45mg/0.5ml
Commissioned in accordance with LSCMMG biologics pathways.
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MHRA: Ustekinumab (Stelara): risk of exfoliative dermatitis
NICE TA340: Ustekinumab for treating active psoriatic arthritis
|
| 10.01.03 |
Sulfasalazine |
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Sulfasalazine
|
Formulary
|
Tablets 500mg
Gastro-resistant tablets 500mg
Sulfasalazine has been confused with sulfadiazine; care must be taken to ensure the correct drug is prescribed and dispensed.
|
LSCMMG: Sulfasalazine shared care guideline
|
| 10.01.04 |
Gout and cytotoxic-induced hyperuricaemia |
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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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MHRA: Colchicine: extremely toxic in overdose
|
| 10.01.04 |
Long-term control of gout |
|
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Allopurinol
|
First Choice
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Tablets 100mg, 300mg
|
|
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Febuxostat
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Second Choice
|
Tablets 80mg, 120mg
For patients who are intolerant of allopurinol or for whom allopurinol is contraindicated.
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MHRA: Febuxostat (Adenuric▼): stop treatment if signs or symptoms of serious hypersensitivity
MHRA: Febuxostat: updated advice for the treatment of patients with a history of major cardiovascular disease
|
| 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 |
|
|
| 10.02 |
Drugs used in neuromuscular disorders |
|
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Ataluren (Translarna ®)
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Formulary
|
Granules for oral suspension 125mg, 250mg, 1000mg
Tertiary Centre Only.
|
NICE HST22:Ataluren for treating Duchenne muscular dystrophy with a nonsense mutation in the dystrophin gene
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Nusinersen (Spinraza®)
|
Formulary
|
Solution for injection vials 12mg/5ml
Tertiary Centre Only.
|
MHRA: Nusinersen (Spinraza▼): reports of communicating hydrocephalus; discuss symptoms with patients and carers and investigate urgently
NICE TA588: Nusinersen for treating spinal muscular atrophy
|
Onasemnogene abeparvovec (Zolgensma® )
|
Formulary
|
2 × 1013 vector genomes/mL solution for infusion
Tertiary Centre Only.
|
NICE HST15: Onasemnogene abeparvovec for treating spinal muscular atrophy
NICE HST24: Onasemnogene abeparvovec for treating presymptomatic spinal muscular atrophy
|
Risdiplam (Evrysdi®)
|
Formulary
|
Powder for oral solution 0.75mg/mL
Tertiary Centre Only.
|
NICE TA755: Risdiplam for treating spinal muscular atrophy
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Vamorolone (Agamree®)
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Formulary
|
Oral suspension 40 mg/ml
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MHRA: Corticosteroids: rare risk of central serous chorioretinopathy with local as well as systemic administration
NHSE: Steroid Emergency Card to support early recognition and treatment of adrenal crisis in adults
NICE TA1031: Vamorolone for treating Duchenne muscular dystrophy in people 4 years and over
|
| 10.02.01 |
Drugs which enhance neuromuscular transmission |
|
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| 10.02.01 |
Anticholinesterases |
|
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Pyridostigmine Bromide
|
Formulary
|
Tablets 60mg
|
|
|
| 10.02.01 |
Immunosuppressant therapy |
|
|
| 10.02.01 |
Acetylcholine-release enhancers |
|
|
| 10.02.02 |
Skeletal muscle relaxants |
|
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Baclofen
|
Formulary
|
Tablets 5mg, 10mg
Oral solution 5mg/5mL
|
|
|
Cannabis extract (Sativex®)
|
Formulary
|
Oromucosal spray cannabidiol 2.5mg per dose, Dronabinol 2.7mg per dose
for Refractory neuropathic pain.
|
NICE NG144: Cannabis-based medicinal products
|
Dantrolene
|
Formulary
|
Capsules 25mg,100mg
|
|
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Diazepam
|
Formulary
|
Tablets 2mg, 5mg, 10mg
Syrup 2mg/5mL
Injection 10mg/2ml
|
MHRA: Benzodiazepines and opioids: reminder of risk of potentially fatal respiratory depression
|
Mexiletine hydrochloride (Namuscla ® )
|
Formulary
|
Capsules 167mg
|
NICE TA748: Mexiletine for treating the symptoms of myotonia in non-dystrophic myotonic disorders
|
Tizanidine
|
Formulary
|
Tablets 2mg, 4mg
Consultant initiation only.
|
|
|
| 10.02.02 |
Other muscle relaxants |
|
|
| 10.02.02 |
Nocturnal leg cramps |
|
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Quinine
|
Formulary
|
Tablets 200mg, 300mg
|
MHRA: Quinine: not to be used routinely for nocturnal leg cramps
MHRA: Quinine: reminder of dose-dependent QT-prolonging effects; updated medicine interactions
|
| 10.03 |
Drugs for the treatment of soft-tissue disorders and topical pain relief |
|
|
| 10.03 |
Extravasation |
|
|
| 10.03.01 |
Enzymes |
|
|
Hyaluronidase
|
Formulary
|
Injection 1500 units
|
|
|
| 10.03.02 |
Rubefacients, topical NSAIDs, capsaicin, and poultices |
|
|
Rubefacients
|
Formulary
|
Exclusions to DNP RAG:
Topical NSAIDs (see section 10.03.02)
Capsaicin patches (see section 10.03.02)
Deep Heat cream for aiding the collection of arterial blood gases.
|
LSCMMG: Over the Counter Items that Should not be Routinely Prescribed in Primary Care Policy
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| 10.03.02 |
Topical NSAIDs and counter-irritants |
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Ibuprofen gel
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Formulary
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Gel 5%, 10% (30g, 50g, 100g)
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LSCMMG: Over the Counter Items that Should not be Routinely Prescribed in Primary Care Policy
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| 10.03.02 |
Capsaicin |
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Capsaicin
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Formulary
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Cream 0.025%, 0.075%
Capsaicin cream is currently unavailable and this is likely to be the case until June 2026.
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Capsaicin (Qutenza®)
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Formulary
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Patch 179mg (8%)
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LSCMMG: Qutenza (capsaicin) 179mg cutaneous patch NMR
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| 10.03.02 |
Poultices |
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| 10.04 |
Dibotermin |
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Dibotermin alfa (InductOs®)
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Formulary
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for acute tibia fractures in adults (licensed)
for non-union long bone fractures (unlicensed)
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LSCMMG: Dibotermin alfa (InductOs®) NMR
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| 10.05 |
Devices |
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Therabite Jaw Rehabilitation Device (Therabite ®)
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Formulary
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LSCMMG: TheraBite® Jaw Rehabilitation Device NMR
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| .... |
Key |
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Restricted Drug |
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Unlicensed |
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Link to adult BNF
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Link to children's BNF
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Link to SPCs
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Scottish Medicines Consortium |
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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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ICB |
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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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| 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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