| 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... |
| 10.01.01 |
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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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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