| 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... |
| 10.02 |
Drugs used in neuromuscular disorders |
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Ataluren (Translarna ®)
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Formulary
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Granules for oral suspension 125mg, 250mg, 1000mg
Tertiary Centre Only.
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 NICE HST22: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
Tertiary Centre Only.
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MHRA: Nusinersen (Spinraza▼): reports of communicating hydrocephalus; discuss symptoms with patients and carers and investigate urgently
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 Only.
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NICE HST15: Onasemnogene abeparvovec for treating spinal muscular atrophy
NICE HST24: Onasemnogene abeparvovec for treating presymptomatic 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
Tertiary Centre Only.
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NICE TA755: Risdiplam for treating spinal muscular atrophy
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Vamorolone (Agamree®)
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Formulary
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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
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| 10.02.01 |
Drugs which enhance neuromuscular transmission |
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| 10.02.01 |
Anticholinesterases |
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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 5mg, 10mg
Oral solution 5mg/5mL
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Cannabis extract (Sativex®)
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Formulary
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Oromucosal spray cannabidiol 2.5mg per dose, Dronabinol 2.7mg per dose
 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,100mg
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Diazepam
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Formulary
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Tablets 2mg, 5mg, 10mg
Syrup 2mg/5mL
Injection 10mg/2ml
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MHRA: Benzodiazepines and opioids: reminder of risk of potentially fatal respiratory depression
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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
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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: not to be used routinely for nocturnal leg cramps
MHRA: Quinine: reminder of dose-dependent QT-prolonging effects; updated medicine interactions
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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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