NHS Greater Glasgow & Clyde Area Drug and Therapeutics Committee
Greater Glasgow and Clyde Prescribing
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10 Musculoskeletal and joint diseases

10.1 Drugs used in rheumatic diseases and gout

10.1.1 Non-steroidal anti-inflammatory drugs

Preferred list
IBUPROFEN

Restrictions: Use of MR preparations is restricted. Modified-release preparations of any NSAID should be restricted to patients with early morning stiffness or compliance problems as they encourage regular/higher doses of NSAIDs and do not afford flexibility in reducing the dose.

BNF Link: http://www.medicinescomplete.com/mc/bnf/current/5192.htm

NAPROXEN (tablets)

Prescribing Notes:

There is a significant cost difference between the tablets and the enteric coated tablets.

BNF Link: http://www.medicinescomplete.com/mc/bnf/current/5243.htm

CELECOXIB

Restrictions: Use in ankylosing spondylitis remains non-Formulary.

BNF Link: http://www.medicinescomplete.com/mc/bnf/current/86687.htm

Total Formulary
MEFENAMIC ACID

Restrictions: Restricted to gynaecological indications only.

BNF Link: http://www.medicinescomplete.com/mc/bnf/current/5239.htm

DICLOFENAC AND MISOPROSTOL (ARTHROTEC)

Prescribing Notes:

In June 2013, the MHRA issued new contraindications and warnings for diclofenac following a review of the cardiovascular risk, which it states is similar to that of the selective COX-2 inhibitors.  A summary of the guidance on the MHRA website is available HERE

BNF Link: http://www.medicinescomplete.com/mc/bnf/current/5212.htm#_5212

ETORICOXIB

Restrictions: Restricted to use in acute gout only. Other indications, including the use in the treatment of ankylosing spondylitis which has not been accepted by SMC, are non-Formulary.

BNF Link: http://www.medicinescomplete.com/mc/bnf/current/106541.htm

DICLOFENAC

Restrictions: Use of MR preparations is restricted. Modified-release preparations of any NSAID should be restricted to patients with early morning stiffness or compliance problems as they encourage regular/higher doses of NSAIDs and do not afford flexibility in reducing the dose.

Prescribing Notes:

In June 2013, the MHRA issued new contraindications and warnings for diclofenac following a review of the cardiovascular risk, which it states is similar to that of the selective COX-2 inhibitors.  A summary of the guidance on the MHRA website is available HERE

BNF Link: http://www.medicinescomplete.com/mc/bnf/current/5206.htm

NAPROXEN (effervescent tablets)

Restrictions: Restricted to use in patients unable to swallow naproxen tablets.

10.1.2 musculoskeletal-corticosteroids

Preferred list
METHYLPREDNISOLONE (INJECTION)

Prescribing Notes:

For oral preparations, see section 6.3.

BNF Link: http://www.medicinescomplete.com/mc/bnf/current/4284.htm

10.1.2.1 Systemic corticosteroids

10.1.2.2 Local corticosteroid injections

Total Formulary

10.1.3 Drugs that suppress the rheumatic disease process

Preferred list
HYDROXYCHLOROQUINE

Restrictions: Restricted to specialist initiation.

BNF Link: http://www.medicinescomplete.com/mc/bnf/current/5302.htm

METHOTREXATE (2.5MG TABLETS)

Restrictions: Restricted to specialist initiation.

Prescribing Notes:

Oral methotrexate should only be prescribed as 2.5mg tablets to avoid patient confusion. The dose should be clearly specified on the dispensing label. In view of reports of blood dyscrasias (including fatalities) and liver cirrhosis with low-dose methotrexate, the CSM has advised: - full blood count and renal and liver function tests before starting treatment and repeated weekly until therapy stabilised, thereafter patients should be monitored every 2-3 months. - that patients should be advised to report all symptoms and signs suggestive of infection, especially sore throat.

BNF Link: http://www.medicinescomplete.com/mc/bnf/current/5305.htm

SULFASALAZINE (ec tablets)

Prescribing Notes:

The CSM has advised that patients should be advised to report any unexplained bleeding, bruising, purpura, sore throat, fever or malaise (potential signs of blood dyscrasia).

BNF Link: http://www.medicinescomplete.com/mc/bnf/current/5308.htm

Total Formulary
ADALIMUMAB

Restrictions:

Restricted to specialist use only in accordance with the prescribing notes below.

Prescribing Notes:

Ankylosing Spondylitis

  • Use for ankylosing spondylitis is restricted to use in accordance with the British Society for Rheumatology guidelines of July 2004.

Axial Spondyloarthritis

  • The treatment of adults with severe axial spondyloarthritis without radiographic evidence of ankylosing spondylitis but with objective signs of inflammation by elevated C-reactive protein (CRP) and/or magnetic resonance imaging (MRI), who have had an inadequate response to, or are intolerant to non-steroidal anti-inflammatory drugs (NSAIDs) is restricted to specialist use in accordance with Assessment in Spondyloarthritis Internation Society (ASIS) guidance. 

Active polyarticular idiopathic arthritis

  • Use for active polyarticular idiopathic arthritis in adolescents aged 13-17 years is restricted to those who have an inadequate response to one or more DMARDs.

For the use in other indications see section 1.5.3 and 13.5.3

BNF Link: http://www.medicinescomplete.com/mc/bnf/current/128230.htm

AZATHIOPRINE

Restrictions: Restricted to specialist initiation.

BNF Link: http://www.medicinescomplete.com/mc/bnf/current/17371.htm

ETANERCEPT

Restrictions:

Restricted to specialist use only.

In adults, etanercept is restricted to initiation by consultant rheumatologists for:

  • Treatment of ankylosing spondylitis is restricted to use in accordance with the British Society for Rheumatology (BSR) guidelines of July 2004.
  • Treatment of axial spondyloarthritis is restricted to specialist use in accordance with the recommendations made in NICE TA 383 click here

In children and adolescents, etanercept is restricted to initiation by consultant rheumatologists for:

  • Treatment of juvenile idiopathic arthritis is restricted to use by paediatric rheumatologists. Etanercept is restricted to use according to SMC and local implementation protocols.
  • Severe chronic plaque psoriasis treated under supervision only by specialist physicians in accordance with SMC criteria.

BNF Link: http://www.medicinescomplete.com/mc/bnf/current/PHP6639-etanercept.htm

INFLIXIMAB

Restrictions:

Restricted to specialist use only.

In adults, infliximab is restricted to initiation by consultant rheumatologists for:

  • Treatment of psoriatic arthritis is restricted to criteria set out in NICE Technology Appraisal 104.
  • Treatment of ankylosing spondylitis is restricted to use in accordance with recommendations made in the NICE TA 383 click here.

Prescribing Notes:

Infliximab should be prescribed by brand name

BNF Link: http://www.medicinescomplete.com/mc/bnf/current/128234.htm

LEFLUNOMIDE

Restrictions: Restricted to specialist initiation. In adults, leflunomide is restricted to initiation by consultant rheumatologists.

BNF Link: http://www.medicinescomplete.com/mc/bnf/current/82653.htm

METHOTREXATE (Metoject) (PRE-FILLED SYRINGE)

Restrictions: To be initiated and supervised by a specialist, though GPs are able to continue prescribing.

BNF Link: http://www.medicinescomplete.com/mc/bnf/current/5305.htm

MINOCYCLINE

Restrictions: Restricted to specialist initiation. This is an unlicensed indication of minocycline and is restricted to initiation by consultant rheumatologists for use in patients who could not be successfully treated with other DMARDs or anti-TNF therapy because of sepsis.

BNF Link: http://www.medicinescomplete.com/mc/bnf/current/3823.htm

PENICILLAMINE

Restrictions: Restricted to specialist initiation.

BNF Link: http://www.medicinescomplete.com/mc/bnf/current/5295.htm

SODIUM AUROTHIOMALATE

Restrictions: Restricted to specialist initiation.

BNF Link: http://www.medicinescomplete.com/mc/bnf/current/5290.htm

RITUXIMAB

Restrictions: Restricted to specialist use only. Use in rheumatoid arthritis is restricted to specialist use in accordance with local protocol.

BNF Link: http://www.medicinescomplete.com/mc/bnf/current/129937.htm

ABATACEPT (infusion, sub-cutaneous injection)

Restrictions:

Restricted to specialist use in combination with methotrexate for adult patients with active rheumatoid arthritis as measured by a disease activity score (DAS28) greater than 5.1 confirmed on at least two occasions 1 month apart who have responded inadequently to previous therapy with one or more disease-modifying anti-rheumatic drugs including methotrexate or a TNF-alpha inhibitor.

Prescribing Notes:

The treatment of patients not previously treated with methotrexate is not recommended by SMC and remains non-Formulary.

BNF Link: http://www.medicinescomplete.com/mc/bnf/current/130136.htm

TOCILIZUMAB (IV infusion, sub-cutaneous injection)

Restrictions: Specialist use only. Use for moderate to severe active rheumatoid arthritis in combination with methotrexate, or as monotherapy, in patients who are intolerant to methotrexate or where continued treatment with methotrexate is inappropriate, is restricted in accordance with the British Society of Rheumatology guidelines (2005).

Prescribing Notes:

The treatment of severe, active and progressive rheumatoid arthritis in adults not previously treated with methotrexate remains non-Formulary.

BNF Link: http://www.medicinescomplete.com/mc/bnf/current/203908.htm

APREMILAST (tablets)

Restrictions: Use in the treatment of Psoriatic Arthritis (PsA) is restricted to specialist use in adults with active psoriatic athritis who have had an inadequate response with at least two prior disease modifying anti-rheumatics drugs (DMARDs) or who are intolerant to such therapies.

Prescribing Notes:

For other indications please see chapter 13.5.3

BELIMUMAB (infusion)

Restrictions:

Restricted to specialist use in patients with evidence of serological disease activity (i.e. positive anti-dsDNA and low complement) and a Safety of Estrogens in Lupus Erythematosus National Assessment-Systemic Lupus Erythematosus Disease Activity Index (SELENA-SLEDAI) score of ≥10.

BNF Link: https://www.medicinescomplete.com/mc/bnf/current/PHP6635-belimumab.htm?q=belimumab&t=search&ss=text&tot=4&p=1#_hit

CERTOLIZUMAB

Restrictions: Restricted to specialist use only for the indications as outlined below in the Prescribing Notes section:

Prescribing Notes:

Formulary indications and restrictions:

  • Moderate to severe active rheumatoid arthritis in combination with methotrexate in adult patients when the response to disease modifying anti-rheumatic drugs, including methotrexate, has been inadequate and monotherapy in case of intolerance to methotrexate or when continued treatment with methotrexate is inappropriate
  • The treatment of adult patients with severe active axial spondyloarthritis, comprising (1) Ankylosing spondylitis (AS) and (2) Axial spondyloarthritis without radiographic evidence of AS (nr-axSpA)
  • Active psoriatic arthritis is restricted to specialist use in patients whose disease has not responded to adequate trials of at least two standard DMARDs either individually or in combination. It may be used in combination with methotrexate or as monotherapy in cases of intolerance to methotrexate or when continued treatment with methotrexate is inappropriate.

Non-formulary indications:

  • Treatment of severe, active and progressive RA in adults not previously treated with MTX or other DMARDs.

BNF Link: http://www.medicinescomplete.com/mc/bnf/current/204103.htm

CICLOSPORIN

Restrictions: Restricted to specialist initiation. Restricted to specialist use for refractory patients.

Prescribing Notes:

Prescribe by brand name.

BNF Link: http://www.medicinescomplete.com/mc/bnf/current/17350.htm

GOLIMUMAB (SIMPONI) (injection)

Restrictions: Golimumab is included in the Formulary for use in specific patient groups in ankylosing spondylitis, psoriatic arthritis, rheumatoid arthritis and axial spondyloarthritis in accordance with SMC advice/local formulary restrictions as detailed in the prescribing notes below.

Prescribing Notes:

Ankylosing spondylitis:

The treatment of severe active ankylosing spondylitis in adults is restricted to use in accordance with the British Society of Rheumatology guidelines. 

For the relevant SMC advice for ankylosing spondylitis click here

Psoriatic Arthritis:

Use in combination with methotrexate, for the treatment of active and progressive psoriatic arthritis in adult patients when the response to previous disease-modifying anti-rheumatic drug (DMARD) therapy has been inadequate is restricted to specialist use in patients whose disease has not responded to adequate trials of at least two standard DMARDs, administered either individually or in combination. .

For the relevant SMC advice for psoriatic arthritis click here

Rheumatoid Arthritis:

The use in combination with methotrexate, for the treatment of moderate to severe, active rheumatoid arthritis is restricted to use in accordance with the British Society for Rheumatology (BSR) guidelines (2005). 

For relevant SMC advice for rheumatoid arthritis click here

Axial Spondyloarthritis:

The treatment of adults with severe, active non-radiographic axial spondyloarthritis with objective signs of inflammation as indicated by elevated C-reactive protein (CRP) and/or magnetic resonance imaging (MRI) evidence, who have had an inadequate response to, or are intolerant to non-steroidal anti-inflammatory drugs (NSAIDs) is restricted to specialist use.

For the relevant SMC advice for axial spondyloarthritis click here

BNF Link: http://www.medicinescomplete.com/mc/bnf/current/212247.htm

SECUKINUMAB

Restrictions: Restricted to specialist use as detailed in the prescribing notes below.

Prescribing Notes:

  • Treatment of psoriatic arthritis is restricted to specialist use only in patients whose disease has not responded to adequate trials of at least two standard DMADRs either individually or in combination
  • Treatment of active ankylosing spondylitis (AS) in adults who have responded inadequately to conventional therapy

See section 13.5.3 for use in plaque psoriasis.

USTEKINUMAB (STELARA) (sub-cutaneous injection)

Restrictions: The use as monotherapy or in combination with methotrexate, for the treatment of active psoriatic arthritis in adult patients when the response to previous non-biological disease-modifying anti-rheumatic drug therapy has been inadequate, is restricted to specialist use in patients with active psoriatic arthritis who have failed on, or are unsuitable for, treatment with an anti-TNF drug

Prescribing Notes:

For use in psoriasis, see section 13.5.3

BNF Link: http://www.medicinescomplete.com/mc/bnf/current/PHP34016-preparations.htm#PHP34016-preparations

10.1.4 Gout and cytotoxic-induced hyperuricaemia

Preferred list
ALLOPURINOL

Prescribing Notes:

Allopurinol alone should not be initiated during the acute phase as it may precipitate further attacks or make the gout worse.

BNF Link: http://www.medicinescomplete.com/mc/bnf/current/5315.htm

Total Formulary
ETORICOXIB

Restrictions: Etoricoxib is restricted to use only in acute gout in high risk patients. See section 10.1.1 in preferred list for CSM advice. All other indications are non-Formulary.

BNF Link: http://www.medicinescomplete.com/mc/bnf/current/106541.htm

RASBURICASE

Restrictions: Restricted to specialist use only. Restricted to use under the supervision of haematologists and oncologists and subject to NHSGGC protocol for adults and children.

BNF Link: http://www.medicinescomplete.com/mc/bnf/current/106160.htm

AZAPROPAZONE
FEBUXOSTAT

Restrictions: Restricted to use as outlined in Prescribing Notes section below.

Prescribing Notes:

  • Chronic hyperuricaemia: restricted to symptomatic patients whose uric acid levels have failed to respond adequately despite optimal dosing of allopurinol.
  • Hyperuricaemia related to chemotherapy:  prevention and treatment of hyperuricaemia in adult patients undergoing chemotherapy for haematologic malignancies is restricted to specialist use for patients at intermediate risk of tumour lysis syndrome (TLS) in whom allopurinol is either unsuitable or contraindicated, such as those intolerant of allopurinol or those in whom allopurinol is contraindicated, e.g. patients with renal impairment.

BNF Link: http://www.medicinescomplete.com/mc/bnf/current/204954.htm

10.1.5 Other drugs for rheumatic diseases