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Musculoskeletal & Joint Diseases
| 1 ARTHRITIS | ||
| Surrey APC Pathways | Rheumatoid Arthritis High Cost DMARDs Drug Treatment Pathway (2019) Psoriatic Arthritis (PsA) Treatment Pathway in Adults (2019) | |
| DISEASE MODIFYING ANTI-RHEUMATIC DRUGS (DMARDs) | NOTES | |
| HYDROXYCHLOROQUINE | Tablets 200mg | Minimum of 1 month supply from hospital APC traffic light status: BLUE |
| LEFLUNOMIDE | Tablets 10mg, 20mg, 100mg | RESTRICTED for RHEUMATOLOGY use only Link to Shared Care Guideline for approved indications Shared Care Agreement Communication FormAPC traffic light status: AMBER |
| PENICILLAMINE | Tablets 125mg | APC Policy Statement: Penicillamine for the treatment of rheumatoid arthritis APC traffic light status: RED |
| SODIUM AUROTHIOMALATE | Injection 10mg in 0.5ml, 20mg in 0.5ml, 50mg in 0.5ml | APC Policy Statement: Intramuscular sodium aurothiomalate for the treatment of rheumatoid arthritis (2018) APC traffic light status: RED |
| IMMUNOSUPPRESSANTS – Interleukin Inhibitors | NOTES | |
| IXEKIZUMAB | 80mg/1ml solution for injection | NICE TA537: Ixekizumab for treating active psoriatic arthritis after inadequate response to DMARDs Prescribing should be by a specialist only, in line with NICE and/or local pathways. Adults indications are CCG commissioned, funding is only available with the use of Blueteq initiation and continuation forms. APC traffic light status: RED |
| SARILUMAB | 200mg/1.14ml, 150mg/1.14ml | NICE TA485: Sarilumab for moderate to severe rheumatoid arthritis Prescribing should be by a specialist only, in line with NICE and/or local pathways. Adults indications are CCG commissioned, funding is only available with the use of Blueteq initiation and continuation forms. Paediatric indications are NHSE commissioned. APC Policy Statement: Sarilumab for moderate to severe of rheumatoid arthritis (2017) APC traffic light status: RED |
| SECUKINUMAB | Pre-filled pen or syringe 150mg | Prescribing should be by a specialist only, in line with NICE and/or local pathways. Adults indications are CCG commissioned, funding is only available with the use of Blueteq initiation and continuation forms. Paediatric indications are NHSE commissioned. APC Policy Statement: Certolizumab pegol and secukinumab for treating active psoriatic arthritis after inadequate response to DMARDs (2017)APC Policy Statement: Secukinumab for active ankylosing spondylitis after treatment with non-steroidal anti-inflammatory drugs or TNF-alpha inhibitors (2016) APC traffic light status: RED |
| TOCILIZUMAB | 162mg/0.9ml solution for injection pre-filled pen | NICE TA 375 – 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 Prescribing should be by a specialist only, in line with NICE and/or local pathways. Rheumatoid arthritis is CCG commissioned, funding is only available with the use of Blueteq initiation and continuation forms. Arteritis and paediatric indications are NHSE commissioned. APC traffic light status: RED |
| USTEKINUMAB | Injection 45mg | Prescribing should be by a specialist only, in line with NICE and/or local pathways. Adults indications are CCG commissioned, funding is only available with the use of Blueteq initiation and continuation forms. Paediatric indiations are NHSE commissioned. NICE Guidance Ustekinumab for treating active psoriatic arthritis APC Policy Statement: Ustekinumab for treating active psoriatic arthritis (2015) APC traffic light status: RED |
| IMMUNOSUPPRESSANTS – Protein Kinase Inhibitors | NOTES | |
| BARICITINIB | Tablets, 2mg & 4mg | Prescribing should be by a specialist only, in line with NICE and/or local pathways. Commissioned by CCGs, funding is only available with the use of Blueteq initiation and continuation forms. Paediatric indiations are NHSE commissioned. NICE TA466: Baricitinib for moderate to severe rheumatoid arthritis APC traffic light status: RED |
| TOFACITINIB | Tablets 5mg | Prescribing should be by a specialist only, in line with NICE and/or local pathways. Adults indications are CCG commissioned, funding is only available with the use of Blueteq initiation and continuation forms. Paediatric indiations are NHSE commissioned. NICE TA480 Tofacitinib for moderate to severe rheumatoid arthritis NICE TA543: Tofacitinib for treating active psoriatic arthritis after inadequate response to DMARDs APC Policy Statement: Tofactinib for the treatment of Rheumatoid Arthritis (2017) APC traffic light status: RED |
| IMMUNOSUPPRESSANTS – T-Cell Activation Inhibitors | NOTES | |
| ABATACEPT | 40mg S/C pre-filled pen or syringe | Prescribing should be by a specialist only, in line with NICE and/or local pathways. Adults indications are CCG commissioned, funding is only available with the use of Blueteq initiation and continuation forms. Paediatric indiations are NHSE commissioned. APC traffic light status: RED |
| IMMUNOSUPPRESSANTS – Tumor Necrosis Factor (TNF) Alpha Inhibitors | NOTES | |
| Biologics | Biologics should be prescribed by Brand. The brand providing best value in local health economy should be prescribed for all new patients. Following receipt of consent from existing patients, biologics should be switched to the brand providing best value in local health economy. | |
| ADALIMUMAB | 40mg S/C pre-filled syringe | Prescribing should be by aspecialist only, in line with NICE and/or local pathways. Adults indications are CCG commissioned, funding is only available with the use of Blueteq initiation and continuation forms. Paediatric indiations are NHSE commissioned. APC Policy Statement: Adalimumab for all CCG-commissioned indications (2019) APC traffic light status: RED |
| CERTOLIZUMAB PEGOL | 200mg pre-filled syringe | Prescribing should be by a specialist only, in line with NICE and/or local pathways. Adults indications are CCG commissioned, funding is only available with the use of Blueteq initiation and continuation forms. Paediatric indiations are NHSE commissioned. APC traffic light status: RED |
| ETANERCEPT | 25mg S/C Injection | Prescribing should be by a specialist only, in line with NICE and/or local pathways. Adults indications are CCG commissioned, funding is only available with the use of Blueteq initiation and continuation forms. Paediatric indiations are NHSE commissioned. Benepali® is currently the brand providing best value in local health economy. APC Policy Statement: Etanercept for all CCG-commissioned indications (2019) APC traffic light status: RED |
| GOLIMUMAB | Pre-filled pen 50mg, 100mg, Pre-filled syringe 50mg | Prescribing should be by a specialist only, in line with NICE and/or local pathways. Adults indications are CCG commissioned, funding is only available with the use of Blueteq initiation and continuation forms. Paediatric indications are NHSE commissioned. NICE TA 220 – Golimumab for the treatment of psoriatic arthritis NICE TA497 – Golimumab for treating non-radiographic axial spondyloarthritis APC traffic light status: RED |
| INFLIXIMAB | Injection 100mg | Prescribing should be by a specialist only, in line with NICE and/or local pathways. Adults indications are CCG commissioned, funding is only available with the use of Blueteq initiation and continuation forms. Paediatric indiations are NHSE commissioned. Inflectra® is currently the brand providing best value in local health economy. APC Policy Statement: Infliximab for all CCG-commissioned indications (2019) APC traffic light status: RED |
| RITUXIMAB | Prescribing should be by a specialist only, in line with NICE and/or local pathways. Adults indications are CCG commissioned, funding is only available with the use of Blueteq initiation and continuation forms. Paediatric indiations are NHSE commissioned. APC Policy Statement: Rituximab biosimilar – August 2019 APC traffic light status: RED | |
| PHOSPHODIESTERASE TYPE-4 INHIBITORS | NOTES | |
| APREMILAST | Tablets 30mg, titration pack | Prescribing should be by a specialist only, in line with NICE and/or local pathways. Adults indications are CCG commissioned, funding is only available with the use of Blueteq initiation and continuation forms. Paediatric indiations are NHSE commissioned. NICE TA 433 -Apremilast for treating active psoriatic arthritis APC Policy Statement: Apremilast (Otezla) for the treating active Psoriatic Arthritis (2017) APC traffic light status: RED |
| Antimetabolites | NOTES | |
| AZATHIOPRINE | Tablets 25mg, 50mg Oral solution 100mg/ml (unlicensed) Injection 50mg | This preparation is RESTRICTED to use by clinicians expert in the use of anti-inflammatory drugs. APC traffic light status: AMBER Prescribing to remain with Specialist until patient is stabilised (usually minimum 3 months). Shared Care Guidelines for approved indications |
| METHOTREXATE | Tablets 2.5mg Injection – 10mg/0.2ml strength (multiple volumes). | NPSA ALERT Methotrexate Summary(2006) NPSA has received reports of prescription and dispensing errors including fatalities. Remember that methotrexate in rheumatoid/inflammatory disease is a weekly dose. National standard for only the 2.5mg strength tablets to be supplied.Patient Resources Information designed specifically for patients: NPSA Methotrexate ALERT(2006) for Patients NPSA Pre-Treatment PIL & Patient Held Monitoring & DosageCardMethotrexate Paeds SCGAPC traffic light status: AMBER Shared Care Guidelines for approved indications[ prettyfilelink size=”” src=”https://surreyandsussex.nhs.uk/wp-content/uploads/2019/11/POST-APC-Shared-Care-Agreement-Communication-Sheet-AS-3.docx” type=”doc”]Shared Care Agreement Communication Form[/prettyfilelink] Injection RESTRICTED for CONSULTANT use only. Caution: Significant interaction with trimethoprim – must not be co-prescribed |
| Calcineurin Inhibitors and Related Drugs | NOTES | |
| CICLOSPORIN | Capsules 10mg, 25mg, 50mg, 100mg Liquid 100mg/ml | Prescribe by brand name but avoid high cost products, such as Neoral. APC traffic light status: AMBER Prescribing to remain with Specialist until patient is stabilised (usually minimum 3 months). Shared Care Guidelines for approved indications |
| Aminosalicylates | NOTES | |
| SULFASALAZINE | Tablets 500mg | APC traffic light status: AMBER Prescribing to remain with Specialist until patient is stabilised (usually minimum 3 months). Shared Care Guidelines for approved indications |
| BNF CODE – 10.2 HYPERURICAEMIA AND GOUT | ||
| ALKALOIDS – Plant Alkaloids | NOTES | |
| COLCHICINE | Tablets 500micrograms | |
| XANTHINE OXIDASE INHIBITORS | NOTES | |
| ALLOPURINOL | Tablets 100mg, 300mg | |
| HYPERURICAEMIA associated with CYTOTIXIC DRUGS | NOTES | |
| RASBURICASE | Injection 1.5mg | RESTRICTED for ONCOLOGY use only APC traffic light status: RED |
| FEBUXOSTAT | Tablets 80mg, 120mg | RESTRICTED for patients INTOLERANT or ALLERGIC to Allopurinol (as per NICE Guidance) NICE TA164: Febuxostat for the management MHRA / CHM Advice on Hypersensitivity APC Policy Statement: Febuxostat for the management of chronic hyperuricaemia in gout (2018) APC traffic light status: GREEN |
| BNF CODE – 10.3 NEUROMUSCULAR DISORDERS | ||
| XANTHINE OXIDASE INHIBITORS | NOTES | |
| RILUZOLE | Tablets, 50mg | APC Policy Statement: Riluzole for the treatment of Motor Neurone Disease (2018) NICE TA20: Guidance on the use of Riluzole (Rilutek) for the treatment of Motor Neurone Disease APC traffic light status: AMBER Link to Shared Care Guideline for approved indications |
| BNF CODE – 10.3.2 Myasthenia Gravis and Lambert-Easton Myasthenic Syndrome | ||
| NEOSTIGMINE | Tablets 15mg Injection 2.5mg/ml | |
| PYRIDOSTIGMINE BROMIDE | Tablets 60mg | |
| BNF CODE – 10.3.3 Nocturnal Leg Cramps | ||
| QUNINE SULPHATE | Tablets 200mg, 300mg | Due to risks of toxicity, quinine is not recommended for routine treatment of cramps unless they cause regular disruption to sleep, are very painful or frequent. Only prescribe when other treatable causes of cramps have been excluded and when non-pharmacological treatments have not worked. |
| BNF CODE – 10.3.4 Spasticity | ||
| CANNABINOIDS | NOTES | |
| There are currently no cannabis based products on the SaSH formulary. For further information see the ‘updates’ section of the formulary webpage or contact the formulary pharmacist. | ||
| MUSCLE RELAXANTS – Directly Acting | NOTES | |
| DANTROLENE | Capsules 25mg | |
| MUSCLE RELAXANTS – Centrally Acting | NOTES | |
| BACLOFEN | Tablets 10mg Liquid 5mg in 5ml | APC traffic light status: GREEN |
| METHOCARBAMOL | Tablets 750mg | |
| TIZANIDINE HYDROCHLORIDE | Tablets 2mg, 4mg | RESTRICTED for NEUROLOGY use only No information sheet. Prescribe for minimum of 4 months before transfer to primary care. APC Policy Statement: Tizanidine for treatment of spasticity (2018) APC traffic light status: BLUE |
| Benzodiazepines | NOTES | |
| DIAZEPAM | Tablets 2mg, 5mg Liquid 2mg in 5ml, 5mg in 5ml, 10mg in 5ml | |
| BNF CODE – 10.4 PAIN AND INFLAMMATION IN MUSCULOSKELETAL DISORDERS | ||
ANALGESICS – Non-Steroidal Anti-Inflammatory Drugs | NOTES | |
| MHRA Safety Alerts: | MHRA Safety Alert – Cox-2 inhibitors and NSAIDs; Cardiovascular safety | |
| APC Guidelines: | The Pharmacological Management of Persistent Non Malignant Pain in Adults Safer Prescribing of NSAIDs – GI and CV safety considerations | |
| CELECOXIB | Capsules 100mg, 200mg | APC Policy Statment: Celecoxib for the treatment of pain and inflammation (2019) Preferred COX II inhibitor for licensed indications: Osteoarthritis, Rheumatoid arthritis, Ankylosing Spondiolitis, acute gouty arthritis APC traffic light status: GREEN |
| DICLOFENAC | Suppositories 12.5mg, 25mg, 50mg, 100mg Injection 75mg 1.16% gel
| Diclofenac is associated with an increased risk of thrombotic events (stroke and myocardial infarction), compared with other non-selective NSAIDs Oral diclofenac is restricted to Rheumatology for patients who cannot tolerate or unresponsive to other NSAIDs APC traffic light status: GREEN |
| ETODOLAC | Tablets SR 600mg | |
| ETORICOXIB | Tablets 30mg, 60mg | APC Policy Statement: Etoricoxib for pain and inflammation (2019) 2nd line COX II inhibitor for licensed indications: Osteoarthritis, Rheumatoid arthritis, Ankylosing Spondiolitis, acute gouty arthritis APC traffic light status: GREEN |
| IBUPROFEN | Tablets 200mg, 400mg, SR 800mg Syrup 100mg/5ml Gel 5% | APC traffic light status: GREEN |
| INDOMETACIN | Capsules 25mg, 50mg, SR Capsules 75mg | |
| KETOPROFEN | Capsules 50mg, MR capsules 100mg, 200mg | |
| MEFENAMIC ACID | Capsules 250mg Tablets 500mg | |
| NABUMETONE | Tablets 500mg | |
| NAPROXEN | Tablets 250mg | APC traffic light status: GREEN |
| RUBEFACIENTS, TOPICAL NSAIDS, CAPSAICIN | NOTES | |
| NHSE Guidance | NHSE – do not routinely prescribe rubefacients | |
| CAPSAICIN | 0.075% Cream (45g) | Restricted : For use in post herpatic neuralgia only |
| BNF CODE – 10.5 SOFT TISSUE AND JOINT DISORDERS | ||
| CORTICOSTEROIDS | NOTES | |
| DEXAMETHASONE (Contains dexamethasone sodium phosphate 4mg in 1 ml) | Injection 6.6mg in 2ml | INTRA ARTICULAR |
| METHYLPREDNISOLONE | Injection 40mg in 1ml, 80mg in 2ml, 120mg in 3ml (Depo-Medrone) | INTRA ARTICULAR |
| METHYLPREDNISOLONE with LIDOCAINE | 40mg + 10mg in 1ml, 80mg + 20mg in 2ml (Depo-Medrone with lidocaine) | RESTRICTED for INTRA – ARTICULAR USE |
| TRIAMCINOLONE ACETONIDE | Injection 10mg in 1ml, 40mg in 1ml, 50mg in 5ml | RESTRICTED for INTRA – ARTICULAR USE ONLY |
| BNF CODE – 10.5.2 Soft Tissue Disorders | ||
| ENZYMES | NOTES | |
| COLLAGENASE CLOSTRIDIUM HISTOLYTICUM | powder and solvent for injection, 900micrograms (Xiapex) | NOTE: The product manufacturer are discontinuing the sale of Xiapex by the end of December 2019. There are no other CCH licensed products in the UK. NICE TA459 – Collagenase clostridium histolyticum for treating Dupuytren’s contracture APC traffic light status: RED |
| HYALURONIDASE | 1500 units Injection | |
1. Gastro-Intestinal System | 2. Cardiovascular System | 3. Respiratory System | 4. Central Nervous System | 5. Antimicrobials | 6. Endocrine System | 7. Obstetrics, Gynaecology & Urology | 8. Malignant Disease & Immunosuppression | 9. Nutrition & Blood | 10. Musculoskelatal & Joint Diseases | 11. Opthalmology | 12. Ear, Nose & Oropharynx | 13. Dermatology | 14. Immunology & Vaccines | 15. Anaesthetics | GP Centre Home