BNF Chapter 10

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. Musculoskeletal & Joint Diseases | 11. Opthalmology | 12. Ear, Nose & Oropharynx | 13. Dermatology | 14. Immunology & Vaccines | 15. Anaesthetics |  GP Centre Home


Musculoskeletal & Joint Diseases

1 ARTHRITIS
Surrey APC PathwaysRheumatoid 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 Policy statement: Hydroxychloroquine for the treatment of rheumatology and dermatology conditions

APC traffic light status: BLUE

LEFLUNOMIDE Tablets 10mg, 20mg, 100mgRESTRICTED for RHEUMATOLOGY use only

Link to Shared Care Guideline for approved indications

Shared Care Agreement Communication Form

APC traffic light status: AMBER

PENICILLAMINETablets 125mgAPC Policy Statement: Penicillamine for the treatment of rheumatoid arthritis

APC traffic light status: RED

SODIUM AUROTHIOMALATEInjection 10mg in 0.5ml, 20mg in 0.5ml, 50mg in 0.5mlAPC Policy Statement: Intramuscular sodium aurothiomalate for the treatment of rheumatoid arthritis (2018)

APC traffic light status: RED

IMMUNOSUPPRESSANTS – Interleukin InhibitorsNOTES
IXEKIZUMAB80mg/1ml solution for injectionNICE 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 Policy Statement: Ixekizumab for treating active psoriatic arthritis after inadequate response to DMARDs (2018)

APC traffic light status: RED

SARILUMAB200mg/1.14ml, 150mg/1.14mlNICE 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

SECUKINUMABPre-filled pen or syringe 150mgPrescribing 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 407 – Secukinumab for active ankylosing
spondylitis after treatment with nonsteroidal
anti-inflammatory drugs or TNF-alpha inhibitors

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

TOCILIZUMAB162mg/0.9ml solution for injection pre-filled penNICE 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

USTEKINUMABInjection 45mgPrescribing 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 InhibitorsNOTES
BARICITINIBTablets, 2mg & 4mgPrescribing 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 Policy Statement: Baricitinib for the treatment of moderate to severe Rheumatoid Arthritis (2017)

APC traffic light status: RED

TOFACITINIB Tablets 5mgPrescribing 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 InhibitorsNOTES
ABATACEPT40mg S/C pre-filled pen or syringePrescribing 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 TA373 – Abatacept, adalimumab, etanercept and tocilizumab for treating juvenile idiopathic arthritis

NICE TA 195Adalimumab, etanercept, infliximab, rituximab and abatacept for the treatment of rheumatoid arthritis after the failure of a TNF inhibitor

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

APC traffic light status: RED

IMMUNOSUPPRESSANTS – Tumor Necrosis Factor (TNF) Alpha Inhibitors NOTES
BiologicsBiologics 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.
ADALIMUMAB40mg S/C pre-filled syringePrescribing 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.

NICE TA 195-Adalimumab, etanercept, infliximab, rituximab and abatacept for the treatment of rheumatoid arthritis after the failure of a TNF inhibitor

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

APC Policy Statement: Adalimumab for all CCG-commissioned indications (2019)

APC traffic light status: RED

CERTOLIZUMAB PEGOL200mg pre-filled syringePrescribing 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 415-Certolizumab pegol for treating rheumatoid arthritis after inadequate response to a TNF-alpha inhibitor

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 TA 383 -TNF-alpha inhibitors for ankylosing spondylitis and non-radiographic axial spondyloarthritis 

NICE TA 445 – Certolizumab pegol and secukinumab for treating active psoriatic arthritis after inadequate response to DMARDs

APC traffic light status: RED

ETANERCEPT25mg S/C InjectionPrescribing 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.

NICE TA 195 – Adalimumab, etanercept, infliximab, rituximab and abatacept for the treatment of rheumatoid arthritis after the failure of a TNF inhibitor

APC Policy Statement: Etanercept for all CCG-commissioned indications (2019)

APC traffic light status: RED

GOLIMUMABPre-filled pen 50mg, 100mg, Pre-filled syringe 50mgPrescribing 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 TA 225 – Golimumab for the treatment of rheumatoid arthritis after the failure of previous disease-modifying anti-rheumatic drugs

NICE TA 383 – TNF-alpha inhibitors for ankylosing spondylitis and non-radiographic axial spondyloarthritis

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 TA497 – Golimumab for treating non-radiographic axial spondyloarthritis

APC traffic light status: RED

INFLIXIMABInjection 100mgPrescribing 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.

NICE TA 195 – Adalimumab, etanercept, infliximab, rituximab and abatacept for the treatment of rheumatoid arthritis after the failure of a TNF inhibitor

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

APC Policy Statement: Infliximab for all CCG-commissioned indications (2019)

APC traffic light status: RED

RITUXIMABPrescribing 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 195 – Adalimumab, etanercept, infliximab, rituximab and abatacept for the treatment of rheumatoid arthritis after the failure of a TNF inhibitor

APC Policy Statement: Rituximab biosimilar – August 2019

APC traffic light status: RED

PHOSPHODIESTERASE TYPE-4 INHIBITORSNOTES
APREMILASTTablets 30mg, titration packPrescribing 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

AntimetabolitesNOTES
AZATHIOPRINETablets 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

Shared Care Agreement Communication Form

METHOTREXATETablets 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[

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Injection RESTRICTED for CONSULTANT use only. 

Caution: Significant interaction with trimethoprim – must not be co-prescribed

Calcineurin Inhibitors and Related DrugsNOTES
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

Shared Care Agreement Communication Form

AminosalicylatesNOTES
SULFASALAZINE Tablets 500mgAPC traffic light status: AMBER

Prescribing to remain with Specialist until patient is stabilised (usually minimum 3 months).

Shared Care Guidelines for approved indications

Shared Care Agreement Communication Form

BNF CODE – 10.2 HYPERURICAEMIA AND GOUT
 ALKALOIDS – Plant AlkaloidsNOTES
COLCHICINE Tablets 500micrograms
 XANTHINE OXIDASE INHIBITORSNOTES
ALLOPURINOL Tablets 100mg, 300mg
HYPERURICAEMIA associated with CYTOTIXIC DRUGSNOTES
RASBURICASE Injection 1.5mgRESTRICTED for ONCOLOGY use only

APC traffic light status: RED

FEBUXOSTAT  Tablets 80mg, 120mgRESTRICTED for patients INTOLERANT or ALLERGIC to Allopurinol (as per NICE Guidance)

NICE TA164: Febuxostat for the management
of hyperuricaemia in people with gout

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 INHIBITORSNOTES
RILUZOLETablets, 50mgAPC 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

Shared Care Agreement Communication Form

BNF CODE – 10.3.2 Myasthenia Gravis and Lambert-Easton Myasthenic Syndrome
NEOSTIGMINE Tablets 15mg

Injection 2.5mg/ml

PYRIDOSTIGMINE BROMIDETablets 60mg
BNF CODE – 10.3.3 Nocturnal Leg Cramps
QUNINE SULPHATETablets 200mg, 300mgDue 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
 CANNABINOIDSNOTES
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 ActingNOTES
DANTROLENECapsules 25mg
MUSCLE RELAXANTS – Centrally ActingNOTES
BACLOFENTablets 10mg

Liquid 5mg in 5ml

APC traffic light status: GREEN
METHOCARBAMOL Tablets 750mg
TIZANIDINE HYDROCHLORIDE Tablets 2mg, 4mgRESTRICTED 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

 BenzodiazepinesNOTES
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

CELECOXIBCapsules 100mg, 200mgAPC 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

DICLOFENACSuppositories 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

ETODOLACTablets SR 600mg
ETORICOXIBTablets 30mg, 60mgAPC 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

IBUPROFENTablets 200mg, 400mg, SR 800mg

Syrup 100mg/5ml

Gel 5%

APC traffic light status: GREEN
INDOMETACINCapsules 25mg, 50mg, SR Capsules 75mg
KETOPROFENCapsules 50mg, MR capsules 100mg, 200mg
MEFENAMIC ACIDCapsules 250mg

Tablets 500mg

NABUMETONETablets 500mg
NAPROXENTablets 250mgAPC traffic light status: GREEN
RUBEFACIENTS, TOPICAL NSAIDS, CAPSAICINNOTES
 NHSE GuidanceNHSE – do not routinely prescribe rubefacients
CAPSAICIN0.075% Cream (45g) Restricted : For use in post herpatic neuralgia only
BNF CODE – 10.5 SOFT TISSUE AND JOINT DISORDERS
CORTICOSTEROIDSNOTES
DEXAMETHASONE
(Contains dexamethasone sodium phosphate 4mg in 1 ml)
Injection 6.6mg in 2mlINTRA ARTICULAR

Dexamethasone memo March 2017

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 ACETONIDEInjection 10mg in 1ml, 40mg in 1ml, 50mg in 5mlRESTRICTED
for INTRA – ARTICULAR USE ONLY
BNF CODE – 10.5.2 Soft Tissue Disorders
ENZYMESNOTES
COLLAGENASE CLOSTRIDIUM HISTOLYTICUMpowder 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 Policy Statement – Collagenase clostridium histolyticum (CCH, Xiapex®) for treating Dupuytren’s Contracture (2017)

APC traffic light status: RED

HYALURONIDASE1500 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