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 Formulary Chapter 10: Musculoskeletal and joint diseases - Full Chapter
Notes:

Prescribing Guidance

Please see our Prescribing Guidelines page for all prescribing guidance relating to this chapter.

Shared Care Agreements

Please see our Shared Care Agreements page for all shared care agreements (SCAs) relating to this chapter.

Self-care

Many of the products in this chapter are available for purchase over-the-counter, and patients are encouraged to self-care, with the support of their community pharmacist, in the first instance.

For further information on self-care & the NHS, please refer to https://www.england.nhs.uk/medicines/conditions-for-which-over-the-counter-items-should-not-routinely-be-prescribed/

 Details...
10.01  Drugs used in rheumatic diseases and gout
 note 

NICE NG100 July 2018 Rheumatoid arthritis in adults: management

10.01.01  Non-steroidal anti-inflammatory drugs
 note 

NHSE Acute use of non-steroidal anti-inflammatory drugs (NSAIDs) in people with or at risk of COVID-19 (14/04/2020)

General Information on prescribing NSAIDS:

  • See NICE Clinical Knowledge Summary Prescribing Issues - NSAIDs August 2018
  • See MHRA guidance on Cardiovascular Safety of Cox-2 inhibitors and non-selective NSAIDs 
  • NSAIDs should be used at the LOWEST effective dose for the SHORTEST possible time. Patients on chronic non-selective NSAIDs - consider need for gastro-protection e.g PPIs
  • NSAIDs may worsen asthma, heart failure, hypertension, renal impairment, peptic ulceration; they are contra-indicated if aspirin or any other NSAID has precipitated attacks of asthma.
Ibuprofen
(Oral)
View adult BNF View SPC online
First Choice
traffic lightSelf
  • 200mg, 400mg and 600mg tablets
  • Oral suspension
  • For minor conditions associated with pain and inflammation, patients should self-care in the first instance.

 

 
Naproxen
(Tablets)
View adult BNF View SPC online
Second Choice
traffic lightGreen
  • 250mg and 500mg tablets
  • Oral suspension and effervescent tablets available 
  • No evidence for GI benefit of EC preparation - use standard tablets.
 
 
Diclofenac
(Oral)
View adult BNF View SPC online
Third Choice
  • Green - Salisbury & Swindon.
  • Red - RUH - Oral diclofenac is only included on the formulary for maternity services for a short course of inpatient treatment post delivery.
  • 25mg & 50mg gastro-resistant tablets
  • Cardiovascular risk is higher with diclofenac than other non-selective NSAIDs and similar to selective COX-2 inhibitors.
  • Oral diclofenac should be used for short courses only
 
Link  MHRA DSU Dec 2014: Diclofenac: new contraindications and warnings
 
Diclofenac
(Rectal & Injection)
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Third Choice
traffic lightGreen
  • 12.5mg, 25mg, 50mg and 100mg suppositories
  • 75mg in 3ml injection
  • Cardiovascular risk is higher with diclofenac than other non-selective NSAIDs and similar to selective COX-2 inhibitors.
  • Diclofenac should be used for short courses only.
 
Link  MHRA DSU Dec 2014: Diclofenac: new contraindications and warnings
 
Diclofenac (Akis®)
(Injection)
View adult BNF View SPC online
Third Choice
  • Red GWH ONLY - For the short-term prevention & treatment of post - operative pain.
  • Non- formulary at RUH and SFT
  • 75mg in 1ml injection.
  • Cardiovascular risk is higher with diclofenac than other non-selective NSAIDs and similar to selective COX-2 inhibitors.
  • Diclofenac should be used for short courses only.
 
Link  MHRA DSU Dec 2014: Diclofenac: new contraindications and warnings
 
Celecoxib (Celebrex®)
(Capsule)
View adult BNF View SPC online
Formulary
traffic lightAmber
  • Salisbury only
  • Non formulary in BaNES and Swindon
  • 100mg and 200mg capsules
 
 
Etodolac
(Tablet, capsule)
View adult BNF View SPC online
Formulary
traffic lightAmber
  • Salisbury only
  • Non formulary in BaNES and Swindon
  • 300mg capsules
  • 600mg tablets and 600mg MR tablets
 
 
Etoricoxib
(Tablet)
View adult BNF View SPC online
Formulary
  • Amber- BaNES - Second line for treament of Ankylosing Spondylitis ONLY.
  • Amber - Swindon - Reserved for severe inflammatory arthritis unresponsive or intolerant to other NSAIDS.
  •  Red - GWH ONLY - For the short-term prevention & treatment of post-operative pain in patients with known hypersensitivity to conventional NSAIDs, or patients at high risk of hypersenstivitiy to conventional NSAIDs (e.g. asthmatics).
  • Non formulary - Salisbury.
  • 30mg, 60mg, 90mg and 120mg tablets.
 
Link  MHRA DSU Oct 2016: Etoricoxib (Arcoxia): revised dose recommendation for rheumatoid arthritis and ankylosing spondylitis
 
Indometacin
(Capsules and suppositories)
View adult BNF View SPC online
Formulary
traffic lightGreen
  • BaNES and Swindon only
  • Non formulary in Salisbury
  • 25mg and 50mg
  • 100mg suppositories
 
 
Mefenamic Acid
(Tablets and capsules)
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Formulary
traffic lightGreen
  • 500mg tablets
  • 250mg capsules
 
 
Meloxicam
(Tablets)
View adult BNF View SPC online
Formulary
  • Green - Swindon - Second-line after conventionals NSAIDs.
  • Amber - BaNES and Salisbury.
  • Red - GWH ONLY - For the short-term prevention and treatment of post-operative pain in patients at high risk of bleeding with conventional NSAIDs (e.g. adult tonsillectomy, colorectal surgery, etc).
  • 7.5mg and 15mg tablets. 
 
 
Phenylbutazone
View adult BNF View SPC online
Formulary
traffic lightRed
  • RUH and GWH - Restricted for prescribing by Consultant Rheumatologist for named patients with ankylosing spondylitis.
  • SFT - Restricted for prescribing by Consultant Rheumatologist for named patients with ankylosing spondylitis stabilised on therapy. No new patients.

 

 
 
10.01.01  Aspirin
10.01.02  Corticosteroids
 note 

Treatment with corticosteroids in rheumatic diseases should be reserved for specific indications e.g. when other anti-inflammatory drugs are unsuccessful. 

Corticosteroids can induce osteoporosis.

See MHRA Drug Safety Update Aug 2017 for information and advice on the rare risk of central serous chorioretinopathy with local and systemic administration of corticosteroids.

10.01.02.01  Systemic corticosteroids to top
Prednisolone
(Tablet)
View adult BNF View SPC online
First Choice
traffic lightGreen
  • 5mg tablets
  • Do not prescribe EC tablets
  • Plain prednisolone tablets 5mg may be crushed and dispersed in water and administered orally or via NG/PEG tube (off-label).
  • Soluble tablets 5mg are considerably more expensive than both plain tablets 5mg and oral solution 1mg/ml.
 
10.01.02.02  Local corticosteroids injections
Methylprednisolone Acetate
(Depo-Medrone®)
(Injection)
View adult BNF View SPC online
First Choice
traffic lightGreen
  • 120mg/3ml, 40mg/1ml and 80mg/2ml injection

 

 
Triamcinolone Acetonide
(Injection)
View adult BNF View SPC online
First Choice
traffic lightGreen
  • Adcortyl® Intra-articular/Intradermal injection 10mg in 1mL
  • Kenalog® injection/Intramuscular injection 40mg in 1mL

June 2020 Update: Adcortyl 10mg in 1mL vials have been discontinued.

Adcortyl 50mg in 5mL vials remain available.  Kenalog 40mg in 1mL vials are also available. When prescribing and administering consider indication and most appropriate product for required dose. Ensure correct volume is drawn up. Ensure any remaining contents of vial are discarded and NOT used for multiple patients.

 
Hydrocortisone acetate
(Hydrocortistab®)
(Injection)
View adult BNF View SPC online
Formulary
traffic lightGreen
  • 25mg/1ml injection
 
 
10.01.03  Drugs which suppress the rheumatic disease process
Apremilast (Otezla®)
(Tablet)
View adult BNF View SPC online
Formulary
traffic lightRed
High Cost Medicine
CCG
Homecare
BlueTeq
  • Titration pack, tablets, f/c, 14-day starter pack of apremilast 4 x 10 mg (pink) with 4 x 20 mg (brown) and 19 x 30 mg (beige).  
  • Tablet, f/c, apremilast 30 mg (beige) for maintenance treatment.

 

 

 
Link  MHRA DSU Jan 2017: Apremilast (Otezla ¥): risk of suicidal thoughts and behaviour
Link  NICE TA433 Apremilast for treating active psoriatic arthritis Feb 2017
 
Baricitinib (Olumiant®)
(Tablet)
View adult BNF View SPC online
Formulary
traffic lightRed
High Cost Medicine
CCG
BlueTeq
  • 2mg and 4mg tablets
  • CCG commissioned as per NICE TA466
 
Link  MHRA DSU Mar 2020: Baricitinib (Olumiant▼): risk of venous thromboembolism
Link  NICE TA466 August 2017: Baricitinib for moderate to severe rheumatoid arthritis
 
Tofacitinib citrate
(Xeljanz®)
(Tablet)
View adult BNF View SPC online
Formulary
traffic lightRed
High Cost Medicine
CCG
BlueTeq
  • 5mg and 10mg tablets
  • CCG commissioned as per NICE TA543 and TA480
 
Link  MHRA DSU Mar 2020: Tofacitinib (Xeljanz▼): new measures to minimise risk of venous thromboembolism and of serious and fatal infections
Link  NICE TA480: Tofacitinib for moderate to severe rheumatoid arthritis
Link  NICE TA543 October 2018: Tofacitinib for treating active psoriatic arthritis after inadequate response to DMARDs
 
Upadacitinib (Rinvoq®)
(Tablet)
View adult BNF View SPC online
Formulary
traffic lightRed
High Cost Medicine
CCG
BlueTeq
  • 15mg modified-release tablets
  • CCG commissioned as per NICE TA665
 
Link  NICE TA665: Upadacitinib for treating severe rheumatoid arthritis
 
10.01.03  Penicillamine
Penicillamine
(Tablet)
View adult BNF View SPC online
Formulary
  •  Amber with Shared Care - BaNES, Salisbury & Swindon (except Swindon patients monitored via the DAWN system and provided with prescriptions by GWH)
  •  Red - Swindon DAWN patients
  • 125mg and 250mg tablets
  • Please refer to our DMARD Shared Care and Monitoring Guidance for your respective locality for further information
 
Link  3Ts Rheumatology Penicillamine Tablets Shared Care Document
Link  BSW Summary of Shared Care Guidelines and Monitoring of Disease Modifying Drugs (DMARDs) in Adults Feb 2021 Rheumatology, Dermatology, Gastroenterology and Neurology
Link  NICE NG100 Rheumatoid arthritis in adults: management July 2018
 
10.01.03  Antimalarials
Hydroxychloroquine
(Tablet)
View adult BNF View SPC online
Formulary
  • 200mg tablets

  •  Amber with Shared Care - BaNES, Salisbury & Swindon (except Swindon patients monitored via the DAWN system and provided with prescriptions by GWH)
  •  Red - Swindon DAWN patients
  • Please refer to our DMARD Shared Care and Monitoring Guidance for your respective locality for further information

 

 
Link  3Ts Hydroxychloroquine Shared Care Document
Link  BSW Summary of Shared Care Guidelines and Monitoring of Disease Modifying Drugs (DMARDs) in Adults Feb 2021 Rheumatology, Dermatology, Gastroenterology and Neurology
 
10.01.03  Drugs affecting the immune response to top
Azathioprine
(Tablet)
View adult BNF View SPC online
Formulary
  •  Amber with Shared Care - BaNES & Wiltshire
  •  Red - Swindon DAWN patients
  • Please refer to our DMARD Shared Care and Monitoring Guidance for further information (link below)
  • 25mg and 50mg tablets
 
Link  BSW Summary of Shared Care Guidelines and Monitoring of Disease Modifying Drugs (DMARDs) in Adults Feb 2021 Rheumatology, Dermatology, Gastroenterology and Neurology
 
Ciclosporin
(Capsule)
View adult BNF View SPC online
Formulary
traffic lightRed
  •  10mg, 25mg, 50mg and 100mg capsules

 

 

 

 
Link  BSW Summary of Shared Care Guidelines and Monitoring of Disease Modifying Drugs (DMARDs) in Adults Feb 2021 Rheumatology, Dermatology, Gastroenterology and Neurology
 
Leflunomide
(Tablet)
View adult BNF View SPC online
Formulary
  •  Amber with Shared Care - BaNES and Wiltshire
  •  Red - Swindon DAWN patients
  • Please refer to our DMARD Shared Care and Monitoring Guidance below for further information
  • 10mg, 15mg, 20mg and 100mg tablets
 
Link  EMC Risk Minimisation materials: Arava (leflunomide)
Link  BSW Summary of Shared Care Guidelines and Monitoring of Disease Modifying Drugs (DMARDs) in Adults Feb 2021 Rheumatology, Dermatology, Gastroenterology and Neurology
 
Methotrexate
(Tablet)
View adult BNF View SPC online
Formulary
  • 2.5mg tablets ONLY. There should be no prescribing of 10mg tablets. Please refer to NPSA guidance on reducing the risks of oral methotrexate. Patients should have patient held records while they are receiving treatment with any DMARD requiring regular monitoring (record cards and GP protocol advice available from rheumatology).
  • The label on prescribed/dispensed methotrexate should state the instructions clearly, for example: ‘methotrexate 2.5mg tablets: (number of tablets) to be taken as a single dose ONCE A WEEK on XXX  DAY’.
  • Note: Folic Acid 10mg is usually given ONCE A WEEK with methotrexate to reduce side effects. It should NOT be taken on the same day as the methotrexate.
  •  Amber with Shared Care - BaNES and Wiltshire
  •  Red - Swindon DAWN patients.
  • Please refer to our DMARD Shared Care and Monitoring Guidance below for further information.
 
Link  BSW Summary of Shared Care Guidelines and Monitoring of Disease Modifying Drugs (DMARDs) in Adults Feb 2021 Rheumatology, Dermatology, Gastroenterology and Neurology
Link  MHRA DSU Sep 2020: Methotrexate once-weekly for autoimmune diseases: new measures to reduce risk of fatal overdose due to inadvertent daily instead of weekly dosing
 
Methotrexate
(Injection)
View adult BNF View SPC online
Formulary
  • When self-adminstering subcutaneous methotrexate, patients should be maintained on the product they were initiated / trained on. Local formulary brands listed below: 
  • Metoject® 50mg/ml Injection prefilled pen 0.15ml (7.5mg), 0.2ml (10mg), 0.3ml (15mg), 0.4ml (20mg), 0.5ml (25mg), 0.6ml (30mg)
    Metoject is a pre-filled pen type device Local brand of choice
    Instruction guide for Metoject
  • Zlatal® 25mg/ml Injection prefilled syringe 0.3ml (7.5mg), 0.4ml (10mg), 0.5ml (12.5mg), 0.6ml (15mg), 0.7ml (17.5mg), 0.8ml (20mg), 0.9ml (22.5mg), 1ml (25mg)
    Zlatal is a prefilled syringe For those who need to use a syringe and needle
    Instruction guide for Zlatal
  •  Amber with Shared Care BaNES & Wiltshire patients.
  • Red for Swindon DAWN patients. 
  • Please refer to our DMARD Shared Care and Monitoring Guidance for  further information.
 
Link  BSW Guidance - Sharps Disposal and Prescribing Sharps Bins on FP10
Link  GWH Methotrexate Subcutaneous Injection Shared Care Document
Link  Methotrexate subcut Injection (RUH)
Link  SFT Methotrexate Subcutaneous Injections Shared Care Document
Link  MHRA DSU Sep 2020: Methotrexate once-weekly for autoimmune diseases: new measures to reduce risk of fatal overdose due to inadvertent daily instead of weekly dosing
 
Mycophenolate
(Tablet)
View adult BNF View SPC online
Formulary
  •  Amber with Shared Care - BaNES & Wiltshire patients
  •  Red - Swindon DAWN patients
  • Please refer to our DMARD Shared Care and Monitoring Guidance below for further information
  • 500mg tablets
 
Link  BSW Summary of Shared Care Guidelines and Monitoring of Disease Modifying Drugs (DMARDs) in Adults Feb 2021 Rheumatology, Dermatology, Gastroenterology and Neurology
Link  MHRA DSU Dec 2015: Mycophenolate mofetil, mycophenolic acid: new pregnancy-prevention advice for women and men
Link  MHRA DSU Feb 2018: Mycophenolate mofetil, mycophenolic acid: updated contraception advice for male patients
Link  MHRA DSU Jan 2015: Mycophenolate mofetil (CellCept) and mycophenolic acid: risk of hypogammaglobulinaemia and risk of bronchiectasis
 
10.01.03  Cytokine modulators
Abatacept (Orencia®)
(Injection)
View adult BNF View SPC online
Formulary
traffic lightRed
High Cost Medicine
NHS England
CCG
BlueTeq
  • 250mg vial, powder for reconstitution. Injection 125mg pre-filled syringe
  • Commissioned by CCG for:
    • The treatment of rheumatoid arthritis in line with NICE TA195, TA375.
  •  Commissioned by NHS England From Specialist Centres Only for:
    • Juvenile idiopathic arthritis in line with NICE TA373.
    • Paediatric indications where an adult NICE TA is available.
  • Check individual Trust contracting arrangements.

 

 
Link  NICE TA195 August 2010: Adalimumab, etanercept, infliximab, rituximab and abatacept for the treatment of rheumatoid arthritis after the failure of a TNF inhibitor
Link  NICE TA373: Abatacept, adalimumab, etanercept and tocilizumab for treating juvenile idiopathic arthritis
Link  NICE TA375: Rheumatoid arthritis not previously treated with DMARDs or after conventional DMARDs only have failed
 
Adalimumab
(Imraldi®Amgevita®Humira®)
(Injection)
View adult BNF View SPC online
Formulary
traffic lightRed
High Cost Medicine
NHS England
CCG
BlueTeq
  • Injection 40mg prefilled syringe, prefilled pen
  • Prescribe by brand. Biosimilar first-line option.  Imraldi® first line biosimilar across BSW
  • For rheumatoid arthritis in accordance with NICE TA375.
  • Commissioned by NHS England From Specialist Centres Only for:
    • Juvenile idiopathic arthritis in line with NICE TA373.
    • Paediatric indications where an adult NICE TA is available
  • Check Trust contracting arrangements.

 

 
Link  MHRA DSU April 2014: Tumour necrosis factor alpha inhibitors: risk of tuberculosis—screen all
Link  NICE TA195: Rheumatoid arthritis - after failure of a TNF inhibitor
Link  NICE TA199: Psoriatic arthritis
Link  NICE TA373: Abatacept, adalimumab, etanercept and tocilizumab for treating juvenile idiopathic arthritis
Link  NICE TA375: Rheumatoid arthritis not previously treated with DMARDs or after conventional DMARDs only have failed
Link  NICE TA383: TNF-alpha inhibitors for ankylosing spondylitis and non-radiographic axial spondyloarthritis
 
Belimumab (Benlysta® )
(Injection)
View adult BNF View SPC online
Formulary
traffic lightRed
High Cost Medicine
NHS England
BlueTeq
  • Intravenous infusion, powder for reconstitution 120mg vial; 400mg vial
  • Commissioned by NHSE at specialist centres e.g RUH
  • Non Formulary at GWH and SFT 
 
Link  NICE TA397: Belimumab for treating active autoantibody-positive systemic lupus erythematosus
Link  MHRA Drug Safety Update (Apr 2019):Belimumab (Benlysta¥): increased risk of serious psychiatric events seen in clinical trials
 
Certolizumab Pegol
(Cimzia®)
(Injection)
View adult BNF View SPC online
Formulary
traffic lightRed
High Cost Medicine
CCG
BlueTeq
  • Prefilled syringe 200mg.
  • Use in accordance with NICE guidance and local pathways for RA, AS or PSA.
  • Not routinely commissioned by NHS England for paediatric indications - see NHS England drugs list. 

 

 

 
Link  MHRA DSU April 2014: Tumour necrosis factor alpha inhibitors: risk of tuberculosis—screen all
Link  NICE TA375: Rheumatoid arthritis not previously treated with DMARDs or after conventional DMARDs only have failed
Link  NICE TA383: TNF-alpha inhibitors for ankylosing spondylitis and non-radiographic axial spondyloarthritis
Link  NICE TA415: Certolizumab pegol for treating rheumatoid arthritis after inadequate response to a TNF-alpha inhibitor
Link  NICE TA445 : Certolizumab pegol and secukinumab for treating active psoriatic arthritis after inadequate response to DMARD
 
Etanercept
(Benepali®, Enbrel®,Erelzi® )
(Injection)
View adult BNF View SPC online
Formulary
traffic lightRed
High Cost Medicine
NHS England
CCG
BlueTeq
  • 25mg or 50mg solution for injection in pre-filled syringe or pen
  • Prescribe by BRAND. Biosimilar should be used 1st line. BENEPALI® is the biosimilar brand used locally in BSW. First-line etanercept brand. 

Commissioned by CCG for:

  • Rheumatoid arthritis in accordance with NICE TA 375 and local pathway.
  • Ankylosing spondylitis in accordance with NICE TA383 and local pathway
  • Psoriatic arthritis in accordance with NICE TA199 and local pathway

Commissioned by NHS England from specialist centres only for:

  • Juvenile idiopathic arthritis in line with NICE TA373.
  • Paediatric patients in line with adult NICE TAs.
  • Check Trust contracting arrangements.

 

 
Link  MHRA DSU April 2014: Tumour necrosis factor alpha inhibitors: risk of tuberculosis—screen all
Link  NICE TA195: rheumatoid arthritis after the failure of a TNF inhibitor
Link  NICE TA199: Psoriatic arthritis
Link  NICE TA375: Rheumatoid arthritis not previously treated with DMARDs or after conventional DMARDs only have failed
Link  NICE TA383: TNF-alpha inhibitors for ankylosing spondylitis and non-radiographic axial spondyloarthritis
 
Golimumab (Simponi®)
(Injection)
View adult BNF View SPC online
Formulary
traffic lightRed
High Cost Medicine
NHS England
CCG
BlueTeq
  • 50mg or 100mg pre-filled pen or syringe
  • Commissioned by NHS England for paediatric indications.
  • Commissioned by CCG for:
    • Psoriatic arthritis in accordance with NICE TAs and local pathway.
    • Rheumatoid arthritis in accordance with NICE TAs and local pathway.
    • Ankylosing spondylitis in accordance with NICE TAs and local pathway.
 
Link  MHRA DSU April 2014: Tumour necrosis factor alpha inhibitors: risk of tuberculosis—screen all
Link  NICE TA220 April 2011: Golimumab for the treatment of psoriatic arthritis
Link  NICE TA375 January 2016: Adalimumab, etanercept, infliximab, certolizumab pegol, golimumab, tocilizumab and abatacept for rheumatoid arthritis not previously treated with DMARDs or after conventional DMARDs only have failed
Link  NICE TA383 February 2016: TNF-alpha inhibitors for ankylosing spondylitis and non-radiographic axial spondyloarthritis
Link  NICE TA497: Golimumab for treating non-radiographic axial spondyloarthritis
 
Infliximab
(Remsima®Inflectra®Remicade®)
(Infusion)
View adult BNF View SPC online
Formulary
traffic lightRed
High Cost Medicine
NHS England
CCG
BlueTeq
  • 100mg powder for concentrate for solution for infusion
  • All products should be prescribed by brand. Biosimilars should be used 1st line.
  • For rheumatoid arthritis in accordance with NICE recommendations TA130 and TA195 and local pathway.
  • For ankylosing spondylitis in accordance with NICE TA145 and TA140 and local pathway.
  • For psoriatic arthritis in accordance with NICE TA199 and local pathway.
  • Commissioned by NHS England for paediatric indications (where adult TA available). According to adult TAs (TA130, TA134, TA140, TA143, TA163, TA199) for the range of arthritis-related indications. 
  • Check Trust contracting arrangements first before prescribing 
  • Not routinely commissioned by NHS England for: connective tissue disease - interstitial lung disease, graft versus host disease, renal indications, sarcoidosis, progressive pulmonary sarcoidosis, uveitis or hidradenitis suppurativa.  

 

 
Link  MHRA DSU April 2014: Tumour necrosis factor alpha inhibitors: risk of tuberculosis—screen all
Link  NICE TA195: Rheumatoid arthritis (after failure of a TNF inhibitor)
Link  NICE TA199: Psoriatic arthritis
Link  NICE TA375: Rheumatoid arthritis not previously treated with DMARDs or after conventional DMARDs only have failed
Link  NICE TA383: TNF-alpha inhibitors for ankylosing spondylitis and non-radiographic axial spondyloarthritis
 
Ixekizumab (Taltz®)
(Injection)
View adult BNF View SPC online
Formulary
traffic lightRed
High Cost Medicine
CCG
BlueTeq
  • 80mg solution for injection in pre-filled syringe or pen
  • CCG commissioned as per NICE TA537 for psoriatic arthritis
 
Link  NICE TA537 August 2018: Ixekizumab for treating active psoriatic arthritis after inadequate response to DMARDs
 
Rituximab
(MabThera®,Truxima®)
(Injection)
View adult BNF View SPC online
Formulary
traffic lightRed
High Cost Medicine
NHS England
CCG
BlueTeq
  • 100mg or 500mg concentrate for solution for infusion
  • All products should be prescribed by brand. Biosimilars should be used where possible.
  • CCG commissioned as per NICE TA195 for Rheumatoid Arthritis
  • In accordance with NHS England policies only from specialist centres for:
    • paediatric rheumatology indications where adult TA is available (TA195).
    • ANCA-positive vasculitis as per NICE TA308 and NHS England Policy: A13/P/a.
    • SLE as per NHS England Policy: A13/PS/a.
    • Dermatomyositis and polymyositis.
    • Neuromyelitis optica, as per specification.
    • ABO-incompatible kidney transplants, as per specification.
    • Myasthenia gravis as per NHSE policy 170084P (Restricted Item specialist centres only).
  • Check Trust contracting arrangements first before prescribing
 
Link  NHSE 2018: Clinical Commissioning Policy Statement: Rituximab bio-similar for the treatment of myasthenia gravis (adults)
Link  NHSE July 2016: Clinical Commissioning Policy: Rituximab for the treatment of dermatomyositis and polymyositis (adults)
Link  NHSE September 2013 Interim Clinical Commissioning Policy Statement: Rituximab for the treatment of Systemic Lupus Erythematosus in adults
Link  NICE TA195 August 2010: Adalimumab, etanercept, infliximab, rituximab and abatacept for the treatment of rheumatoid arthritis after the failure of a TNF inhibitor
Link  NICE TA308 March 2014: Rituximab in combination with glucocorticoids for treating anti-neutrophil cytoplasmic antibody-associated vasculitis
Link  Safety Letter April 2013: Direct Healthcare Professional Communication on the association of MabThera® (rituximab) with Toxic Epidermal Necrolysis and Stevens-Johnson Syndrome
 
Sarilumab (Kevzara®)
(Injection)
View adult BNF View SPC online
Formulary
traffic lightRed
High Cost Medicine
CCG
BlueTeq
  • 150 mg or 200mg solution for injection in pre-filled syringe
  • 150 mg or 200mg solution for injection in pre-filled pen
  • Commissioned by NHS England for:
    • For patients admitted to ICU with COVID-19- see link below.

 

 
Link  NHSE Interim Position Statement: Interleukin-6 inhibitors (tocilizumab or sarilumab) for patients admitted to ICU with COVID-19 pneumonia (adults) Nov 2020
Link  NICE TA485: Sarilumab for moderate to severe rheumatoid arthritis
 
Secukinumab (Cosentyx®)
(Injection)
View adult BNF View SPC online
Formulary
traffic lightRed
High Cost Medicine
CCG
BlueTeq
  • 150 mg solution for injection in pre-filled syringe or pen
 
Link  NICE TA407 September 2017: Secukinumab for active ankylosing spondylitis after treatment with non-steroidal anti-inflammatory drugs or TNF-alpha inhibitors
Link  NICE TA445 May 2017: Certolizumab pegol and secukinumab for treating active psoriatic arthritis after inadequate response to DMARDs
 
Tocilizumab (RoActemra®)
(Injection)
View adult BNF View SPC online
Formulary
traffic lightRed
High Cost Medicine
NHS England
CCG
BlueTeq
  • 162mg solution for injection in pre-filled syringe or pen.
  • 20mg/ml concentrate for solution for infusion

Commissioned by CCG for:

  • treating rheumatoid arthritis in line with NICE TA375

Commissioned by NHS England for:

  • For patients admitted to ICU with COVID-19- see link below.
  • Juvenile idiopathic arthritis in line with NICE TA238 and TA373.
  • Giant cell arteritis in line with NICE TA518 (specialist centres/networks only)
  • Adult-Onset Still’s Disease refractory to second-line therapy in line with clinical commissioning policy 170056P (specialist centres/networks only).
  • Check Trust contracting arrangements first before prescribing

 

 
Link  NHSE Interim Position Statement: Interleukin-6 inhibitors (tocilizumab or sarilumab) for patients admitted to ICU with COVID-19 pneumonia (adults) Nov 2020
Link  MHRA Drug Safety Update (Jul 2019):Tocilizumab (RoActemra): rare risk of serious liver injury including cases requiring transplantation
Link  Letter to HCP June 2019 - Rare risk of serious hepatic injury including acute liver failure requiring transplantation
Link  NICE TA238 December 2011: Tocilizumab for the treatment of systemic juvenile idiopathic arthritis
Link  NICE TA373: Abatacept, adalimumab, etanercept and tocilizumab for treating juvenile idiopathic arthritis
Link  NICE TA375: Rheumatoid arthritis not previously treated with DMARDs or after conventional DMARDs only have failed
Link  NICE TA518: Tocilizumab for treating giant cell arteritis
 
Ustekinumab (Stelara®)
(Injection)
View adult BNF View SPC online
Formulary
traffic lightRed
High Cost Medicine
CCG
BlueTeq
  • 45mg/90mg pre-filled syringe or 45mg solution for injection (vials)
  • Rheumatology
  • CCG commissioned for for the treatment of active psoriatic arthritis in accordance with NICE TA340
 
Link  NICE TA340 March 2017 update: Ustekinumab for treating active psoriatic arthritis
Link  Policy for dose escalation of Ustekinumab in psoriasis or psoriatic arthritis (outside of NICE)
 
10.01.03  Sulfasalazine
Sulfasalazine
(Oral)
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Formulary
  •  Amber with Shared Care - Bath, Salisbury & Swindon (except Swindon patients monitored via the DAWN system and provided with prescriptions by GWH)
  •  Red - Swindon DAWN patients
  • Please refer to our DMARD Shared Care and Monitoring Guidance for your respective locality for further information
  • 500mg enteric coated tablets
  • 500mg plain tablets

 

 
Link  BSW Summary of Shared Care Guidelines and Monitoring of Disease Modifying Drugs (DMARDs) in Adults Feb 2021 Rheumatology, Dermatology, Gastroenterology and Neurology
 
10.01.04  Gout and cytotoxic-induced hyperuricaemia
10.01.04  Acute attacks of gout
Colchicine
(Tablets)
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Formulary
traffic lightGreen
  • 500 microgram tablets
  • The dose of colchicine in acute gout is 1mg initially followed by 500 micrograms every 2-3 hours until relief of pain is obtained or vomiting or diarrhoea occurs or until a total dose of 6mg (12 tablets) has been reached. The course should not be repeated within 3 days.
 
Link  MHRA CAS Alert Feb 2021 Colchicine in the Management of COVID-19 (SARS-CoV 2) Positive Patients - Trial Use Only
Link  MHRA DSU Dec 2014: Colchicine: extremely toxic in overdose
 
10.01.04  Long-term control of gout to top
Allopurinol
(Tablets)
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First Choice
traffic lightGreen
  • 100mg and 300mg tablets
  • The dose of allopurinol should be reduced in patients with renal failure.
 
Febuxostat (Adenuric®)
(Tablets)
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Second Choice
traffic lightGreen
  • 80mg and 120mg
  • To be prescribed only when patients have failed on Allopurinol in line with NICE TA below.
  • SFT Febuxostat guidelines


      

 
Link  MHRA DSU July 2019: Febuxostat (Adenuric): increased risk of cardiovascular death and all-cause mortality in clinical trial in patients with a history of major cardiovascular disease
Link  MHRA DSU Dec 2014: Febuxostat (Adenuric¥): stop treatment if signs or symptoms of serious hypersensitivity
Link  NICE TA164 Dec 2008: Febuxostat for the management of hyperuricaemia in people with gout
 
10.01.04  Hyperuricaemia associated with cytotoxic drugs
Rasburicase (Fastertec®)
(Infusion)
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Formulary
traffic lightRed
High Cost Medicine
  • 1.5mg and 7.5mg infusion
  • For Haematology/Oncology use only.
 
 
10.01.05  Other drugs for rheumatic diseases
10.02  Drugs used in neuromuscular disorders
10.02.01  Drugs which enhance neuromuscular transmission
10.02.01  Anticholinesterases to top
Edrophonium Chloride
View adult BNF View SPC online
Formulary
traffic lightRed
  • Included on formulary as a diagnostic agent for myasthenia gravis.  
 
 
Pyridostigmine Bromide
(Mestinon®)
(Tablets)
View adult BNF View SPC online
Formulary
  • Amber Amber TLS across BSW when used for licensed indication
  • Red RUH only, pyridostigmine is included on the formulary for the management of postural hypotension (unlicensed) RUH inpatient use (RED TLS)
  • 60mg tablets
 
 
10.02.02  Skeletal muscle relaxants
Baclofen
(Oral)
View adult BNF View SPC online
Formulary
traffic lightGreen
  • Tablets 10mg
  • Liquid 5mg in 5ml 
  • Serious side-effects can follow abrupt withdrawal of baclofen; therapy should be discontinued by gradual dose reduction over at least 1-2 weeks (longer if symptoms occur)
  • Bath only - Intrathecal Baclofen - Refer to the NHS Commissioning Board Clinical Policy D04/P/c: Intrathecal baclofen (ITB) 
 
 
Dantrolene
(Capsules)
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Formulary
  • Green Swindon and Salisbury
  • Amber BaNES
  • 25mg and 100mg capsules
  • Liver function tests should be performed before commencing dantrolene, and then repeated on discharge from hospital (or 6 weeks after starting therapy) and then at 3 monthly intervals. 
 
 
Diazepam (Muscle relaxant)
(Oral, IV and rectal)
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Formulary
traffic lightGreen
  • 2mg, 5mg and 10mg tablets
  • 10mg/2ml injection
  • 2mg/5ml oral suspension
  • 2.5mg, 5mg and 10mg rectal tubes
  • For short term use only

 

 
 
Tizanidine
(Tablets)
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Formulary
traffic lightAmber
  • 2mg and 4mg tablets  
 
 
10.02.02  Nocturnal leg cramps
Quinine
(Tablets)
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Formulary
traffic lightGreen
  • 200mg and 300mg tablets
  • MHRA Drug Safety Update June 2010  Quinine is not a routine treatment for nocturnal leg cramps, and should only be used when cramps regularly disrupt sleep. Treatment should be reviewed after 4 weeks to see whether there is any benefit and monitor for toxicity. Interrupt treatment at intervals of every 3 months to assess the need for further quinine treatment.
 
Link  Quinine: not to be used routinely for nocturnal leg cramps
Link  Quinine: reminder of dose-dependent QT-prolonging effects; updated medicine interactions
 
10.03  Drugs for the treatment of soft-tissue disorders and topical pain relief
10.03.01  Enzymes
10.03.02  Rubefacients, topical NSAIDs, capsaicin, and poultices to top
10.03.02  Topical NSAIDs and counter-irritants
Ibuprofen
(Topical)
View adult BNF View SPC online
First Choice
traffic lightSelf
  • 100g gel containing 5% ibuprofen
  • Fenbid brand is most cost effective    
  • NICE clinical guideline 177 Osteoarthritis: Feb 2014 Paracetamol and/or topical NSAIDs should be offered to patients with knee or hand osteoarthritis before considering oral NSAIDs, COX-2 inhibitors or opioids
 
Transvasin
View adult BNF View SPC online
Formulary
traffic lightGreen
  • Bath only - included on the formulary to aid taking blood for capillary blood gas sampling
  • Non formulary in Swindon and Salisbury        

 

 
 
10.03.02  Capsaicin
Capsaicin (Axsain®)
(Topical)
View adult BNF View SPC online
Formulary
traffic lightGreen
  • Amber Swindon only - for painful diabetic peripheral polyneuropathy.
  • Cream containing 0.075% capsaicin (Axsain®)
  • For treatment of post herpetic neuralgia (after lesions have healed) & painful diabetic peripheral neuropathy
 
Link  Sep 2019 - Shortage of capsaicin cream
 
Capsaicin (Zacin®)
(Topical)
View adult BNF View SPC online
Formulary
traffic lightGreen
  • Amber Swindon only - for painful diabetic peripheral polyneuropathy (off-label)
  • Cream containing 0.025% capsaicin (Zacin®)
  • For symptomatic relief in osteoarthritis. It may need to be used for 1-2 weeks before pain is relieved
 
Link  Sep 2019 - Shortage of capsaicin cream
 
Capsaicin (Qutenza®)
View adult BNF View SPC online
Formulary
traffic lightRed
  • Pain clinic use only as per local policy below.  
 
Link  BSW CCG Qutenza patch (capsaicin 8%) for peripheral neuropathic pain in non-diabetic patients commissioning statement: low priority intervention
Link  USE OF QUTENZA PATCHES IN ADULTS for PERIPHERAL NEUROPATHIC PAIN IN NON-DIABETIC PATIENTS: PRIOR APPROVAL FORM
 
 ....
 Non Formulary Items
Aceclofenac

View adult BNF View SPC online
Non Formulary
 
Acemetacin (Emflex®)

View adult BNF View SPC online
Non Formulary
 
Algesal
(Topical gel)

View adult BNF View SPC online
Non Formulary

NOT RECOMMENDED

 
Azapropazone (Rheumox®)

View adult BNF View SPC online
Non Formulary
 
Betamethasone
(Betnesol®)
(injection - local)

View adult BNF View SPC online
Non Formulary
 
Controlled Drug  Cannabis extract
(Sativex®)

View adult BNF View SPC online
Non Formulary

The publication of the NICE guideline that covers prescribing of cannabis-based medicinal products for people with intractable nausea and vomiting, chronic pain, spasticity and severe treatment-resistant epilepsy.  The BSW commissioning position on sativex can be found on the link below.

Link  BSW Sativex® spray (delta-9-tetrahydrocannabinol (THC): cannabidiol (CBD)) for treatment for symptom improvement in adult patients with moderate to severe spasticity due to multiple sclerosis (MS) March 2021 (not commissioned)
 
Celecoxib (Onsenal®)

View adult BNF View SPC online
Non Formulary
 
Chloroquine

View adult BNF View SPC online
Non Formulary
 
Collagenase (Xiapex®)
(Injection)

View adult BNF View SPC online
Non Formulary

May 2020 - removed from formulary
NICE HAVE WITHDRAWN TA459 - collagenase clostridium histolyticum (Xiapex) is no longer available in the UK.

Link  NICE TA459 : Collagenase clostridium histolyticum for treating Dupuytren’s contracture
 
Dexamethasone
(joint injection)

View adult BNF View SPC online
Non Formulary
 
Dexibuprofen (Seractil®)

View adult BNF View SPC online
Non Formulary
 
Diclofenac with Misoprostol
(Arthrotec 50 and 75®)

View adult BNF View SPC online
Non Formulary
 
Distigmine Bromide

View adult BNF View SPC online
Non Formulary
 
Felbinac (Traxam®)

View adult BNF View SPC online
Non Formulary
 
Fenbufen

View adult BNF View SPC online
Non Formulary
 
Fenoprofen (Fenopron®)

View adult BNF View SPC online
Non Formulary
 
Flurbiprofen

View adult BNF View SPC online
Non Formulary
 
Glucosamine

View adult BNF View SPC online
Non Formulary

This drug is NOT included on the formulary in line with NHSE. See https://www.england.nhs.uk/wp-content/uploads/2017/11/items-which-should-not-be-routinely-precscribed-in-pc-ccg-guidance.pdf 

 
Hydroxychloroquine
(300mg Tablet )

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Non Formulary
Black

Black TLS - BSW APC decision Oct 2020 

300mg tablets made by Blackrock are not currently included on the formulary. They are more expensive than 200mg tablets and are not a cost-effective use of NHS resources for their licensed indications. 300mg dosing can continue to be achieved with the established practice of 200mg/400mg alternate day dose.

 
Ibuprofen 10% gel

View adult BNF View SPC online
Non Formulary

NOT RECOMMENDED

 
Ibuprofen and famotidine
(Duexis®)

View adult BNF View SPC online
Non Formulary
 
Ketoprofen

View adult BNF View SPC online
Non Formulary
 
Ketoprofen 2.5%
(Oruvail ®, Powergel®)

View adult BNF View SPC online
Non Formulary
 
Lesinurad (Zurampic®)

View adult BNF View SPC online
Non Formulary
Link  NICE TA506: Lesinurad for treating chronic hyperuricaemia in people with gout
 
Movelat (Topical gel / cream)

View adult BNF View SPC online
Non Formulary
 
Nabumetone

View adult BNF View SPC online
Non Formulary
 
Nabumetone (Relifex®)

View adult BNF View SPC online
Non Formulary
 
Naproxen & esomeprazole
(Vimovo®)

View adult BNF View SPC online
Non Formulary
 
Neostigmine

View adult BNF View SPC online
Non Formulary
 
Nusinersen (Spinraza)

View adult BNF View SPC online
Non Formulary
 
Piroxicam (Feldene®)

View adult BNF View SPC online
Non Formulary
 
Probenecid

View adult BNF View SPC online
Non Formulary
 
Sodium hyaluronic acid
(Injection)

View adult BNF View SPC online
Non Formulary
  • NICE does not recommend the use of intra-articular hyaluronic acid (hyaluronan) injections for the treatment of osteoarthritis (CG177).
  • Examples include: Durolane®, Euflexxa®, Fermathron®, Hyalgan® , Orthovisc®, Ostenil®, Ostenil Plus®, RenehaVis®, Suplasyn®, Synocrom®, Synopsis®.
  • BSW CCG local not commissioned policy can be found on the link below.
Link  BSW CCG Policy for the use of sodium hyaluronic acid injections in osteoarthritis
 
Sulfinpyrazone

View adult BNF View SPC online
Non Formulary
 
Sulindac

View adult BNF View SPC online
Non Formulary
 
Tenoxicam (Mobiflex®)

View adult BNF View SPC online
Non Formulary
 
Tiaprofenic Acid

View adult BNF View SPC online
Non Formulary
 
  
Key
note Notes
Section Title Section Title (top level)
Section Title Section Title (sub level)
First Choice Item First Choice item
Non Formulary Item Non Formulary section
Restricted Drug
Restricted Drug
Unlicensed Drug
Unlicensed
Track Changes
Display tracking information
click to search medicines.org.uk
Link to adult BNF
click to search medicines.org.uk
Link to SPCs
SMC
Scottish Medicines Consortium
Cytotoxic Drug
Cytotoxic Drug
CD
Controlled Drug
High Cost Medicine
High Cost Medicine
Cancer Drugs Fund
Cancer Drugs Fund
NHSE
NHS England
Homecare
Homecare
CCG
CCG
Blueteq
High Cost Drug Approval System

Traffic Light Status Information

Status Description

Traffic LightRed

RED - Hospital only – to be prescribed by a specialist and supplied from secondary care ONLY throughout treatment.  

Traffic LightAmber

Amber medicines are considered suitable for GP prescribing following specialist initiation or recommendation.  

Traffic LightAmber with Shared Care

Shared Care - these medicines require specialist initiation and stabilisation. Ongoing division of responsibility for drug and disease monitoring between specialist and GP by a Shared Care Guideline (SCG). If no SCG in place status reverts to red.  

Traffic LightGreen

These medicines are appropriate for initiation in both primary and secondary care. Prescribing is appropriate within licensed or local recommendations.  

Traffic LightSelf

Suitable for patient to be directed to buy themselves  

Traffic LightGrey

Not currently used. We intend to include this TLS in future to highlight where a decision to use this medicine is under review.   

Traffic LightBlack

(In use from Oct 2020) Used where a decision has been made by the BSW APC not to routinely commission this preparation for its licensed indications. Do not prescribe.   

Traffic LightRed Specialist Centre

Not currently used. We intend to include this TLS in future to highlight where this medicine and indication is ONLY available through a Specialist Centre according to a NICE Highly Specialised Technology or NHSE Specialised Commission Circular / Policy.  

netFormulary