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Royal United Hospitals Bath NHS Foundation Trust
Great Western Hospitals NHS Foundation Trust
Salisbury NHS Foundation Trust
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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...
10.01.01  Expand sub section  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)
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First Choice
Self
  • 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)
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Second Choice
Green
  • 250mg and 500mg tablets
  • Oral suspension and effervescent tablets available 
  • No evidence for GI benefit of EC preparation - use standard tablets.
 
   
Diclofenac 
(Oral)
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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
Green
  • 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)
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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)
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Formulary
Amber
  • Salisbury only
  • Non formulary in BaNES and Swindon
  • 100mg and 200mg capsules
 
   
Etodolac 
(Tablet, capsule)
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Formulary
Amber
  • Salisbury only
  • Non formulary in BaNES and Swindon
  • 300mg capsules
  • 600mg tablets and 600mg MR tablets
 
   
Etoricoxib 
(Tablet)
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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)
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Formulary
Green
  • BaNES and Swindon only
  • Non formulary in Salisbury
  • 25mg and 50mg
  • 100mg suppositories
 
   
Mefenamic Acid 
(Tablets and capsules)
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Formulary
Green
  • 500mg tablets
  • 250mg capsules
 
   
Meloxicam 
(Tablets)
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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 
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Formulary
Red
  • 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  Expand sub section  Aspirin
 ....
 Non Formulary Items
Aceclofenac 

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Non Formulary
 
Acemetacin (Emflex)

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Non Formulary
 
Azapropazone (Rheumox)

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Non Formulary
 
Celecoxib (Onsenal)

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Non Formulary
 
Dexibuprofen (Seractil)

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Non Formulary
 
Diclofenac with Misoprostol
(Arthrotec 50 and 75)

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Non Formulary
 
Fenbufen 

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Non Formulary
 
Fenoprofen (Fenopron)

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Non Formulary
 
Flurbiprofen 

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Non Formulary
 
Ibuprofen and famotidine
(Duexis)

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Non Formulary
 
Ketoprofen 

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Non Formulary
 
Nabumetone 

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Non Formulary
 
Nabumetone (Relifex)

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Non Formulary
 
Naproxen & esomeprazole
(Vimovo)

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Non Formulary
 
Sulindac 

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Non Formulary
 
Tenoxicam (Mobiflex)

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Non Formulary
 
Tiaprofenic Acid 

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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

Red

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

Amber

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

Amber 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.  

Green

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

Self

Suitable for patient to be directed to buy themselves  

Grey

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

Black

Not currently used. We intend to include this TLS in future to highlight where a decision has been made by either or both the local or national NHS not to routinely commission this preparation for its licensed indications. Do not prescribe.  

Red 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.  

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