Formulary


	NHS Bath and North East Somerset, Swindon and Wiltshire CCG 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

Non-steroidal anti-inflammatory drugs

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)

First Choice

200mg, 400mg and 600mg tablets
Oral suspension
For minor conditions associated with pain and inflammation, patients should self-care in the first instance.

MHRA DSU June 2015: High-dose ibuprofen (¡Ý2400mg/day): small increase in cardiovascular risk

Naproxen
(Tablets)

Second Choice

250mg and 500mg tablets
Oral suspension and effervescent tablets available
No evidence for GI benefit of EC preparation - use standard tablets.

Diclofenac
(Oral)

Third Choice

- Salisbury & Swindon.
- 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

MHRA DSU Dec 2014: Diclofenac: new contraindications and warnings

Diclofenac
(Rectal & Injection)

Third Choice

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.

MHRA DSU Dec 2014: Diclofenac: new contraindications and warnings

Diclofenac (Akis^®)
(Injection)

Third Choice

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.

MHRA DSU Dec 2014: Diclofenac: new contraindications and warnings

Celecoxib (Celebrex^®)
(Capsule)

Formulary

Salisbury only
Non formulary in BaNES and Swindon
100mg and 200mg capsules

Etodolac
(Tablet, capsule)

Formulary

Salisbury only
Non formulary in BaNES and Swindon
300mg capsules
600mg tablets and 600mg MR tablets

Etoricoxib
(Tablet)

Formulary

- BaNES - Second line for treament of Ankylosing Spondylitis ONLY.
- Swindon - Reserved for severe inflammatory arthritis unresponsive or intolerant to other NSAIDS.
- 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.

MHRA DSU Oct 2016: Etoricoxib (Arcoxia): revised dose recommendation for rheumatoid arthritis and ankylosing spondylitis

Indometacin
(Capsules and suppositories)

Formulary

BaNES and Swindon only
Non formulary in Salisbury
25mg and 50mg
100mg suppositories

Mefenamic Acid
(Tablets and capsules)

Formulary

500mg tablets
250mg capsules

Meloxicam
(Tablets)

Formulary

- Swindon - Second-line after conventionals NSAIDs.
- BaNES and Salisbury.
- 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

Formulary

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.

NICE CG160: Feverish illness in children

NICE CG177: Osteoarthritis

10.01.01

Aspirin

....

Non Formulary Items

Aceclofenac

Non Formulary

Acemetacin (Emflex^®)

Non Formulary

Azapropazone (Rheumox^®)

Non Formulary

Celecoxib (Onsenal^®)

Non Formulary

Dexibuprofen (Seractil^®)

Non Formulary

Diclofenac with Misoprostol
(Arthrotec 50 and 75^®)

Non Formulary

Fenbufen

Non Formulary

Fenoprofen (Fenopron^®)

Non Formulary

Flurbiprofen

Non Formulary

Ibuprofen and famotidine
(Duexis^®)

Non Formulary

Ketoprofen

Non Formulary

Nabumetone

Non Formulary

Nabumetone (Relifex^®)

Non Formulary

Naproxen & esomeprazole
(Vimovo^®)

Non Formulary

Sulindac

Non Formulary

Tenoxicam (Mobiflex^®)

Non Formulary

Tiaprofenic Acid

Non Formulary

Key

	Notes
	Section Title (top level)
	Section Title (sub level)
	First Choice item
	Non Formulary section
	Restricted Drug
	Unlicensed
	Display tracking information
	Link to adult BNF
	Link to SPCs
	Scottish Medicines Consortium

	Cytotoxic Drug
	Controlled Drug
	High Cost Medicine
	Cancer Drugs Fund
	NHS England
	Homecare
	CCG
	High Cost Drug Approval System

Traffic Light Status Information

Status	Description
	RED - Hospital only – to be prescribed by a specialist and supplied from secondary care ONLY throughout treatment.
	Amber medicines are considered suitable for GP prescribing following specialist initiation or recommendation.
	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.
	These medicines are appropriate for initiation in both primary and secondary care. Prescribing is appropriate within licensed or local recommendations.
	Suitable for patient to be directed to buy themselves
	Not currently used. We intend to include this TLS in future to highlight where a decision to use this medicine is under review.
	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.
	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.