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 Formulary Chapter 10: Musculoskeletal and joint diseases - Full Chapter
Notes:
The development of this chapter for the George Eliot Formulary is in progress
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10.01.03  Expand sub section  Drugs which suppress the rheumatic disease process
10.01.03  Expand sub section  Antimalarials
10.01.03  Expand sub section  Drugs affecting the immune response
 note 

Methotrexate is a disease-modifying antirheumatic drug suitable for moderate to severe rheumatoid arthritis. Azathioprine, ciclosporin, cyclophosphamide, leflunamide and the cytokine modulators are considered more toxic and they are used in cases that have not responded to other disease-modifying drugs.

Methotrexate is given once weekly, dose adjusted according to response. In patients who experience mucosal or GI side effects with methotrexate, folic acid given every week [unlicensed indication] on a different day from the methotrexate, may help to reduce the frequency of such side effects.

Leflunomide acts on the immune system as a DMARD, its therapeutic effect starts after 4-6 weeks and improvement may continue for a further 4-6 months. Leflunomide, which is similar in efficacy to sulfasalazine and methotrexate, may be chosen when these drugs cannot be used.

Ciclosporin is licensed for severe active rheumatoid arthritis when conventional second line tharapy is inappropriate or ineffective. There is some evidene that ciclosporin may retard the rate of erosive progression and improve symptom control in those who respond only partially to methotrexate.

Abatacept (Orencia)
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Red SO
High Cost Medicine
Homecare
BlueTeq
  • Available as  SC injection
  • Restricted for use in line with NICE TAs below by rheumatology specialist
 
Link  NICE TA195: Adalimumab, etanercept, infliximab, rituximab and abatacept for the treatment of rheumatoid arthritis after the failure of a TNF inhibitor
Link  NICE TA280: Rheumatoid arthritis - abatacept (2nd line) (rapid review of TA234)
Link  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
   
Adalimumab (Hyrimoz)
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Formulary
Red SO
High Cost Medicine
Homecare
BlueTeq
  • Available as  SC injection
  • Restricted for use in line with NICE TAs below by rheumatology specialist
  • Biosimilar Hyrimoz<sup>®</sup> is new first line agent for GEH patients

 

 

 
Link  NICE TA195: Adalimumab, etanercept, infliximab, rituximab and abatacept for the treatment of rheumatoid arthritis after the failure of a TNF inhibitor
Link  NICE TA199: Etanercept, infliximab and adalimumab for the treatment of psoriatic arthritis
Link  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
Link  NICE TA383: TNF-alpha inhibitors for ankylosing spondylitis and non-radiographic axial spondyloarthritis
   
Cytotoxic Drug Azathioprine
(rheumatology)
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Formulary
Amber SC
  • Available as tablets
 
Link  APC - Shared Care Agreement: Azathiorprine
   
Certolizumab Pegol (Cimzia)
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Formulary
Red SO
High Cost Medicine
Homecare
BlueTeq
  • Available as  SC injection
  • Restricted for use in line with NICE TAs below by rheumatology specialist
 
Link  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
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 DMARDs
   
Ciclosporin
(rheumatology)
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Formulary
Amber SC
  • Available as capsules
 
Link  APC - Shared Care Agreement: Ciclosporin
   
Etanercept (Benepali Enbrel )
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Formulary
Red SO
High Cost Medicine
Homecare
BlueTeq
  • Available as  SC injection
  • Restricted for use in line with NICE TAs below by rheumatology specialist
 
Link  NICE TA195: Adalimumab, etanercept, infliximab, rituximab and abatacept for the treatment of rheumatoid arthritis after the failure of a TNF inhibitor
Link  NICE TA199: Etanercept, infliximab and adalimumab for the treatment of psoriatic arthritis
Link  NICE TA35: Arthritis (juvenile idiopathic) - etanercept
Link  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
Link  NICE TA383: TNF-alpha inhibitors for ankylosing spondylitis and non-radiographic axial spondyloarthritis
   
Golimumab (Simponi)
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Formulary
Red SO
High Cost Medicine
Homecare
BlueTeq
  • Available as  SC injection
  • Restricted for use in line with NICE TAs below by rheumatology specialist
 
Link  Infliximab, adalimumab and golimumab for treating moderately to severely active ulcerative colitis after the failure of conventional therapy
Link  NICE TA220: Psoriatic arthritis - golimumab
Link  NICE TA225: Golimumab for the treatment of rheumatoid arthritis after the failure of previous disease-modifying anti-rheumatic drugs
Link  NICE TA233: Ankylosing spondylitis - golimumab
Link  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
Link  NICE TA497: Golimumab for treating non-radiographic axial spondyloarthritis
   
Infliximab (Remsima)
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Formulary
Red SO
High Cost Medicine
BlueTeq
  • Available as IV infusion via aseptics
  • Restricted for use in line with NICE TAs below by rheumatology specialist
 
Link  NICE TA195: Adalimumab, etanercept, infliximab, rituximab and abatacept for the treatment of rheumatoid arthritis after the failure of a TNF inhibitor
Link  NICE TA199: Etanercept, infliximab and adalimumab for the treatment of psoriatic arthritis
Link  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
   
Leflunomide
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Formulary
Amber SC
  • Available as tablets
 
Link  APC - Shared Care Agreement: Leflunamide
   
Cytotoxic Drug Methotrexate
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Formulary
Amber SC
  • Available as:
    • Tablets 2.5mg only
    • SC injection
 
Link  APC - Shared Care Agreement: Methotrexate
Link  UKMI Q&A: Methotrexate and alcohol guidance
   
Rituximab (rheumatology) (Truxima)
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Formulary
Red SO
High Cost Medicine
BlueTeq
  • Available as IV infusion
  • Restricted for use in line with NICE TAs below by rheumatology specialist
 
Link  NICE TA195: Adalimumab, etanercept, infliximab, rituximab and abatacept for the treatment of rheumatoid arthritis after the failure of a TNF inhibitor
Link  NICE TA308: Rituximab in combination with glucocorticoids for treating anti-neutrophil cytoplasmic antibody-associated vasculitis
   
TofacitinibBlack Triangle (Xeljanz)
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Formulary
High Cost Medicine
BlueTeq
  • Available as tablets
  • Approved for use at GEH in January 2019 in line with NICE TA543 for treating active psoriatic arthritis after inadequate response to DMARDs

 

  • Manufacturer advises reduce dose to 5mg once daily with concurrent use of potent CYP3A4 inhibiitors or drugs which are both moderate CYP3A4 and potent CYP2C19 inhibitors.
  • Manufacturer advises patients should receive all recommended vaccinations before starting treatment; live vaccines should be given at least 2 weeks, but preferably 4 weeks before treatment initiation.
  • Manufacturer advises consideration of antituberculosis therapy prior to initiation of tofacitinib in patients with previously untreated latent TB.
 
Link  NICE TA543: Tofacitinib for treating active psoriatic arthritis after inadequate response to DMARDs
   
10.01.03  Expand sub section  Cytokine modulators
10.01.03  Expand sub section  Sulfasalazine to top
 ....
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 children's 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

Traffic Light Status Information

Status Description

Red SO

SPECIALIST ONLY - These drugs are deemed to be not appropriate for prescribing by GPs. Specialists should not ask GPs to prescribe these drugs.   

Green SI

SPECIALIST INITIATED - These drugs must be initiated, i.e. the first dose prescribed, by the specialist and then may be continued when appropriate by the patients GP following communication from the specialist.   

Green SA

SPECIALIST ADVISED Specialists may simply advise a patients GP to initiate these drugs themselves after they have made an initial assessment.   

Amber SC

SHARED CARE - Responsibility for prescribing may be transferred from secondary to primary care with the agreement of an individual GP and when agreed shared care arrangements have been established. The specialist MUST stabilize the patient before asking for care to be transferred. Only specialists should initiate these drugs. Prescribing should be transferred to GPs according to an Shared Care Agreement [SCA]   

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