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10.1 Arthritis

First line drugs Second line drugs Specialist drugs Secondary care drugs

Traffic light status (TLS) explained:

  • Green: Routine prescribing within licensed indication
  • Amber 1: specialist recommendation followed by GP initiation and continuation
  • Amber 2: specialist or GP initiation in line with local guideline after 1st line failure followed by GP continuation
  • Amber 3: specialist initiation and stabilisation followed by GP continuation
  • Amber SCG: specialist initiation and stabilisation followed by GP continuation in line with an agreed shared care guideline
  • Red: Hospital or specialist prescribing only
  • Double Red: These medicines have been evaluated and rejected by MKPAG and are NOT approved for use within MK. They are not recommended for use because of lack of clinical effectiveness, cost effectiveness or safety.

 

 

Disease-Modifying Rheumatic Drugs (DMARDS)

 

Shared Care Guideline

DMARD Shared Care Guideline can be found by clicking on the following link: https://www.formularymk.nhs.uk/includes/documents/Shared-Care-Guideline-for-the-use-of-DMARDs-Final-Jan-2019.pdf

 

 

Azathioprine (Amber SCG, DMARD SCG)

  • Tablets 25mg, 50mg

 

 

Chloroquine (Amber 2)

  • Tablets 250mg
  • Syrup 68mg in 5ml (Hospital only)

 

 

Ciclosporin (Amber SCG, DMARD SCG)

  • Capsules 10mg, 25mg, 50mg, 100mg
  • Oral solution 100mg/ml

Notes:

  • Ciclosporin (Neoral®) is licensed for severe active RA when conventional second-line therapy is inappropriate or ineffective.
  • It is contraindicated in abnormal renal function, uncontrolled hypertension, uncontrolled infections and malignancy.
  • Monitor hepatic function if concomitant NSAIDs given.
  • As there are differences in bioavailability, the brand of ciclosporin to be dispensed should be specified by the prescriber. 

 

 

Hydroxychloroquine sulfate  (Amber SCG, DMARD SCG)

  • Tablets 200mg

     

 

Leflunomide  (Amber SCG, DMARD SCG)

  • Tablets 10mg,20mg

 

 

Methotrexate (Amber SCG, DMARD SCG)

 

  • Tablets 2.5mg
  • Metoject® Injection prefilled syringe 10mg, 15mg, 20mg, 25mg     

Notes:

  1. CSM Warning – Methotrexate: In view of reports of blood dyscrasias (including fatalities) and liver cirrhosis with low-dose methotrexate, the CSM has advised:
    • specific monitoring guidance (superseded by NPSA alerts and nGMS);
    • that patients should be advised to report all symptoms and signs suggestive of infection, especially sore throat.
  2. Treatment with folinic acid (as calcium folinate) may be required in acute toxicity.
  3. The CSM has received reports of prescription and dispensing errors with methotrexate, including fatalities. Attention should be paid to the strength of methotrexate tablets prescribed and the frequency of dosing.
  4. 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 XXXDAY’.
  5. Keep repeat prescriptions for methotrexate separate from others
  6. In the treatment of non-cancer conditions (eg. rheumatology and dermatology), methotrexate must be given once a week or once a month. Staff that encounter methotrexate prescriptions must ensure the correct dosing interval is given.
  7. In patients who experience mucosal or gastrointestinal side effects with methotrexate, folic acid 5mg each week (taken 48 hours after the methotrexate dose) may be given. It may be given routinely to help reduce the frequency of such side effects.
    Methotrexate-induced mucositis or myelosuppression: folinic acid (given as calcium folinate) is used to counteract the folate-antagonist action of methotrexate and so facilitate recovery from methotrexate-induced mucositis or myelosuppression.
  8. Methotrexate and NSAIDs: if aspirin or other NSAIDs are given concurrently the dose of methotrexate should be carefully monitored. Patients should be advised to avoid self-medication with over-the-counter aspirin or ibuprofen. 

 

 

 

Penicillamine  (Amber SCG, DMARD SCG)

  •  Tablets 125mg,250mg

 

 

Sodium aurothiomalate (Amber SCG, DMARD SCG) 

  • Injection 10mg in 0.5mL, 50mg in 0.5mL 

 

 

Sulfasalazine  (Amber SCG, DMARD SCG) 

  • Tablets e/c 500mg

 

 

 

 

Interleukin inhibitors

 

Sarilumab

  • Kevzara® Solution for injection 150mg, 200mg pre-filled syringe or pen

Note:

 

Secukinumab

  • Cosentyx® Solution for injection, 150mg in pre-filled pen or syringe

Notes:

 

 

 

Tocilizumab

  • RoActemra® 162mg solution for injection in pre-filled pen or pre-filled syringe.
  • RoActemra® Intravenous infusion 20mg in 1mL 

  Notes:

 

 

 

 

Ustekinumab      

  • Stelara® Injection, 45mg, 90mg solution in pre-filled syringe or vial

Notes: 

 

 

 

 

 

Protein Kinase Inhibitors

 

Baricitinib

  • Olumiant® Tablets film-coated 2mg, 4mg

Note:

 

 

Tofacitinib citrate

  • Xeljanz® Tablets film-coated 5mg

Notes:

 

 

 

 

 

 

T-Cell Activation Inhibitors

 

Abatacept

  • Orencia® Intravenous infusion 250mg

Notes:

 

 

 

Tumour Necrosis Factor Alpha (TNF-alpha) Inhibitors

 

 

Adalimumab 

  • Imraldi, Injection, 40mg/0.8mL prefilled pen or prefilled syringe
  • Amgevita, Injection, 20mg/0.4mL; 40mg/0.8mL prefilled pen or prefilled syringe
  • Humira, Injection, 40mg/0.4mL; 80mg/0.8mL prefilled pen or prefilled syringe
  • Humira, Injection, 20mg/0.2mL pre-filled syringe, 40mg/0.8mL solution in vial for first line use in paediatrics

Notes:

  • To be prescribed by brand.
  1. First line brand in adults = Imraldi®
  2. Second line brand in adults = Amgevita®
  3. Third line brand in adults = Humira®

 

  • Hulio and Hyrimoz are non-formulary within Milton Keynes Healthcare 

 

 

 

 

 

 

Certolizumab Pegol

  • Cimzia® Solution for injection, 200mg in pre-filled pen or in pre-filled syringe 

Notes:

 

 

 

 

Etanercept

  • Enbrel® 25mg in 0.5mL pre filled syringe, 25mg injection.

Notes:

 

 

 

 

 

Golimumab

 

 

 

 

Infliximab

  • Remicade®  100mg vial powder for reconstition.

Notes:

 

 

 

 

 

Rituximab

  • MabThera®Concentrate for IV infusion 100mg in 10mL, 500mg in 50mL      

Notes: 

 

 

 

Phosphodiesterase type-4 inhibitors

 

Apremilast

  • Tablet 10mg,20mg,30mg 

Notes:

 

 

 

 

 

 

 

 

 

Traffic light status (TLS) explained:

  • Green: Routine prescribing within licensed indication
  • Amber 1: specialist recommendation followed by GP initiation and continuation
  • Amber 2: specialist or GP initiation in line with local guideline after 1st line failure followed by GP continuation
  • Amber 3: specialist initiation and stabilisation followed by GP continuation
  • Amber SCG: specialist initiation and stabilisation followed by GP continuation in line with an agreed shared care guideline
  • Red: Hospital or specialist prescribing only
  • Double Red: These medicines have been evaluated and rejected by MKPAG and are NOT approved for use within MK. They are not recommended for use because of lack of clinical effectiveness, cost
  • effectiveness or safety

 

Return to Chapter: 10. Musculoskeletal and Joint Diseases

Last updated by: Sheila Wood on 05-06-2019 13:39