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10.4 Pain and inflammation in musculoskeletal disorders

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

 

Non-Steriodal inflammatory drugs

 

Only prescribe an NSAID if the benefits of treatment clearly outweigh the risks and a need for an anti-inflammatory agent is identified.       

3 Steps to NSAID Prescribing

Don’t use them unless you have to

  • The only way to avoid NSAID side-effects is not to use them
  • Paracetamol works for many
  • Employ non-drug interventions routinely
  • Consider short-term course (1-2 weeks) of topical NSAID

If you have to use them, use them wisely

  • The balance of benefits and risks needs to be carefully assessed; think about CV, GI and renal issues routinely.
  • Use a safer drug (ibuprofen, then naproxen) in the lowest effective dose for the shortest period
  • NSAID users should be a high priority for medication review: are NSAIDs effective/needed? Drug holidays? Don’t issue repeat prescriptions without review.
  • Short acting NSAIDs are preferred for the majority of patients as they allow flexible dosing leading to better control of symptoms using lower daily doses.

Consider gastroprotection in those at high risk (NICE definition)

  • Options are PPIs, double-dose H2RAs, Misoprostol
  • COX-2 should be considered only in those at high GI risk, but also consider the CV risks.
  • Systemic as well as local effects of NSAIDs contribute to gastrointestinal damage. This damage may not be prevented by the use of enteric-coated tablets or suppositories.

 

 

Ibuprofen 

  • Tablets 200mg, 400mg, 600mg
  • SuspensionSF 100mg in 5ml 
  • Gel containing 5% 

Notes:

  • Should not be prescribed in Primary Care or at Discharge
  • Advise patient to purchase, unless prescription is for long-term regular use
  • Treatment should be reviewed after two weeks and stopped if not effective.

 

Naproxen

  • Tablets 250mg, 500mg

 

 

Celecoxib (Amber 2)

  • Tablets 100mg, 200mg

 

Diclofenac (Amber 2)

  • Tablets e/c 25mg, 50mg
  • Dispersible tablets 50mg
  • Suppositories 12.5mg, 25mg, 50mg, 100mg
  • Injection 75mg in 3ml 

 

Flurbiprofen (Amber 2)

Tablet 50mg

  •  

 

Indometacin (Amber 2)

  • Capsules 25mg, 50mg
  • Suppository 100mg

 

Mefenamic acid (Amber 2)

  • Capsule 250mg
  • Tablet 500mg

Notes:

a) Restricted to first line use only in patients that require a reduction in blood flow e.g. patient with both menorrhagia and dysmenorrhea 

b) Restricted to second line use in patients intolerant to other NSAIDs 

 

 

Other

Algesal®

  • Cream containing diethylamine salicylate 10%       

Notes: 

  • Should not be prescribed in Primary Care or at Discharge
  • Advise patient to purchase, unless prescription is for long-term regular use

 

Transvasin®

  • Cream 

Notes: 

  • Should not be prescribed in Primary Care or at Discharge
  • Advise patient to purchase, unless prescription is for long-term regular use

 

 

Capsaicin 

Qutenza® 

  •  Patches 179mg

 

 

 

 

 

 

 

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: Dupe Fagbenro on 05-12-2018 14:04