Section 10: Musculoskeletal and Joint Diseases

Section Description

BNF 10.1

Drugs used in rheumatic diseases and gout

BNF 10.1.1

Non-steroidal anti-inflammatory drugs

BNF 10.1.2

CorticosteroidsLocal Corticosteroid Injections

BNF 10.1.3

Drugs which suppress the rheumatic disease process

BNF 10.1.4

Gout and cytotoxic-induced hyperuricaemia

BNF 10.2.1

Drugs which enhance neuromuscular transmission

BNF 10.2.2

Skeletal muscle relaxants

BNF 10.3

Drugs for the relief of soft-tissue inflammation

BNF 10.3.1

Enzymes

BNF 10.3.2

Rubefacients and other topical antirheumatics

BNF 10.1 Drugs used in rheumatic diseases and gout

Management of Osteoarthritis

Paracetamol

 

Paracetamol is considered the drug of choice.
Paracetamol taken regularly (to a maximum of 4g per 24 hours) is as effective as NSAIDs.
Peak plasma paracetamol concentration at 1-2 hours.
Add therapeutic dose of codeine / dihydrocodeine before changing to NSAID.

BNF 10.1.1 Non-steroidal anti-inflammatory drugs

First-line NSAID for all indications

NSAID Drug Information
First-line

Ibuprofen

Low risk of gastrointestinal (GI) and CV side effects with low dose ibuprofen (<1200mg per day)

Naproxen

 

Low risk of CV effects with low-dose naproxen (<1000mg per day). Naproxen is longer acting than ibuprofen and may be more useful if morning stiffness is a problem.

Second-line

Diclofenac sodium(short-course only)

Consider CV risk. Modified release preparations are premium priced (29-62p per day) and offer little advantage over conventional three times a day dosing

Mefenamic acid  For dysmenorrheoa and menorrhagia only

Piroxicam dispersible tablets (Feldene Melts®)

For the treatment of juvenile idiopathic arthritis [unlicensed use] following initiation by consultant paediatric rheumatologist only

Third-line Meloxicam

 
 

Remember:

Etoricoxib

For use by Rheumatology and Orthopaedics Only; may be suitable for continuation in primary care. Discuss MHRA cardiovascular safety warning with patient and document discussion in patient’s clinical record before prescribing in primary care. 

 

BNF 10.1.2 CorticosteroidsLocal Corticosteroid Injections

Methylprednisolone

Depo-Medrone®

Methylprednisolone with Lidocaine

 

Triamcinolone

Kenalog® is no longer recommended for hay fever prophylaxis [Drugs and Therapeutics Bulletin 1999;37: 17-8]

BNF 10.1.3 Drugs which suppress the rheumatic disease process

WCCG Pathway for Rheumatoid Arthritis (inc. TA375)

Azathioprine

Prescribed and monitored within the guidance of a shared care agreement.


Ciclosporin

Specialist/ Hospital prescribing only

Cyclophosphamide

Specialist/ Hospital prescribing only

Gold: Auranofin

Product discontinued by manufacturer 31 December 2009

Gold: Sodium aurothiomalate injection

Prescribed and monitored within the guidance of a shared care agreement

Hydoxychloroquine & chloroquine (antimalarials)

Annual review either by an optometrist or enquiring about visual symptoms, rechecking visual acuity and assessing for blurred vision using reading chart. Discuss with opthalmologist if on treatment for more than 5 years. Patients should be advised to report any visual disturbance BSR Guidelines

Leflunomide

Prescribed and monitored within the guidance of a shared care agreement

Methotrexate (oral)

Prescribed and monitored within the guidance of a shared care agreement.

CAUTION: ORAL DOSE GIVEN ONCE WEEKLY ONLY
NPSA Improving compliance with oral methotrexate http://www.npsa.nhs.uk/patientsafety/alerts-and-directives/alerts/oral-methotrexate/

Methotrexate (subcutaneous)  Specialist/ Hospital prescribing only

Penicillamine

Prescribed and monitored within the guidance of a shared care agreement

Sulfasalazine

Prescribed and monitored within the guidance of a shared care agreement


CYTOKINE INHIBITORS

Abatacept 

Specialist/ Hospital prescribing only

Adalimumab, etanercept, infliximab, rituximab and abatacept for the treatment of rheumatoid arthritis after the failure of a TNF inhibitor NICE TA195

Abatacept, adalimumab, etanercept and tocilizumab for treating juvenile idiopathic arthritis NICE TA373

Adalimumab, etanercept, infliximab, certolizumab pegol, golimumab, tocilizumab and abatacept for rheumatoid arthritis not previously treated with DMARDs or after conventional DMARDs only have failed NICE TA375 (replacing NICE TA280)

Adalimumab

Specialist/ Hospital prescribing onlyAdalimumab, etanercept, infliximab, rituximab and abatacept for the treatment of rheumatoid arthritis after the failure of a TNF inhibitor NICE TA195

Etanercept, infliximab and adalimumab for the treatment of psoriatic arthritis NICE TA199

Abatacept, adalimumab, etanercept and tocilizumab for treating juvenile idiopathic arthritis NICE TA373

TNF-alpha inhibitors for ankylosing spondylitis and non-radiographic axial spondyloarthritis NICE TA383

Adalimumab, etanercept, infliximab, certolizumab pegol, golimumab, tocilizumab and abatacept for rheumatoid arthritis not previously treated with DMARDs or after conventional DMARDs only have failed NICE TA375  (replacing NICE TA130)

Belimumab

Specialist/ Hospital prescribing only

Belimumab for treating active autoantibody-positive systemic lupus erythematosus NICE TA397

Certolizumab

Specialist/ Hospital prescribing only

TNF-alpha inhibitors for ankylosing spondylitis and non-radiographic axial spondyloarthritis NICE TA383

Adalimumab, etanercept, infliximab, certolizumab pegol, golimumab, tocilizumab and abatacept for rheumatoid arthritis not previously treated with DMARDs or after conventional DMARDs only have failed NICE TA375 (replacing NICE TA186)

Certolizumab pegol for treating rheumatoid arthritis after inadequate response to a TNF-alpha inhibitor NICE TA415

Certolizumab pegol and secukinumab for treating active psoriatic arthritis after inadequate response to DMARDs NICE TA445

Etanercept

Specialist/ Hospital prescribing only

Adalimumab, etanercept, infliximab, rituximab and abatacept for the treatment of rheumatoid arthritis after the failure of a TNF inhibitor NICE TA195

Rheumatoid arthritis - adalimumab, etanercept and infliximab NICE TA130

TNF-alpha inhibitors for ankylosing spondylitis and non-radiographic axial spondyloarthritis NICE TA383

Abatacept, adalimumab, etanercept and tocilizumab for treating juvenile idiopathic arthritis NICE TA373 

Adalimumab, etanercept, infliximab, certolizumab pegol, golimumab, tocilizumab and abatacept for rheumatoid arthritis not previously treated with DMARDs or after conventional DMARDs only have failed NICE TA375  

Golimumab 

Specialist/ Hospital prescribing only

Rheumatoid arthiritis after the failure of previous anti-rheumatic drugs NICE TA225

Psoriatic arthritis NICE TA220

Adalimumab, etanercept, infliximab, certolizumab pegol, golimumab, tocilizumab and abatacept for rheumatoid arthritis not previously treated with DMARDs or after conventional DMARDs only have failed NICE TA375  

TNF-alpha inhibitors for ankylosing spondylitis and non-radiographic axial spondyloarthritis NICE TA383

Golimumab for treating non-radiographic axial spondyloarthritis NICE TA497

Ixekizumab 

Specialist/Hospital prescribing only

Ixekizumab for treating active psoriatic arthritis after inadequate response to DMARDs NICE TA537 

Infliximab (Remicade®, Inflectra®, Remsima®)

Specialist/ Hospital prescribing only

Rheumatoid arthritis - adalimumab, etanercept and infliximab NICE TA130

Adalimumab, etanercept, infliximab, rituximab and abatacept for the treatment of rheumatoid arthritis after the failure of a TNF inhibitor NICE TA195

Adalimumab, etanercept, infliximab, certolizumab pegol, golimumab, tocilizumab and abatacept for rheumatoid arthritis not previously treated with DMARDs or after conventional DMARDs only have failed NICE TA375  

TNF-alpha inhibitors for ankylosing spondylitis and non-radiographic axial spondyloarthritis NICE TA383

Rituximab 

Specialist/ Hospital prescribing only

Adalimumab, etanercept, infliximab, rituximab and abatacept for the treatment of rheumatoid arthritis after the failure of a TNF inhibitor NICE TA195

Sarilumab 

Specialist/ Hospital prescribing only

Sarilumab for moderate to severe rheumatoid arthritis NICE TA485

Secukinumab  

Specialist/ Hospital prescribing only

Secukinumab for active ankylosing spondylitis after treatment with nonsteroidal anti-inflflammatory drugs or TNF-alpha inhibitors NICE TA407

Certolizumab pegol and secukinumab for treating active psoriatic arthritis after inadequate response to DMARDs NICE TA445  

Tocilizumab

Specialist/ Hospital prescribing only

Tocilizumab and methotrexate for moderate to severe active rheumatoid arthirits NICE TA247

Arthritis (juvenile idiopathic, systemic) NICE TA238

Abatacept, adalimumab, etanercept and tocilizumab for treating juvenile idiopathic arthritis NICE TA373 

Adalimumab, etanercept, infliximab, certolizumab pegol, golimumab, tocilizumab and abatacept for rheumatoid arthritis not previously treated with DMARDs or after conventional DMARDs only have failed NICE TA375  

Tofacitinib 

Specialist/ Hospital prescribing only

Tofacitinib for moderate to severe rheumatoid arthritis NICE TA480  

Tofacitinib for treating active psoriatic arthritis after inadequate response to DMARDs NICE TA543

BNF 10.1.4 Gout and cytotoxic-induced hyperuricaemia

Acute Attacks  
NSAID  
Colchicine Colchicine is the treatment of choice for patients with heart failure or receiving anticoagulants.Colchicine 500mcg tablets. 2 tablets immediately then ONE every 2-3 hours until pain relieved or vomiting / diarrhoea occur. Maximum dose is 6mg (12 tablets) per course. May be repeated after 3 days.
Long-term control  
Allopurinol Start 2-3 weeks after acute attack has settled.
Febuxostat If allopurinol is contra-indicated or not tolerated, in accordance with NICE Guidance (Hyperuricaemia - febuxostat) NICE TA164

Hyperuricaemia associated with cytotoxic drugs

Rasburicase For use by Haematologists only, for the prevention and treatment of acute hyperuricaemia in patients with haematological malignancy.    

BNF 10.2.1 Drugs which enhance neuromuscular transmission

Neostigmine
Edrophonium chloride injection - Specialist/ Hospital prescribing only
Pyridostigmine bromide

BNF 10.2.2 Skeletal muscle relaxants

Preparation Notes
Baclofen  
Dantrolene sodium  
Tizanidine  
Nocturnal Leg Cramps
Quinine sulphate 300mg at bedtime It may take up to 4 weeks for improvement to become apparent.Treatment should be interrupted at approximately 3-monthly intervals to assess need for further treatment.

BNF 10.3 Drugs for the relief of soft-tissue inflammation

Extravasation information http://www.extravasation.org.uk/home.html

BNF 10.3.1 Enzymes

Hyaluronidase - Specialist/ Hospital prescribing only

BNF 10.3.2 Rubefacients and other topical antirheumatics

Topical NSAIDs and Counter-Irrtiants

Ibuprofen gel 5% Not routinely stocked by RWHT. Fenbid® is the preferred brand in primary care.

 

Capsaicin Capsaicin 0.025% cream Osteoarthritis – symptomatic relief
  Capsaicin 0.075% cream Post-herpetic neuralgia
  Capsaicin 8% patch (Qutenza®)

Specialist/ Hospital prescribing only

Peripheral neuropathic pain in non-diabetic patients