Greater Glasgow and Clyde Medicines
Key to symbols The medicine should be initiated by, or on the advice of a specialist, but is suitable for continuation by a GP The medicine should only be used and prescribed by a specialist Indicates the preferred choice within a class or group of medicines
The medicine should be initiated by, or on the advice of a specialist, but is suitable for continuation by a GP
The medicine should only be used and prescribed by a specialist
Indicates the preferred choice within a class or group of medicines
10. Musculoskeletal and joint diseases

10.1. Drugs used in rheumatic diseases and gout

10.1.1. Non-steroidal anti-inflammatory drugs

Preferred List
Preferred List First Line
NAPROXEN (tablets)

Prescribing Notes:

There is a significant cost difference between the tablets and the enteric coated tablets.

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Preferred List First Line
IBUPROFEN

Restrictions: Use of MR preparations is restricted. Modified-release preparations of any NSAID should be restricted to patients with early morning stiffness or compliance problems as they encourage regular/higher doses of NSAIDs and do not afford flexibility in reducing the dose.

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CELECOXIB

Restrictions: Use in ankylosing spondylitis remains non-Formulary.

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ETODOLAC
Total Formulary
ETORICOXIB

Restrictions: Restricted to use in acute gout only. Other indications, including the use in the treatment of ankylosing spondylitis which has not been accepted by SMC, are non-Formulary.

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NAPROXEN (effervescent tablets)

Restrictions: Restricted to use in patients unable to swallow naproxen tablets.

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DICLOFENAC AND MISOPROSTOL (ARTHROTEC)

Prescribing Notes:

In June 2013, the MHRA issued new contraindications and warnings for diclofenac following a review of the cardiovascular risk, which it states is similar to that of the selective COX-2 inhibitors.  A summary of the guidance on the MHRA website is available HERE

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MELOXICAM
DICLOFENAC

Restrictions: Use of MR preparations is restricted. Modified-release preparations of any NSAID should be restricted to patients with early morning stiffness or compliance problems as they encourage regular/higher doses of NSAIDs and do not afford flexibility in reducing the dose.

Prescribing Notes:

In June 2013, the MHRA issued new contraindications and warnings for diclofenac following a review of the cardiovascular risk, which it states is similar to that of the selective COX-2 inhibitors.  A summary of the guidance on the MHRA website is available HERE

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10.1.2. musculoskeletal-corticosteroids

10.1.2.1. Systemic corticosteroids

10.1.2.2. Local corticosteroid injections

Total Formulary
TRIAMCINOLONE
HYDROCORTISONE
Preferred List
METHYLPREDNISOLONE (INJECTION)

Prescribing Notes:

For oral preparations, see section 6.3.

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10.1.3. Drugs that suppress the rheumatic disease process

Preferred List
Specialist and GP
METHOTREXATE (2.5MG TABLETS)

Restrictions:

Restricted to specialist initiation.

Prescribing Notes:

Oral methotrexate should only be prescribed as 2.5mg tablets to avoid patient confusion. The dose should be clearly specified on the dispensing label. In view of reports of blood dyscrasias (including fatalities) and liver cirrhosis with low-dose methotrexate, the CSM has advised: - full blood count and renal and liver function tests before starting treatment and repeated weekly until therapy stabilised, thereafter patients should be monitored every 2-3 months. - that patients should be advised to report all symptoms and signs suggestive of infection, especially sore throat.

Near Patient Testing (NPT) arrangements for GPs may be in place for this medicine.  See the relevant section in the Prescribing Resources page for current information.

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Specialist and GP
HYDROXYCHLOROQUINE

Restrictions: Restricted to specialist initiation.

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SULFASALAZINE (ec tablets)

Prescribing Notes:

The CSM has advised that patients should be advised to report any unexplained bleeding, bruising, purpura, sore throat, fever or malaise (potential signs of blood dyscrasia).

Near Patient Testing (NPT) arrangements for GPs may be in place for this medicine.  See the relevant section in the Prescribing Resources page for current information.

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Total Formulary
Specialist Only
IXEKIZUMAB (injection)

Restrictions:

Ixekizumab as monotherapy or in combination with methotrexate for the treatment of active psoriatic athritis in adults is restricted to specialist use in accordance with local guidelines.

Prescribing Notes:

For the use of ixekizumab in psoriasis, see section 13.5.3.

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Specialist Only
ANAKINRA (KINERET)

Restrictions:

Restricted to specialist use and the indications listed under Prescribing Notes below.

Prescribing Notes:

Formulary indications:

  • Treatment of Still's disease, including Systematic Juvenile Idiopathis Arthritis (SJIA) and Adult-Onset Still's Diease (AOSD), in adults and adolescents with active systemic features of moderate to high disease activity, or in patients with continued disease activity after treatment with non-steroidal anti-inflammatory drugs (NSAIDs) or glucocorticosteroids. Anakinra can be given as monotherapy or in combination with other anti-inflammatory and disease-modifying anti-rheumatic drugs (DMARDs).

Non-formulary indications:

  • Treatment of rheumatoid arthritis is not recommended by SMC.
  • Treatment of Cryopyrin-Associated Periodic Syndromes (CAPS) in adults and adolescents is not recommended by SMC.

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Specialist Only
SARILUMAB (KEVZARA) (injection)

Restrictions:

The use in the treatment of active rheumatoid athritis is restricted to patients with severe disease (a disease activity score [DAS28] greater than 5.1) that has not responded to intensive therapy with a combination of conventional disease-modifying anti-rheumatic drugs (DMARDs) including methotrexate. In patients with severe disease inadequately controlled by a TNF antagonist, it may be used in patients ineligible to receive rituxumab.

Prescribing Notes:

Where the treatment choice is an IL-6 inhibitor, then sarilumab is the preferred choice.

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Specialist Only
TOFACITINIB (XELJANZ) (tablets)

Restrictions:

Rheumatoid Athritis:
  • Use in rheumatoid athritis is restricted to specialist use in patients with severe disease (a disease activity score [DAS28] >5.1) that has not responded to intensive therapy with at least two conventional DMARDs including methotrexate.  In patients with severe disease inadequately controlled by a tumour necrosis factor (TNF) antagonist, it may be used in patients ineligible to receive rituximab

Psoriatic Arthritis:

  • Use in combination with methotrexate for the treatment of active psoriatic arthritis in adults is restricted to use in accordance with local guidelines.

Prescribing Notes:

Where a JAK inhibitor is the selected treatment option, baricitinib would be the preferred choice in NHSGGC.

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Specialist Only
BARICITINIB (OLUMIANT) (tablets)

Restrictions:

Use in rheumatoid athritis is restricted to specialist use in patients with severe disease (a disease activity score [DAS28] >5.1) that has not responded to intensive therapy with at least two conventional DMARDs including methotrexate.  In patients with severe disease inadequately controlled by a tumour necrosis factor (TNF) antagonist, it may be used in patients ineligible to receive rituximab.

Prescribing Notes:

Where a JAK inhibitor is the selected treatment option, baricitinib would be the preferred choice in NHSGGC.

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Specialist Only
BELIMUMAB (infusion)

Restrictions:

Restricted to specialist use in patients with evidence of serological disease activity (i.e. positive anti-dsDNA and low complement) and a Safety of Estrogens in Lupus Erythematosus National Assessment-Systemic Lupus Erythematosus Disease Activity Index (SELENA-SLEDAI) score of ≥10.

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Specialist Only
SECUKINUMAB

Restrictions: Restricted to specialist use as detailed in the prescribing notes below.

Prescribing Notes:

  • Treatment of psoriatic arthritis is restricted to specialist use only in patients whose disease has not responded to adequate trials of at least two standard DMADRs either individually or in combination
  • Treatment of active ankylosing spondylitis (AS) in adults who have responded inadequately to conventional therapy

See section 13.5.3 for use in plaque psoriasis.

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Specialist Only
APREMILAST (tablets)

Restrictions: Use in the treatment of Psoriatic Arthritis (PsA) is restricted to specialist use in adults with active psoriatic athritis who have had an inadequate response with at least two prior disease modifying anti-rheumatics drugs (DMARDs) or who are intolerant to such therapies.

Prescribing Notes:

For other indications please see chapter 13.5.3

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Specialist Only
USTEKINUMAB (STELARA) (sub-cutaneous injection)

Restrictions:

The use as monotherapy or in combination with methotrexate, for the treatment of active psoriatic arthritis in adult patients when the response to previous non-biological disease-modifying anti-rheumatic drug therapy has been inadequate, is restricted to specialist use in patients with active psoriatic arthritis who have failed on, or are unsuitable for, treatment with an anti-TNF drug

Prescribing Notes:

For use in psoriasis, see section 13.5.3 and use in Crohn's disease, see section 1.5.3.

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Specialist Only
GOLIMUMAB (SIMPONI) (injection)

Restrictions: Golimumab is included in the Formulary for use in specific patient groups in ankylosing spondylitis, psoriatic arthritis, rheumatoid arthritis and axial spondyloarthritis in accordance with SMC advice/local formulary restrictions as detailed in the prescribing notes below.

Prescribing Notes:

Ankylosing spondylitis:

The treatment of severe active ankylosing spondylitis in adults is restricted to use in accordance with the British Society of Rheumatology guidelines. 

For the relevant SMC advice for ankylosing spondylitis click here

Psoriatic Arthritis:

Use in combination with methotrexate, for the treatment of active and progressive psoriatic arthritis in adult patients when the response to previous disease-modifying anti-rheumatic drug (DMARD) therapy has been inadequate is restricted to specialist use in patients whose disease has not responded to adequate trials of at least two standard DMARDs, administered either individually or in combination. .

For the relevant SMC advice for psoriatic arthritis click here

Rheumatoid Arthritis:

The use in combination with methotrexate, for the treatment of moderate to severe, active rheumatoid arthritis is restricted to use in accordance with the British Society for Rheumatology (BSR) guidelines (2005). 

For relevant SMC advice for rheumatoid arthritis click here

Axial Spondyloarthritis:

The treatment of adults with severe, active non-radiographic axial spondyloarthritis with objective signs of inflammation as indicated by elevated C-reactive protein (CRP) and/or magnetic resonance imaging (MRI) evidence, who have had an inadequate response to, or are intolerant to non-steroidal anti-inflammatory drugs (NSAIDs) is restricted to specialist use.

For the relevant SMC advice for axial spondyloarthritis click here

BNF Link

Specialist Only
ABATACEPT (infusion, sub-cutaneous injection)

Restrictions:

Restricted to specialist use in combination with methotrexate for adult patients with active rheumatoid arthritis as measured by a disease activity score (DAS28) greater than 5.1 confirmed on at least two occasions 1 month apart who have responded inadequently to previous therapy with one or more disease-modifying anti-rheumatic drugs including methotrexate or a TNF-alpha inhibitor.

Prescribing Notes:

The following indications are not recommended by SMC and remain non-Formulary

  • The treatment of patients with RA not previously treated with methotrexate
  • Alone, or in combination with methotrexate, for the treatment of active psoriatic arthritis in adults when the response to previous disease-modifying anti-rheumatic drug (DMARD) therapy including methotrexate, has been inadequate, and for whom additional systemic therapy for psoriatic skin lesions is not required.

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Specialist Only
CERTOLIZUMAB

Restrictions:

Restricted to specialist use only for the indications as outlined below in the Prescribing Notes section:

Prescribing Notes:

Formulary indications and restrictions:

  • Moderate to severe active rheumatoid arthritis in combination with methotrexate in adult patients when the response to disease modifying anti-rheumatic drugs, including methotrexate, has been inadequate and monotherapy in case of intolerance to methotrexate or when continued treatment with methotrexate is inappropriate
  • The treatment of adult patients with severe active axial spondyloarthritis, comprising (1) Ankylosing spondylitis (AS) and (2) Axial spondyloarthritis without radiographic evidence of AS (nr-axSpA)
  • Active psoriatic arthritis is restricted to specialist use in patients whose disease has not responded to adequate trials of at least two standard DMARDs either individually or in combination. It may be used in combination with methotrexate or as monotherapy in cases of intolerance to methotrexate or when continued treatment with methotrexate is inappropriate.

Non-formulary indications:

  • Treatment of severe, active and progressive RA in adults not previously treated with MTX or other DMARDs.

For indications in dermatology, see section 13.5.3

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Specialist Only
RITUXIMAB

Restrictions: Restricted to specialist use only. Use in rheumatoid arthritis is restricted to specialist use in accordance with local protocol.

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Specialist and GP
SODIUM AUROTHIOMALATE

Restrictions:

Restricted to specialist initiation.

Prescribing Notes:

Near Patient Testing (NPT) arrangements for GPs may be in place for this medicine.  See the relevant section in the Prescribing Resources page for current information.

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Specialist and GP
PENICILLAMINE

Restrictions: Restricted to specialist initiation.

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Specialist and GP
MINOCYCLINE

Restrictions: Restricted to specialist initiation. This is an unlicensed indication of minocycline and is restricted to initiation by consultant rheumatologists for use in patients who could not be successfully treated with other DMARDs or anti-TNF therapy because of sepsis.

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Specialist and GP
METHOTREXATE (Metoject) (PRE-FILLED SYRINGE)

Restrictions: To be initiated and supervised by a specialist, though GPs are able to continue prescribing.

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Specialist and GP
LEFLUNOMIDE

Restrictions:

Restricted to specialist initiation. In adults, leflunomide is restricted to initiation by consultant rheumatologists.

Prescribing Notes:

Near Patient Testing (NPT) arrangements for GPs may be in place for this medicine.  See the relevant section in the Prescribing Resources page for current information.

BNF Link

Specialist Only
INFLIXIMAB

Restrictions:

Restricted to specialist use only.

In adults, infliximab is restricted to initiation by consultant rheumatologists for:

  • Treatment of psoriatic arthritis is restricted to criteria set out in NICE Technology Appraisal 104.
  • Treatment of ankylosing spondylitis is restricted to use in accordance with recommendations made in the NICE TA 383 click here.

Prescribing Notes:

Infliximab should be prescribed by brand name. Remsima® is the preferred biosimilar.

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Specialist Only
ETANERCEPT

Restrictions:

Restricted to specialist use only.

In adults, etanercept is restricted to initiation by consultant rheumatologists for:

  • Treatment of ankylosing spondylitis is restricted to use in accordance with the British Society for Rheumatology (BSR) guidelines of July 2004.
  • Treatment of axial spondyloarthritis is restricted to specialist use in accordance with the recommendations made in NICE TA 383 click here

In children and adolescents, etanercept is restricted to initiation by consultant rheumatologists for:

  • Treatment of juvenile idiopathic arthritis is restricted to use by paediatric rheumatologists. Etanercept is restricted to use according to SMC and local implementation protocols.
  • Severe chronic plaque psoriasis treated under supervision only by specialist physicians in accordance with SMC criteria.

Prescribing Notes:

Etanercept should be prescribed by brand name. Benepali® is the preferred biosimilar.

BNF Link

Specialist Only
TOCILIZUMAB (IV infusion, sub-cutaneous injection)

Restrictions:

Specialist use only.

  • Use for moderate to severe active rheumatoid arthritis in combination with methotrexate, or as monotherapy, in patients who are intolerant to methotrexate or where continued treatment with methotrexate is inappropriate, is restricted in accordance with the British Society of Rheumatology guidelines (2005).
  • Treatment of Giant Cell Arteritis (GCA) in adults is restricted to use in accordance with local guidelines and is subject to a 12-month clinical stopping rule.

Prescribing Notes:

Non-formulary indications:

  • Treatment of severe, active and progressive rheumatoid arthritis in adults not previously treated with methotrexate is not recommended by SMC.

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Specialist and GP
CICLOSPORIN

Restrictions: Restricted to specialist initiation. Restricted to specialist use for refractory patients.

Prescribing Notes:

Prescribe by brand name.

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Specialist and GP
AZATHIOPRINE

Restrictions:

Restricted to specialist initiation.

Prescribing Notes:

Near Patient Testing (NPT) arrangements for GPs may be in place for this medicine.  See the relevant section in the Prescribing Resources page for current information.

BNF Link

Specialist Only
ADALIMUMAB

Restrictions:

Restricted to specialist use only in accordance with the prescribing notes below.

Prescribing Notes:

Adalimumab should be prescribed by brand name. Amgevita® is the preferred biosimilar.

Ankylosing Spondylitis

  • Use for ankylosing spondylitis is restricted to use in accordance with the British Society for Rheumatology guidelines of July 2004.

Axial Spondyloarthritis

  • The treatment of adults with severe axial spondyloarthritis without radiographic evidence of ankylosing spondylitis but with objective signs of inflammation by elevated C-reactive protein (CRP) and/or magnetic resonance imaging (MRI), who have had an inadequate response to, or are intolerant to non-steroidal anti-inflammatory drugs (NSAIDs) is restricted to specialist use in accordance with Assessment in Spondyloarthritis Internation Society (ASIS) guidance. 

Active polyarticular idiopathic arthritis

  • Use for active polyarticular idiopathic arthritis in adolescents aged 13-17 years is restricted to those who have an inadequate response to one or more DMARDs.

For the use in other indications, see sections 1.5.3, 11.8 and 13.5.3

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10.1.4. Gout and cytotoxic-induced hyperuricaemia

Preferred List
INDOMETACIN
ALLOPURINOL

Prescribing Notes:

Allopurinol alone should not be initiated during the acute phase as it may precipitate further attacks or make the gout worse.

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COLCHICINE
Total Formulary
FEBUXOSTAT

Restrictions: Restricted to use as outlined in Prescribing Notes section below.

Prescribing Notes:

  • Chronic hyperuricaemia: restricted to symptomatic patients whose uric acid levels have failed to respond adequately despite optimal dosing of allopurinol.
  • Hyperuricaemia related to chemotherapy:  prevention and treatment of hyperuricaemia in adult patients undergoing chemotherapy for haematologic malignancies is restricted to specialist use for patients at intermediate risk of tumour lysis syndrome (TLS) in whom allopurinol is either unsuitable or contraindicated, such as those intolerant of allopurinol or those in whom allopurinol is contraindicated, e.g. patients with renal impairment.

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Specialist Only
RASBURICASE

Restrictions: Restricted to specialist use only. Restricted to use under the supervision of haematologists and oncologists and subject to NHSGGC protocol for adults and children.

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ETORICOXIB

Restrictions: Etoricoxib is restricted to use only in acute gout in high risk patients. See section 10.1.1 in preferred list for CSM advice. All other indications are non-Formulary.

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AZAPROPAZONE

10.1.5. Other drugs for rheumatic diseases