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10. Musculoskeletal and Joint Diseases
Diclofenac / Misoprostol
BNF | BNFC | SPC

Misofen, Arthrotec

Tees Do Not Prescribe/Grey List

BNF recommends a higher starting dose of misoprostol for prophylaxis against NSAID induced GI ulceration than that provided by combination preparations.

Ibuprofen
BNF | BNFC | SPC

Tablets 200mg, 400mg

Liquid 100mg/5ml

Doses above 1200mg/day increase adverse drug reactions

Naproxen
BNF | BNFC | SPC

Tablets 250mg, 500mg

Naproxen / Esomeprazole
BNF | BNFC | SPC
Apremilast
BNF | BNFC | SPC

Tariff Excluded; CCG Commissioned (NHSE in paediatric indications)

Approved: NICE TA419TA433

 

Azathioprine – see section 8.2.1
BNF | BNFC | SPC
Baricitinib
BNF | BNFC | SPC

Tariff-Excluded; CCG Commissioned

Approved: NICE TA466

Ciclosporin (Neoral) see section 8.2.2
BNF | BNFC | SPC

Capsules, 25mg and 50mg

Shared Care

Initiated by specialist only

Dermatology Shared Care Guideline

Nephrology Shared Care Guideline

Rheumatology Shared Care Guideline

Important safety information: Patients should be stabilised on a particular brand of oral ciclosporin because switching between formulations without close monitoring may lead to clinically important changes in the blood-ciclosporin concentration

Hydroxychloroquine
BNF | BNFC | SPC
Leflunomide
BNF | BNFC | SPC

Tablets 10mg, 20mg

Initiated by rheumatology only

Shared Care

Rheumatology Shared Care Guideline

Methotrexate Injection
BNF | BNFC | SPC
Methotrexate ONCE WEEKLY DOSE
BNF | BNFC | SPC

Tablets 2.5mg

Shared Care as per guidelines:

Rheumatology Shared Care Guideline

Penicillamine
BNF | BNFC | SPC

Tablets 125mg, 250mg

Shared Care

Initiated by rheumatology only 

Rheumatology Shared Care Guideline

Sodium aurothiomalate
BNF | BNFC | SPC

Shared Care

Initiated by Rheumatology only

Rheumatology Shared Care Guideline

Sulfasalazine
BNF | BNFC | SPC

Tablets 500mg; EC tablets 500mg

Initiated by rheumatology only

Shared Care

Rheumatology Shared Care Guideline

Adalimumab
BNF | BNFC | SPC

Tariff Excluded; CCG/NHSE Commissioned

Approved: NICE TA146, TA187, TA195TA199TA329, TA373, TA375, TA383, TA392, TA455, TA460

Not approved for use: NICE TA262

Abatacept
BNF | BNFC | SPC

Tariff Excluded; CCG Commissioned (NHSE in paediatric indications)

Approved: NICE TA195, TA280, TA373, TA375

Belimumab
BNF | BNFC | SPC

Tariff Excluded; NHSE Commissioned

Approved: NICE TA397

Certolizumab Pegol
BNF | BNFC | SPC

Tariff Excluded; CCG Commissioned (NHSE in paediatric indications)

Approved: NICE TA375, TA383, TA415, TA445

NTAG Recommendation: Certolizumab for the treatment of Psoriatic Arthritis 8/9/15 - Recommended as an option in those patients who fulfil NICE criteria for use of TNF Inhibitor therapy in psoriatic arthritis. However other, more established, NICE approved treatment options would remain first line choices in this patient group.

Etanercept
BNF | BNFC | SPC

Tariff Excluded; CCG Commissioned (NHSE in paediatric indications)

Approved: NICE TA103TA130, TA143TA195, TA199TA373, TA375, TA383, TA455

Golimumab
BNF | BNFC | SPC

Tariff-excluded; CCG commissioned in adult indications (NHSE Paediatric indications)

Approved: NICE TA220, TA225TA329, TA375, TA383, TA497

 

Infliximab
BNF | BNFC | SPC

Tariff Excluded; CCG/NHSE Commissioned

Approved: NICE TA134, TA163, TA187, TA195, TA199, TA329, TA375, TA383

Not Approved: NICE TA140, TA143

NTAG Recommendations: 8/9/15 - Infliximab Biosimilars (Rheumatoid Arthritis, Ankylosing Spondylitis, Psoriatic Arthritis, Psoriasis, Crohn's Disease and Ulcerative Colitis) are recommended where the originator product would normally be prescribed.  They should be considered as a first line option in new patients suitable for treatment with infliximab. For existing patients consideration should be given to switching where it is clinically appropriate and as part of a clinician led management programme which has appropriate monitoring in place.

Rituximab
BNF | BNFC | SPC

Tariff Excluded; NHSE/CCG Commissioned

Approved: NICE TA137, TA174, TA193, TA195, TA226, TA243, TA308

NHSE Commissioned for Acute Anti-NMDA receptor Autoimmune Encephalitis

NTAG Recommendation: Rituximab for Immune (idiopathic) Thrombocytopenic Purpura 9/4/15 - Recommended as an option for second line treatment in adults or children

 

Sarilumab
BNF | BNFC | SPC

Tariff Excluded; CCG Commissioned

Approved: NICE TA485 - for moderate to severe rheumatoid arthritis

Secukinumab
BNF | BNFC | SPC

Tariff Excluded; CCG Commissioned (NHSE in paediatric indications)

Approved: NICE TA350, TA407, TA445

Tocilizumab
BNF | BNFC | SPC

Tariff Excluded; CCG Commissioned in Rheumatoid Arthritis (Adults only), NHSE commissioned in Juvenile Idiopathic Arthritis and Giant Cell Arteritis

Approved: NICE TA238, TA247, TA373, TA375, TA518

Ustekinumab
BNF | BNFC | SPC

Tariff Excluded; CCG Commissioned (NHSE in paediatric indications)

Approved: NICE TA180, TA340, TA455TA456

Tofacitinib
BNF | BNFC | SPC

Tariff Excluded; CCG Commissioned

Approved: NICE TA480 - Tofacitinib for moderate to severe rheumatoid arthritis

Approved: NICE TA543 - Tofacitinib for treating active psoriatic arthritis after inadequate response to DMARDs. CCG is the responsible commissioner for adult patients. 

Approved: NICE TA547: Tofacitinib for treating moderately to severely active ulcerative colitis in adults. CCG is the responsible commissioner for adult patients.

Allopurinol
BNF | BNFC | SPC

Tablets 100mg, 300mg

Colchicine
BNF | BNFC | SPC

Tablets 500microgram

Febuxostat
BNF | BNFC | SPC

Tablets 80mg , 120mg

Prescribed in accordance with NICE TA164

Only in patients intolerant to allopurinol or in whom allopurinol is contraindicated

Lesinurad
BNF | BNFC | SPC

Not Approved: NICE TA506

Pegloticase
BNF | BNFC | SPC

Not Approved: NICE TA291

Rasburicase
BNF | BNFC | SPC

Hyperuricaemia associated with chemotherapy

Autologous chondrocyte implantation
BNF | BNFC | SPC

NHSE commissioned

Approved: NICE TA477TA508

Glucosamine (+/- chondroitin)
BNF | BNFC | SPC

Tees Do Not Prescribe/Grey List

NICE do not recommend glucosamine or chondroitin preparations.  The guidance states that there is limited and uncertain evidence of the effectiveness of these preparations in the management of osteoarthritis.

 

Synovial fluid injections
BNF | BNFC | SPC
Baclofen
BNF | BNFC | SPC

Tablets 10mg

Syrup 5mg/5ml

Cannabis Extract (Sativex)
BNF | BNFC | SPC

Tees Do Not Prescribe/Grey List

NTAG Rejected: Sativex for treatment of non-MS pain 25/11/14 - Rejected due to evidence for efficacy of Sativex® considered to be of low quality and did not demonstrate a clear benefit. Combined with a high acquisition cost, Sativex® was considered unlikely to meet conventional cost-effectiveness criteria

NICE Do Not Do Recommendation

Collagenase
BNF | BNFC | SPC

Tariff Excluded; CCG Commissioned

Dupytren’s contracture in patients with a palpable cord

Approved: NICE TA459

Benzydamine
BNF | BNFC | SPC

Tees prescribing grey list

Prescribing of topical rubefacient preparations is not supported by Hartlepool & Stockton-on-Tees CCGs.

Topical rubefacient preparations may contain nicotinate and salicylic acid compounds, essential oils, capsicum, and camphor which are all irritant
The evidence available does not support the use of topical rubefacients in acute or chronic musculoskeletal pain.  Rubefacients should not be offered to treat osteoarthritis.  Stop any prescribing.

NICE states that capsaicin patches should not be used for neuropathic pain in non-specialist settings, unless advised by a specialist.

PrescQIPP briefing 114: Rubefacients

Capsaicin
BNF | BNFC | SPC

Tees prescribing grey list

Prescribing of topical rubefacient preparations is not supported by Hartlepool & Stockton-on-Tees CCGs.

Topical rubefacient preparations may contain nicotinate and salicylic acid compounds, essential oils, capsicum, and camphor which are all irritant
The evidence available does not support the use of topical rubefacients in acute or chronic musculoskeletal pain.  Rubefacients should not be offered to treat osteoarthritis.  Stop any prescribing.

NICE states that capsaicin patches should not be used for neuropathic pain in non-specialist settings, unless advised by a specialist.

PrescQIPP briefing 114: Rubefacients

Diethylamine Salicylate
BNF | BNFC | SPC

Tees prescribing grey list

Prescribing of topical rubefacient preparations is not supported by Hartlepool & Stockton-on-Tees CCGs.

Topical rubefacient preparations may contain nicotinate and salicylic acid compounds, essential oils, capsicum, and camphor which are all irritant
The evidence available does not support the use of topical rubefacients in acute or chronic musculoskeletal pain.  Rubefacients should not be offered to treat osteoarthritis.  Stop any prescribing.

NICE states that capsaicin patches should not be used for neuropathic pain in non-specialist settings, unless advised by a specialist.

PrescQIPP briefing 114: Rubefacients

Freeze Sprays and Gels
BNF | BNFC | SPC

Tees prescribing grey list

Prescribing of topical rubefacient preparations is not supported by Hartlepool & Stockton-on-Tees CCGs.

Topical rubefacient preparations may contain nicotinate and salicylic acid compounds, essential oils, capsicum, and camphor which are all irritant
The evidence available does not support the use of topical rubefacients in acute or chronic musculoskeletal pain.  Rubefacients should not be offered to treat osteoarthritis.  Stop any prescribing.

NICE states that capsaicin patches should not be used for neuropathic pain in non-specialist settings, unless advised by a specialist.

PrescQIPP briefing 114: Rubefacients

Heparinoid
BNF | BNFC | SPC

Tees prescribing grey list

Prescribing of topical rubefacient preparations is not supported by Hartlepool & Stockton-on-Tees CCGs.

Topical rubefacient preparations may contain nicotinate and salicylic acid compounds, essential oils, capsicum, and camphor which are all irritant
The evidence available does not support the use of topical rubefacients in acute or chronic musculoskeletal pain.  Rubefacients should not be offered to treat osteoarthritis.  Stop any prescribing.

NICE states that capsaicin patches should not be used for neuropathic pain in non-specialist settings, unless advised by a specialist.

PrescQIPP briefing 114: Rubefacients

Ibuprofen
BNF | BNFC | SPC

Gel 5%, 10%

Kaolin Heavy
BNF | BNFC | SPC

Tees prescribing grey list

Prescribing of topical rubefacient preparations is not supported by Hartlepool & Stockton-on-Tees CCGs.

Topical rubefacient preparations may contain nicotinate and salicylic acid compounds, essential oils, capsicum, and camphor which are all irritant
The evidence available does not support the use of topical rubefacients in acute or chronic musculoskeletal pain.  Rubefacients should not be offered to treat osteoarthritis.  Stop any prescribing.

NICE states that capsaicin patches should not be used for neuropathic pain in non-specialist settings, unless advised by a specialist.

PrescQIPP briefing 114: Rubefacients

Methyl Salicylate
BNF | BNFC | SPC

Tees prescribing grey list

Prescribing of topical rubefacient preparations is not supported by Hartlepool & Stockton-on-Tees CCGs.

Topical rubefacient preparations may contain nicotinate and salicylic acid compounds, essential oils, capsicum, and camphor which are all irritant
The evidence available does not support the use of topical rubefacients in acute or chronic musculoskeletal pain.  Rubefacients should not be offered to treat osteoarthritis.  Stop any prescribing.

NICE states that capsaicin patches should not be used for neuropathic pain in non-specialist settings, unless advised by a specialist.

PrescQIPP briefing 114: Rubefacients

Nicotinates
BNF | BNFC | SPC

Tees prescribing grey list

Prescribing of topical rubefacient preparations is not supported by Hartlepool & Stockton-on-Tees CCGs.

Topical rubefacient preparations may contain nicotinate and salicylic acid compounds, essential oils, capsicum, and camphor which are all irritant
The evidence available does not support the use of topical rubefacients in acute or chronic musculoskeletal pain.  Rubefacients should not be offered to treat osteoarthritis.  Stop any prescribing.

NICE states that capsaicin patches should not be used for neuropathic pain in non-specialist settings, unless advised by a specialist.

PrescQIPP briefing 114: Rubefacients

Turpentine Oil
BNF | BNFC | SPC

Tees prescribing grey list

Prescribing of topical rubefacient preparations is not supported by Hartlepool & Stockton-on-Tees CCGs.

Topical rubefacient preparations may contain nicotinate and salicylic acid compounds, essential oils, capsicum, and camphor which are all irritant
The evidence available does not support the use of topical rubefacients in acute or chronic musculoskeletal pain.  Rubefacients should not be offered to treat osteoarthritis.  Stop any prescribing.

NICE states that capsaicin patches should not be used for neuropathic pain in non-specialist settings, unless advised by a specialist.

PrescQIPP briefing 114: Rubefacients

Other Rubefacient and Topical Antirheumatic Preparations
BNF | BNFC | SPC

Tees prescribing grey list

Prescribing of dental products is not supported by Hartlepool & Stockton-on-Tees and South Tees CCGs.  Consider dental referral.

Dental products should only be prescribed by dentists and GPs should not accept requests to prescribe medicines that the dentist could reasonably prescribe themselves, nor accept requests from patients to issue FP10 prescriptions for items prescribed on a private prescription by their dentist.  Patients should be advised of self-care measures and signposted to purchase over the counter remedies for dental conditions where appropriate.