|Therapeutic Area||Formulary Choices||Cost for 28|
(unless otherwise stated)
|Rationale for decision / comments|
|BNF Chapter 10: Musculoskeletal and joint diseases|
|10.1 Drugs used in rheumatic diseases and gout
Related guidance:CG177 Osteoarthritis: Care and management in adults Feb 2014
|Non-steroidal anti-inflammatory drugs|
|NICE recommends cytoprotection with PPIs for patients who require systemic NSAIDs. Recommended PPIs are: Lansoprazole 15mg capsules; Omeprazole 20mg capsules or Pantoprazole 20mg tablets.
Risk of GI bleeds is higher for slow release formulations.
|Note that all NSAIDs should be prescribed at the minimum effective dose for the minimum period in order to limit cardiovascular, renal and GI toxicity.
Consider trial of topical NSAIDs before moving to systemic NSAID for Osteoarthritis
|First line:||Ibuprofen||200mg tablets: £3.40 (84)|
400mg tablets: £3.64 (84)
600mg tablets: £5.77 (84)
|Ibuprofen is 1st choice on grounds of safety and cost|
|Second-line:||Naproxen||250mg tablets: £6.08 (28)|
500mg tablets: £9.16(28)
250mg effervescent tablets: £52.72 (20)
|Naproxen EC tablets are non-formulary, evidence that EC reduces GI events is poor and they are three times the price of standard tablets.|
|Diclofenac is now non-formulary after the EMEA/MHRA added new contraindications and warnings after a Europe-wide review of cardiovascular safety (Jun-13).|
|COX-2 selective NSAIDs||NICE recommends cytoprotection with PPIs for patients who require systemic COX-2s. Recommended PPIs are: Lansoprazole 15mg capsules or Omeprazole 20mg capsules|
|Note that all NSAIDs including COX-2s should be prescribed at the minimum effective dose for the minimum period in order to limit cardiovascular, renal and GI toxicity. Consider trial of topical NSAIDs before moving to systemic COX-2 for Osteoarthritis.|
|First-line:||Meloxicam||7.5mg tablets: £1.15 (30)|
15mg tablets: £1.24 (30)
(named-patient basis only – see comment right)
|100mg capsules: £2.83 (60)|
200mg capsules: £2.77.98 (30)
|NB: Etoricoxib & celecoxib are non-formulary (Celecoxib exception below)
Named-patient basis only when recommended by Consultant Rheumatologist when ibuprofen, naproxen and meloxicam are ineffective. Consider risk benefit compared to diclofenac.
MHRA advised in October 2016 that the recommended dose of etoricoxib in RA and ankylosing spondylitis is reduced to 60mg once daily based on the balance of benefit and risks.
|Rubefacients and |
|Algesal® - suitable for self-care||Cream: £1.49 (50g)||NICE CG59 advises that Paracetamol and/or Topical NSAIDs should be considered AHEAD of oral NSAIDs for OSTEOARTHRITIS
Topical NSAIDs should be considered for use in addition to core treatment for knee or hand inflammation.
For patients using large volumes of topical NSAIDs, Fenbid® 5% gel is the most cost-effective.
Topical ketoprofen is no longer recommended following a Drug Safety Update warning about the risk of photosensitivity reactions after exposure to direct sunlight, uv lamps, etc.
|Transvasin® - suitable for self care||Cream: £1.72 (40g)|
- suitable for self-care
|5% gel: £1.50 (100g)
10% gel £4.00 (100g)
|Piroxicam||0.5% gel: £4.33 (112g)|
|Felbinac (Traxam®) and Diclofenac (Voltarol®) gels / foams are non formulary|
|Capsaicin||0.025% cream £17.71 (45g),|
0.075% cream £14.58 (45g)
|Topical capsaicin should be considered as an adjunct to core treatment for knee or hand osteoarthritis|
|Gout||Guidelines on management of gout available from The British Society for Rheumatology and British Health Professionals in Rheumatology: http://rheumatology.oxfordjournals.org/cgi/reprint/kem056av1|
|First-line:||Naproxen||250mg tablets: £6.08 (28)|
500mg tablets: £9.16 (28)
|Oral NSAIDs at maximum doses are the drugs of choice where there are no contra-indications.
NICE recommends gastroprotection with PPIs for patients who require systemic COX-2s. See above
|Second-line:||Colchicine||500mcg tablets: £9.74 (100)||Colchicine can be an effective alternative to NSAIDs, but has a slower onset of action. To reduce risk of diarrhoea it should be used in doses of 500mcg bd to qds|
|Long term control:|
|First-line||Allopurinol||100mg tablets: £1.37 (28)|
300mg tablets: £1.77 (28)
|Allopurinol is first line therapy for lowering uric acid. In uncomplicated gout, therapy should be started if a second attack or further attacks occur within 1 year. Commence 1-2 weeks after inflammation of acute attack has settled. Treatment should be initiated with 50-100mg/day and increased at 50-100mg increments every few weeks, adjusted in necessary for renal function, until the therapeutic target (Serum Uric Acid < 300 µmol/litre) is reached. Maximum in severe conditions 900mg/day in divided doses.
If mild/moderate renal impairment: seek further advice.
|Second-line:||Febuxostat||80mg tablets: £24.36 (28)|
120mg tablets: £24.36 (28)
|Febuxostat is recommended as an option for the management of chronic hyperuricaemia in gout only when allopurinol is not tolerated at an effective dose or for whom allopurinol is contra-indicated. NICE TA164
Note MHRA Drug Safety Update
|Sulfinpyrazone||100mg tablets: £102.96 (84)|
200mg tablets: £147.65 (84)
|Uricosuric therapy with Sulfinpyrazone (usually 200-600mg/day) may be an appropriate second line option for patients with normal renal function who are under-excretors of uric acid and those resistant to, or intolerant of, Allopurinol. For those with mild/moderate renal impairment seek further advice.|
|Severe active rheumatoid arthritis|
If specialist prescribes methotrexate under shared care
| Methotrexate tablets|
7.5mg £12.87, 10mg £13.26, 12.5mg £14.35
15mg £14.41, 17.5mg £15.25, 20mg £15.56
22.5mg £16.11, 25mg £16.64, 27.5mg £16.50, 30mg £16.56
|Prescribe in multiple of 2.5mg tablets for safety reasons. 10mg are non-formulary
Suggested guide to methotrexate monitoring here
N.B. In October 2020, NICE amended their guidance [NG100] Rheumatoid arthritis in adults: management to clarify that multiple DMARDs can be offered one after the other to achieve treatment targets.
NICE recommendations from CG71
Osteoarthritis: care and management