netFormulary South East London Joint Medicines Formulary NHS
Guy's and St Thomas' NHS Foundation Trust
Kings College Hospital NHS Foundation Trust
Lewisham and Greenwich NHS Trust
 
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 Formulary Chapter 10: Musculoskeletal and joint diseases - Full Chapter
Notes:

Where a formulary entry does not detail a medicine’s indications for use, the medicine can be assumed to be approved for all licensed indications.

Formulary approved "off-label" use is detailed separately.

 Details...
10.01  Drugs used in rheumatic diseases and gout
10.01.01  Non-steroidal anti-inflammatory drugs
Acelofenac tabs
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Formulary  
   
Arthrotec® tabs  (diclofenac + misoprostol)
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Formulary  
   
Aspirin tabs (analgesia)
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Formulary

 
   
Celecoxib capsules
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Formulary  
   
Diclofenac sodium e/c, m/r & disp tabs, suppositories
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Formulary

Approved for all licensed indications, and the following off-label indication:

Stat rectal dose prior to ERCP for prevention of post-ERCP pancreatitis

 
Link  MHRA Jun 2013: Diclofenac: new contraindications and warnings
   
Etoricoxib tabs
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Formulary
Amber 1

Approved for:

Rheumatoid arthritis and ankylosing spondylitis

Restricted to use after a non-selective NSAID (e.g. naproxen), has failed to achieve symptom relief.

Refer to APC recommentation for further information (link below)

 
Link  SE London APC recommendation: Etoricoxib 60mg and 90mg tablets for the symptomatic relief of symptoms in adults with ankylosing spondylitis and rheumatoid arthritis
   
Fenbufen tabs
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Formulary  
   
Flurbiprofen tabs
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Formulary  
   
Ibuprofen tabs, suspension
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Formulary  
   
Indometacin caps, m/r caps, suppositories (licensed use)
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Formulary

 
   
Ketoprofen caps
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Formulary  
   
Mefenamic acid caps, tabs
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Formulary In secondary care use on gynaecology advice only for:
  • dysmenorrhoea
  • Menorrhagia 
  •    
    Meloxicam tabs
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    Formulary  
       
    Nabumetone tabs, suspension
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    Restricted Drug Restricted For palliative care patients with pain relating to soft tissue, visceral or bone inflammation  
       
    Naproxen tabs
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    Formulary

     
       
    Sulindac tabs
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    Formulary  
       
    Indometacin suppositories (prophylaxis of pancreatitis post ERCP)
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    Formulary
    Red

    Approved off label indication:

    • Stat rectal dose prior to ERCP for prevention of post-ERCP pancreatitis
     
       
    Phenylbutazone tablets
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    Unlicensed Drug Unlicensed
    Red

    Restricted use

    Ankylosing spondylitis

     
       
    10.01.02  Corticosteroids
    10.01.02.01  Systemic corticosteroids
    10.01.02.02  Local corticosteroids injections to top
    Dexamethasone injection (rheumatology indications)
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    Formulary  
       
    Hydrocortisone acetate injection
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    Formulary  
       
    Methylprednisolone acetate injection (Depo-Medrone®)
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    Formulary  
       
    Methylprednisolone acetate with lidocaine injection (Depo-Medrone® with Lidocaine)
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    Formulary  
       
    Triamcinolone acetonide injection  (Adcortyl®)
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    Formulary  
       
    Triamcinolone acetonide injection (Kenalog®)
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    Formulary  
       
    Triamcinolone acetonide injection (Kenalog® - off-label musculoskeletal use)
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    Formulary

    Approved off-label use, via intralesional injection, for:

    • Capsulitis
    • Tendonitis
    • Entrapment neuropathy
    • Plantar fasciitis
    • Impingement syndrome
    • Peripheral neuropathy/neuromas
    • Ligamentous injuries

    Dose: 5 mg to 40 mg with a minimum of 4 weeks between injections

     
       
    Triamcinolone acetonide injection (Adcortyl® - off-label musculoskeletal use)
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    Formulary

    Approved off-label use, via intralesional injection, for:

    • Capsulitis
    • Tendonitis
    • Entrapment neuropathy
    • Plantar fasciitis
    • Impingement syndrome
    • Peripheral neuropathy/neuromas
    • Ligamentous injuries

    Alternative to Kenalog® when a larger volume of injection is required in the absence of a local anaesthetic

    Dose: 2.5 mg to 15 mg with a minimum of 4 weeks between injections

     
       
    Hydrocortisone acetate injection 25mg/mL (Hydrocortistab® - off-label musculoskeletal use)
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    Formulary

    Approved off-label use, via intralesional injection, for:

    • Epicondylitis
    • Capsulitis
    • Tendonitis
    • Entrapment nueropathy
    • Plantar fasciitis
    • Impingement syndrome
    • Peripheral neuropathy/neuromas
    • Ligamentous injuries

    Alternative to triamcinolone in cases of previous negative reaction or for use as superficial injections in patients with dark skin

    Dose: 5 mg to 50 mg with a minimum of 4 weeks between injections

     
       
    Methylprednisolone acetate injection (Depo-Medrone® - off-label musculoskeletal use)
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    Formulary

    Approved off-label use, via intralesional injection, for:

    • Capsulitis
    • Tendonitis
    • Entrapment neuropathy
    • Impingement syndrome
    • Peripheral neuropathy/neuromas
    • Ligamentous injuries

    Alternative to triamcinolone in cases of previous negative reaction

    Dose: 4 mg to 80 mg; minimum of 4 weeks between injections

     
       
    Methylprednisolone acetate with lidocaine injection (Depo-Medrone® with Lidocaine - off-label musculoskeletal use)
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    Formulary

    Approved off-label use, via intralesional injection, for:

    • Capsulitis
    • Tendonitis
    • Entrapment neuropathy
    • Impingement syndrome
    • Peripheral neuropathy/neuromas
    • Ligamentous injuries

    Dose: 4mg to 80 mg; minimum of 4 weeks between injections

     
       
    Lidocaine injection 1%, 2% (off-label use in conjunction with steroid injections)
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    Formulary

    Approved off-label indication:

    Intra-articular or intralesional injection, as a local anaesthetic prior to local steroid injection

     
       
    10.01.03  Drugs which suppress the rheumatic disease process
    Tacrolimus caps (Behcet's disease)
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    Restricted Drug Restricted
    Red

    USE UNDER SPECIALIST SUPERVISION ONLY 

    Approved for use in the management of less complex Behcet's disease

    Dose = up to 4mg BD (based on plasma trough concentration)

     
       
    10.01.03  Gold
    Auranofin tablets
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    Formulary
    Amber 2
    USE UNDER SPECIALIST SUPERVISION ONLY 
       
    Soldium aurothomalate imjection
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    Formulary
    Amber 2
    USE UNDER SPECIALIST SUPERVISION ONLY 
       
    10.01.03  Penicillamine
    Penicillamine tabs (rheumatoid athritis)
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    Formulary
    Amber 2
    USE UNDER SPECIALIST SUPERVISION ONLY Approved for:
  • Severe rheumatoid arthritis  
  •    
    10.01.03  Antimalarials
    Chloroquine sulphate tabs
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    Formulary USE UNDER SPECIALIST SUPERVISION ONLY 
       
    Hydroxychloroquine sulphate tabs
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    Formulary
    Amber 3

    USE UNDER SPECIALIST SUPERVISION ONLY

    See SE London Shared Care Agreement (link above) for prescribing advice and approved rheumatology indications (including off-label indications)

     
       
    10.01.03  Drugs affecting the immune response to top
    Cytotoxic Drug Azathioprine tabs (rheumatology)
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    Formulary
    Amber 3

    USE UNDER SPECIALIST SUPERVISION ONLY

    See SE London Shared Care Agreement (link above) for prescribing advice and approved rheumatology indications (including off-label indications)

     
       
    Ciclosporin caps, oral solution (Behcet's Disease)
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    Restricted Drug Restricted
    Red

    USE UNDER SPECIALIST SUPERVISION ONLY

    Approved for use in the management of Behcet's Eye Disease. 

    Dose = 2.5-5mg/kg/day

     
       
    Ciclosporin caps, oral solution (rheumatology)
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    Formulary
    Amber 3
    USE UNDER SPECIALIST SUPERVISION ONLY  
       
    Leflunomide tabs
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    Formulary
    Amber 3

    UUSE UNDER SPECIALIST SUPERVISION ONLY

    See SE London Shared Care Agreement (link above) for prescribing advice and approved rheumatology indications (including off-label indications)

     
       
    Cytotoxic Drug Methotrexate tablets, subcutaneous injection (rheumatology indications)
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    Formulary
    Amber 3

    USE UNDER SPECIALIST SUPERVISION ONLY

    See SE London Shared Care Agreement (link above) for prescribing advice and approved rheumatology indications (including off-label indications)

    Refer to BNF for CSM advice

     
       
    10.01.03  Cytokine modulators - USE UNDER SPECIALIST SUPERVISION ONLY
    Abatacept injection
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    Formulary
    Red
    High Cost Medicine
    Approved as per NICE technology appraisal guidance 
    Link  NICE TA373: Abatacept, adalimumab, etanercept and tocilizumab for treating juvenile idiopathic arthritis
    Link  NICE TA375: Adalimumab, etanercept, infliximab, certolizumab pegol, golimumab, tocilizumab and abatacept for rheumatoid arthritis not previously treated with DMARDs or after conventional DMARDs only have failed
       
    Adalimumab injection (rheumatology indications)
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    Formulary
    Red
    High Cost Medicine
    Approved as per NICE technology appraisal guidance 
    Link  NICE TA195: Rheumatoid arthritis - drugs for treatment after failure of a TNF inhibitor
    Link  NICE TA199: Etanercept, infliximab and adalimumab for the treatment of psoriatic arthritis
    Link  NICE TA373: Abatacept, adalimumab, etanercept and tocilizumab for treating juvenile idiopathic arthritis
    Link  NICE TA375: Adalimumab, etanercept, infliximab, certolizumab pegol, golimumab, tocilizumab and abatacept for rheumatoid arthritis not previously treated with DMARDs or after conventional DMARDs only have failed
    Link  NICE TA383: TNF-alpha inhibitors for ankylosing spondylitis and non-radiographic axial spondyloarthritis
       
    Baricitinib tabs
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    Formulary
    Red
    High Cost Medicine
    Approved as per NICE technology appraisal guidance 
    Link  NICE TA466: Baricitinib for moderate to severe rheumatoid arthritis
       
    Belimumab injection
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    Restricted Drug Restricted
    Red
    High Cost Medicine
    BlueTeq

    Approved as per NICE technology appraisal guidance

    Lupus Consultants only 

     
    Link  MHRA Apr 19: Belimumab (Benlysta▼): increased risk of serious psychiatric events seen in clinical trials
    Link  NICE TA397: Belimumab for treating active autoantibody-positive systemic lupus erythematosus
       
    Certolizumab pegol injection
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    Formulary
    Red
    High Cost Medicine
    Approved for use as per NICE technology appraisal guidance 
    Link  NICE TA375: Adalimumab, etanercept, infliximab, certolizumab pegol, golimumab, tocilizumab and abatacept for rheumatoid arthritis not previously treated with DMARDs or after conventional DMARDs only have failed
    Link  NICE TA383: TNF-alpha inhibitors for ankylosing spondylitis and non-radiographic axial spondyloarthritis
    Link  NICE TA415: Certolizumab pegol for treating rheumatoid arthritis after inadequate response to a TNF-alpha inhibitor
    Link  NICE TA445: Certolizumab pegol and secukinumab for treating active psoriatic arthritis after inadequate response to DMARDs
       
    Etanercept injection (rheumatology indications)
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    Formulary
    Red
    High Cost Medicine

    Approved as per NICE technology appraisal guidance

    Biosimilar products available, to be prescribed by brand name.

    Contact pharmacy department for advice on brand for routine prescribing if unsure

     
    Link  NICE TA195: Rheumatoid arthritis - drugs for treatment after failure of a TNF inhibitor
    Link  NICE TA199: Psoriatic arthritis - etanercept, infliximab and adalimumab
    Link  NICE TA373: Abatacept, adalimumab, etanercept and tocilizumab for treating juvenile idiopathic arthritis
    Link  NICE TA375: Adalimumab, etanercept, infliximab, certolizumab pegol, golimumab, tocilizumab and abatacept for rheumatoid arthritis not previously treated with DMARDs or after conventional DMARDs only have failed
    Link  NICE TA383: TNF-alpha inhibitors for ankylosing spondylitis and non-radiographic axial spondyloarthritis
       
    Golimumab injection (rheumatology indications)
    View adult BNF View SPC online
    Formulary
    Red
    High Cost Medicine
    Approved as per NICE technology appraisal guidance 
    Link  NICE TA220: Psoriatic arthritis - golimumab
    Link  NICE TA225: Rheumatoid arthritis - golimumab
    Link  NICE TA375: Adalimumab, etanercept, infliximab, certolizumab pegol, golimumab, tocilizumab and abatacept for rheumatoid arthritis not previously treated with DMARDs or after conventional DMARDs only have failed
    Link  NICE TA383: TNF-alpha inhibitors for ankylosing spondylitis and non-radiographic axial spondyloarthritis
    Link  NICE TA497: Golimumab for treating non-radiographic axial spondyloarthritis
       
    Infliximab injection (licensed rheumatology indications)
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    Formulary
    Red
    High Cost Medicine

    Approved as per NICE technology appraisal guidance

    Biosimilar products available, to be prescribed by brand name.

    Contact pharmacy department for advice on brand for routine prescribing if unsure

     
    Link  NICE TA195: Rheumatoid arthritis - drugs for treatment after failure of a TNF inhibitor
    Link  NICE TA199: Psoriatic arthritis - etanercept, infliximab and adalimumab
    Link  NICE TA375: Adalimumab, etanercept, infliximab, certolizumab pegol, golimumab, tocilizumab and abatacept for rheumatoid arthritis not previously treated with DMARDs or after conventional DMARDs only have failed
    Link  NICE TA383: TNF-alpha inhibitors for ankylosing spondylitis and non-radiographic axial spondyloarthritis
    Link  SE London APC position statement: Biosimilar infliximab
       
    Rituximab injection (ANCA vasculitis)
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    Formulary
    Red
    High Cost Medicine
    BlueTeq

    Approved as per NICE technology appraisal and NHSE policy guidance below

    Biosimilar products available, to be prescribed by brand name.

    Contact pharmacy department for advice on brand for routine prescribing if unsure

     
    Link  NHSE Policy A13/P/a: Rituximab for the treatment of ANCA-associated vasculitis in adults
    Link  NICE TA308: Rituximab in combination with glucocorticoids for treating anti-neutrophil cytoplasmic antibody-associated vasculitis
       
    Rituximab injection (rheumatology - licensed indications)
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    Formulary
    Red
    High Cost Medicine

    Approved as per NICE technology appraisal guidance below

    Biosimilar products available, to be prescribed by brand name.

    Contact pharmacy department for advice on brand for routine prescribing if unsure

     
    Link  NICE TA195: Rheumatoid arthritis - drugs for treatment after failure of a TNF inhibitor
       
    Sarilumab pre-filled pen or syringe
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    Formulary
    Red
    Approved as per NICE Technology Appraisal guidance 
    Link  NICE TA485: Sarilumab for moderate to severe rheumatoid arthritis
       
    Secukinumab injection (ankylosing spondylitis & psoriatic arthritis)
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    Formulary
    Red
    High Cost Medicine
    CCG

    Approved as per NICE technology appraisal guidance

     
    Link  NICE TA407: Secukinumab for active ankylosing spondylitis after treatment with non-steroidal anti-inflammatory drugs or TNF-alpha inhibitors
    Link  NICE TA445: Certolizumab pegol and secukinumab for treating active psoriatic arthritis after inadequate response to DMARDs
       
    Tocilizumab (cytokine relsease syndrome following CAR T-cell therapy)
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    Formulary
    Red
    High Cost Medicine
    NHS England

    Refer to SPC for management of cytokine release syndrome (including dosing) following CAR T-cell therapy

     
    Link  MHRA Jul 2019: rare risk of serious liver injury including cases requiring transplantation
       
    Tocilizumab injection (Adult-Onset Still's Disease )
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    Formulary
    Red
    High Cost Medicine
    NHS England
    BlueTeq

    Approved for use as per NHSE policy criteria (see link below)

    Note: Anakinra and Tocilizumab cannot be used concurrently

     
    Link  Clinical Commissioning Policy: Anakinra/tocilizumab for the treatment of Adult-Onset Still’s Disease refractory to second-line therapy (adults) (170056P)
    Link  MHRA Jul 2019: rare risk of serious liver injury including cases requiring transplantation
       
    Tocilizumab injection (arthritis)
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    Formulary
    Red
    High Cost Medicine
    Approved as per NICE technology appraisal guidance 
    Link  MHRA Jul 2019: rare risk of serious liver injury including cases requiring transplantation
    Link  NICE TA238: Arthritis (juvenile idiopathic, systemic) - tocilizumab
    Link  NICE TA247: Rheumatoid arthritis - tocilizumab (rapid review TA198)
    Link  NICE TA373: Abatacept, adalimumab, etanercept and tocilizumab for treating juvenile idiopathic arthritis
    Link  NICE TA375: Adalimumab, etanercept, infliximab, certolizumab pegol, golimumab, tocilizumab and abatacept for rheumatoid arthritis not previously treated with DMARDs or after conventional DMARDs only have failed
       
    Tocilizumab subcutaneous injection (giant cell arteritis)
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    Formulary
    Red
    BlueTeq

    Approved as per NICE technology appraisal guidance

     
    Link  MHRA Jul 2019: rare risk of serious liver injury including cases requiring transplantation
    Link  NICE TA518: Tocilizumab for treating giant cell arteritis
       
    Tofacitinib tabs
    View adult BNF View SPC online
    Formulary
    Red
    High Cost Medicine
    Approved as per NICE technology appraisal guidance 
    Link  MHRA Drug Safety Update May 19: Tofacitinib (Xeljanz▼): restriction of 10 mg twice-daily dose in patients at high risk of pulmonary embolism while safety review is ongoing
    Link  NICE TA480: Tofacitinib for moderate to severe rheumatoid arthritis
    Link  NICE TA543: Tofacitinib for treating active psoriatic arthritis after inadequate response to DMARDs
    Link  NICE TA547: Tofacitinib for moderately to severely active ulcerative colitis
       
    Ustekinumab injection (psoriatic arthritis)
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    Formulary
    Red
    High Cost Medicine
    Approved as per NICE technology appraisal guidance 
    Link  NICE TA340: Ustekinumab for treating active psoriatic arthritis
       
    Infliximab injection (rheumatology off-label indications)
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    Restricted Drug Restricted
    Red
    High Cost Medicine

    Approved off-label indication:

    Severe refractory Behcet's disease including Behcet's Eye disease, pulmonary and peripheral arterial aneurysms

    To be prescribed as per the Barts Health Satellite Unit Biologic Referal Pathway. Contact formulary team for further info.

    Note: Biosimilar products available, to be prescribed by brand name. Contact pharmacy department if unsure of brands. 

     
    Link  SE London APC position statement: Biosimilar infliximab
       
    Rituximab injection (rheumatology - off-label indications)
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    Restricted Drug Restricted
    Red
    High Cost Medicine
    BlueTeq

    Approved off-label indications:

    Treatment of resistant acute autoimmune connective tissue disorders (CTDs) such as:

    • Systemic lupus erythematosus (SLE) - Blueteq application required
    • Inflammatory myopathies
    • Sjogren’s syndrome
    • Systemic vasculitides
    • IgG4-related disease (as per NHSE Policy 16057/P)
    • Behcet's Disease; including Behcet's Eye disease (as per Barts Health Satellite Unit Biological Referal Process)

    Reserved for patients with severe active autoimmune diseases that have failed to respond to or are intolerant of at least two immunosuppressants (azathioprine, methotrexate, mycophenolate or cyclophosphamide), each having been taken for at least three months

    Biosimilar products available, to be prescribed by brand name.

    Contact pharmacy department for advice on brand for routine prescribing if unsure

     
    Link  NHSE 16057/P: Rituximab for IgG4-related disease
       
    Tocilizumab injection (Takayasu arteritis -off-label)
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    Formulary
    Red
    High Cost Medicine

    Approved off-label indication:

    For Takayasu arteritis, as per criteria in NHSE commissioning policy 16056/P

     
    Link  NHSE 16056/P: Tocilizumab for Takayasu arteritis (adults)
       
    10.01.03  Sulfasalazine
    Sulfasalazine e/c tablets
    View adult BNF View SPC online
    Formulary
    Amber 3

    See SE London Shared Care Agreement (link above) for prescribing advice and approved rheumatology indications (including off-label indications)

     
       
    10.01.04  Gout and cytotoxic-induced hyperuricaemia
    10.01.04  Acute attacks of gout
    Anakinra injection (Adult-Onset Still's Disease )
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    Formulary
    Red
    High Cost Medicine
    BlueTeq

    Approved for use as per NHSE policy criteria (see link below)

    Note: Anakinra and Tocilizumab cannot be used concurrently

     

     
    Link  Clinical Commissioning Policy: Anakinra/tocilizumab for the treatment of Adult-Onset Still’s Disease refractory to second-line therapy (adults) (170056P)
       
    Anakinra injection (cytokine release syndrome (CRS) or neurotoxicity after CAR-T therapy - off-label)
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    Formulary
    Red

    Approved off-label indications:

    • Cytokine release syndrome (CRS) after CAR-T therapy where tocilizumab has failed.
    • Immune effector cell-associated neurotoxicity syndrome (ICANS) after CAR-T therapy where corticosteroids have failed.

    Approved for KCH only, as patients with CRS should ideally be treated at their CAR-T therapy centre.

    Dose: 200 mg s.c. every 24 hours. Continue for 24 hours after symptom resolution.

     
       
    Colchicine tablets (gout)
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    Formulary

     
       
    Anakinra injection (Polyarticular acute gout - off-label)
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    Restricted Drug Restricted
    Red
    High Cost Medicine

    Approved off-label indication (consultant specialists only):

    Polyarticular acute gout and multiple swollen joints where:

    • There have been recurrent acute flares of gout
    • There has been lack of response to, or contra-indications to NSAIDs, colchicine and steroids

    Dose = 100mg daily for 3 days

    See APC recommendation for further information

     
    Link  SE London APC recommendation: anakinra for acute gout
       
    10.01.04  Long-term control of gout to top
    Allopurinol tabs
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    Formulary
    Green

    Approved for all licensed indications

    And the following off-label indication (Amber):

    In combination with thiopurines (i.e. azathioprine or mercaptopurine) in the treatment of Crohn’s Disease or Ulcerative Colitis where the patient has shown:

    • Hypermethylation of thiopurine (MeMP: TGN ratio >11:1)
    • Abnormal LFTs secondary to standard thiopurine treatment
    • Other non-myelotoxic side-effects, excluding pancreatitis, on standard thiopurines, which limit dose optimization
    • Dose = Allopurinol 100mg daily 
    • Dose reduction of the thiopurine to approximately 25% of the usual target dose is required to avoid dose-related toxicity. 

    • See information leaflet (link below) for further information 

     
    Link  Crohn’s and Colitis UK: Azathioprine & Mercaptopurine
       
    Febuxostat tabs
    View adult BNF View SPC online
    Formulary  
    Link  MHRA Jul 2019: Febuxostat (Adenuric): increased risk of cardiovascular death and all-cause mortality in clinical trial in patients with a history of major cardiovascular disease
    Link  MHRA Jun 2012: Febuxostat (Adenuric): stop treatment if signs or symptoms of serious hypersensitivity
    Link  NICE TA164: Hyperuricaemia - febuxostat
       
    Benzbromarone tabs
    View adult BNF View SPC online
    Unlicensed Drug Unlicensed
    Red

    Approved for use in the treatment of gout for patients resistant to, or intolerant of, xanthine oxidase inhibitors (off-label)

    Dose = 50 mg to 200 mg per day

     
       
    Sulfinpyrazone tabs
    View adult BNF View SPC online
    Unlicensed Drug Unlicensed

     
       
    10.01.04  Hyperuricaemia associated with cytotoxic drugs
    Rasburicase injection
    View adult BNF View SPC online
    Formulary
    Red
    High Cost Medicine
     
       
    Probenecid tabs
    Unlicensed Drug Unlicensed Approved for:
  • Prevention of nephrotoxicity associated with cidofovir
  • Prophylaxis of gout in cases resistant to allopurinol 
  •    
    Probenecid tabs (penicillin augmentation in syphilis)
    Unlicensed Drug Unlicensed
    Red

    Approved for use in:

    • Late latent syphilis and neurosyphilis in conjuction with penicillin treatments (either amoxicillin or procaine pneicillin G) as per BASHH guidance.

    Dose = 500mg qds for duration of penicillin use

     
       
    10.01.05  Other drugs for rheumatic diseases
    Cytotoxic Drug Cyclophosphamide injection
    (Behcet's Disease)
    View adult BNF View SPC online
    Restricted Drug Restricted

    USE UNDER SPECIALIST SUPERVISION ONLY 

    Approved for use in the management of severe refractory Behcet's Disease in accordance with locally agreed protocol

     

     

     

     

     
       
    Interferon alpha (Behcet's Disease)
    View adult BNF View SPC online
    Restricted Drug Restricted
    High Cost Medicine

    USE UNDER SPECIALIST SUPERVISION ONLY 

    Approved for use in the management of Behcet's Disease (including Behcet's Eye disease)

    To be prescribed as per the Barts Health Satellite Unit Biologic Referal Pathway. Contact formulary team for further info.

     

     
       
    10.02  Drugs used in neuromuscular disorders
    10.02.01  Drugs which enhance neuromuscular transmission
    Rituximab injection (myaesthenia gravis - off-label)
    View adult BNF View SPC online
    Formulary
    Red
    High Cost Medicine
    BlueTeq

    Approved off-label indication:

    Management of myaesthenia gravis as per the criteria in NHSE Commissioning Policy 170084P

    The rituximab biologic with the lowest acquisition costs should be used

    Biosimilar products available, to be prescribed by brand name.

    Contact pharmacy department for advice on brand for routine prescribing if unsure

     
    Link  Clinical Commissioning Policy Statement 170084P: Rituximab bio-similar for the treatment of myasthenia gravis (adults)
       
    10.02.01  Anticholinesterases to top
    Neostigmine tabs, injection
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    Formulary
    Red

    Approved off-label indication (injection):

    Post-operative ileus, ileus and pseudo-obstruction

    Dose: 0.4-0.8 mg/hr as a 24 hour infusion, or a 2mg IV bolus over 3-5 minutes

    Refer to local Trust guidelines

     
       
    Pyridostigmine bromide tabs
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    Formulary  
       
    Edrophonium chloride injection
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    Formulary  
       
    10.02.02  Skeletal muscle relaxants
    Baclofen tablets, oral liquid
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    Formulary  
       
    Baclofen tablets (GHB withdrawal - off-label)
    View adult BNF View SPC online
    Formulary

    Approved off-label indication:

    Management of acute withdrawal in patients with dependency on gamma-hydroxybutyrate (GHB) and/or its analogues gammabutyrolactone (GBL) and 1,4- butanediol (1,4BD)

    Must be prescribed under the supervision of the Clinical Toxicology team at the Guy’s and St Thomas’ Poisons Unit

     
       
    Baclofen intrathecal injection
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    Restricted Drug Restricted

    USE UNDER SPECIALIST SUPERVISION ONLY

     
       
    Controlled Drug Cannabis extract oromucosal spray (Sativex®)
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    Restricted Drug Restricted
    Red
    High Cost Medicine

    Treatment of moderate to severe spasticity in multiple sclerosis

    RESTRICTED TO USE BY CONSULTANT SPECIALISTS IN MULTIPLE SCLEROSIS RELATED SPASTICITY

     
    Link  SE London APC position statement: Sativex
       
    Dantrolene sodium caps
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    Formulary
    Amber 2

     
       
    Dantrolene sodium injection
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    Formulary Approved off-label indications:
  • Spasticity
  • Urinary incontinence 
  •    
    Diazepam tabs, injection
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    Formulary  
       
    Tizanidine tabs
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    Formulary
    Amber 2
     
       
    10.02.02  Nocturnal leg cramps
    Quinine bisulphate tabs
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    Formulary  
       
    Quinine sulphate tabs
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    Formulary  
       
    10.03  Drugs for the treatment of soft-tissue disorders and topical pain relief
    10.03  Extravasation
    10.03.01  Enzymes to top
    Collagenase injection (Xiapex® - Dupuytren’s contracture)
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    Restricted Drug Restricted
    Red
    Restricted to surgeons specialising in the treatment of Dupuytren’s contracture, and as per NICE technology appraisal 459  
    Link  NICE TA459: Collagenase clostridium histolyticum for treating Dupuytren’s contracture
       
    Hyaluronidase injection
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    Formulary  
       
    Hylan G-F 20 intra-articular injection  (Synvisc®, Synvisc-One®)
    View adult BNF View SPC online
    Formulary
    Red
    USE UNDER SPECIALIST SUPERVISION ONLY 
       
    10.03.02  Rubefacients, topical NSAIDs, capsaicin, and poultices
    10.03.02  Topical NSAIDs and counter-irritants
    Benzydamine cream  (Difflam®)
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    Formulary  
       
    Ibuprofen 5 % gel
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    Formulary  
       
    Ketoprofen gel
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    Formulary  
       
    10.03.02  Capsaicin
    Capsaicin cream (0.025%)
    View adult BNF View SPC online
    Formulary  
       
    Capsaicin patch 8% (Qutenza ®)
    View adult BNF View SPC online
    Restricted Drug Restricted
    Red

    Prescribing and administration restricted to Pain Consultants who are trained in the administration of capsaicin patch

    Restricted to use in peripheral neuropathic pain in patients who have failed to tolerate or to respond to oral neuropathic agents.

     
       
    10.03.02  Poultices
    Kaolin Poultice
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    Formulary  
       
    10.04  Miscellaneous preparations to top
    Palacos LV 40
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    Formulary Bone cement for use in orthopaedic surgery 
       
    Palacos R 40 with gentamicin
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    Formulary Bone cement for use in orthopaedic surgery 
       
    Dibotermin alfa  (InductOs ®)
    View adult BNF View SPC online
    Unlicensed Drug Unlicensed
    Red
    High Cost Medicine

    Can only be used under the supervision of named spinal surgeons only: MR KHAI LAM, MR JONATHAN LUCAS, MR TOM EMBER

    Approved for:

    • Primary lumbar anterior fusions
    • Revision lumbar spinal fusions
    • Complex idiopathic kyphosis or scoliosis (primary or revision)
    • Complex congenital kyphosis or scoliosis (primary or revision)
     
       
    Eptotermin alfa implant (Ossigraft ®)
    View adult BNF View SPC online
    Unlicensed Drug Unlicensed
    Red
    High Cost Medicine

    For named consultants only: MS SARAH PHILIPS, MR GRAEME GROOM, MR MARK PHILIPS, MR OM LAHOTI, MR VENU KAVARTHAPU

     

    Approved for:

    Treatment of non-union tibia (see EMEA product information for licensed restrictions), and humerus, femur, forearm, tibia, mandible and spine

     

    For named consultant only: MR VENU KAVARTHAPU

    Approved for:

    Major foot and ankle surgical reconstruction due to deformity and or instability caused by severe Charcot Arthropathy that has lasted for more than 12 months, with marked bone loss and non-union of the fractures.

     
       
    Phenol liquid 80% (nail bed ablation in ingrowing toenail)
    View adult BNF View SPC online
    Unlicensed Drug Unlicensed
    Red
    Topical application for nail bed ablation in ingrowing toenail  
       
     ....
     Non Formulary Items
    Canakinumab injection

    View adult BNF View SPC online
    Non Formulary
    Grey

    Not approved for use in SE London.

    See NICE TA281

     
    Glucosamine and/or chondroitin containing preparations

    Non Formulary
    Grey

    Not for prescribing in SE London

    Link  SE London APC: Patient Information Leaflet: Changes to glucosamine and chondroitin prescribing
     
    Lesinurad tabs

    View adult BNF View SPC online
    Non Formulary
    Grey

    Not approved for use in SE London for treating chronic hyperuricaemia in people with gout as per NICE Technology Appraisal guidance (see link below)

    Link  NICE TA506: Lesinurad for treating chronic hyperuricaemia in people with gout
     
    Rubefacients (excluding NSAIDs)  (e.g. Deep Freeze, Movelat, Ralgex)

    Non Formulary
    Grey
    Link  SE London APC position statement (not recommended for prescribing in SE London)
     
      
    Key
    note Notes
    Section Title Section Title (top level)
    Section Title Section Title (sub level)
    First Choice Item First Choice item
    Non Formulary Item Non Formulary section
    Restricted Drug
    Restricted Drug
    Unlicensed Drug
    Unlicensed
    Track Changes
    Display tracking information
    click to search medicines.org.uk
    Link to adult BNF
    click to search medicines.org.uk
    Link to SPCs
    SMC
    Scottish Medicines Consortium
    Cytotoxic Drug
    Cytotoxic Drug
    CD
    Controlled Drug
    High Cost Medicine
    High Cost Medicine
    Cancer Drugs Fund
    Cancer Drugs Fund
    NHSE
    NHS England
    Homecare
    Homecare
    CCG
    CCG

    Traffic Light Status Information

    Status Description

    Red

    Specialist or hospital prescribing only. The responsibility for prescribing, monitoring, dose adjustment and review should remain with the specialist or hospital. In very exceptional circumstances a specialist may discuss individual patient need for a RED drug to be prescribed by a GP and the GP should consider informing the Medicines Management team before a decision is made to prescribe for individual patients.   

    Amber 1

    Treatment can be initiated in primary care after a recommendation from an appropriate specialist  

    Amber 2

    Specialist initiation followed by maintenance prescribing in primary care  

    Amber 3

    Specialist initiation with ongoing monitoring required. After dose stabilisation GPs can be requested to take over prescribing responsibilities using the approved APC shared care documentation  

    Green

    Specialist and non-specialist initiation  

    Grey

    Not recommended for prescribing  

    netFormulary