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...
10.01.03  Expand sub section  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  Expand sub section  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  Expand sub section  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  Expand sub section  Antimalarials
    Chloroquine sulphate tabs
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    Formulary USE UNDER SPECIALIST SUPERVISION ONLY 
       
    Hydroxychloroquine tabs (rheumatology indications - including off-label use)
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    Formulary
    Amber 3

    Refer to SE London immunomodulatory shared care guidance for list of indications (link above at start of BNF section)

     
       
    10.01.03  Expand sub section  Drugs affecting the immune response to top
    Cytotoxic Drug Azathioprine tabs (rheumatology indications - including off-label use)
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    Formulary
    Amber 3

    Refer to SE London immunomodulatory shared care guidance for list of indications (link above at start of BNF section)

     
       
    Ciclosporin caps, oral solution (rheumatology indications, including off-label use)
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    Formulary
    Amber 3

    Refer to SE London immunomodulatory shared care guidance for list of indications (link above at start of BNF section)

     
       
    Leflunomide tabs (rheumatology indications - including off-label use)
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    Formulary
    Amber 3

    Refer to SE London immunomodulatory shared care guidance for list of indications (link above at start of BNF section)

     
       
    Cytotoxic Drug Methotrexate tablets, subcutaneous injection (rheumatology indications - including off-label use)
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    Formulary
    Amber 3

    Refer to SE London immunomodulatory shared care guidance for list of indications (link above at start of BNF section)

     
       
    Mycophenolate mofetil caps, tabs, suspension (rheumatology indications - including off-label use)
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    Formulary
    Amber 3

    Refer to SE London immunomodulatory shared care guidance for list of indications (link above at start of BNF section)

     
       
    Mycophenolate sodium tabs (rheumatology indications - including off-label use)
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    Formulary
    Amber 3

    Refer to SE London immunomodulatory shared care guidance for list of indications (link below)

    • Restricted to use where there is intolerance to mycophenolate mofetil.
    • Refer to APC recommendation (link below)
     
    Link  SE London APC recommendation: Mycophenolate sodium (mycophenolic acid) 360mg tablets for autoimmune rheumatic and dermatological conditions in patients unable to tolerate mycophenolate mofetil
       
    10.01.03  Expand sub section  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)
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    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 Stillís 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 (rheumatology indications)
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    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
       
    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  Expand sub section  Sulfasalazine
    Sulfasalazine e/c tablets (rheumatology indications - including off-label use)
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    Formulary
    Amber 3

    Refer to SE London immunomodulatory shared care guidance for list of indications (link above at start of BNF section)

     
       
     ....
    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  

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