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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...
10.01.04  Expand sub section  Gout and cytotoxic-induced hyperuricaemia
10.01.04  Expand sub section  Acute attacks of gout
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  Expand sub section  Long-term control of gout
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
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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
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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
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Unlicensed Drug Unlicensed

 
   
10.01.04  Expand sub section  Hyperuricaemia associated with cytotoxic drugs
Rasburicase injection
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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

     
       
     ....
     Non Formulary Items
    Canakinumab injection

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    Non Formulary
    Grey

    Not approved for use in SE London.

    See NICE TA281

     
    Lesinurad tabs

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    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
     
      
    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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