10.1 Arthritis

Link to BNF Arthritis

Link to BNF Rheumatic disease, suppressing drugs

Disease-modifying Anti-Rheumatic Drugs

Hydroxychloroquine (TLS Amber 1 month)

• Also licensed for active rheumatoid arthritis (SCP click here, Rheumatology), systemic and discoid lupus erythematosus and dermatological conditions caused or aggravated by sunlight (SCP click here, dermatology)
• Hydroxychloroquine Rheumatology Monitoring Advice Sheet

Leflunomide (TLS Amber 1 month) (SCP click here)

• Leflunomide Concise Monitoring Advice Sheet

Penicillamine (TLS Amber 1 month) (SCP click here)

• Penicillamine Rheumatology Monitoring Advice Sheet

Sodium aurothiomalate (TLS Amber 1 month) (SCP click here)

• Sodium aurothiomalate Rheumatology Monitoring Advice Sheet

Interleukin Inhibitors

Note on Biosimilars

When local procurement has been finalised and as per NICE’s biosimilar position statement, if the originator biologic product is on the BNSSG joint formulary, the new biosimilar product will also be included on the formulary in accordance with its UK licence when it becomes commercially available

For use in Juvenile Idiopathic Arthritis (JIA) see NHS England policy E03/P/d Biologic Therapies for the treatment of Juvenile Idiopathic Arthritis (JIA)

Anakinra (TLS Red)

• According to NHS Commissioning Policy for Adult Onset Still's Disease

Brodalumab (TLS Red)

• According to NICE TA511 Brodalumab for treating moderate to severe plaque psoriasis.

Ixekizumab (TLS Red)

• According to NICE TA537 Ixekizumab for treating active psoriatic arthritis after inadequate response to DMARDs.

Secukinumab (TLS Red)

• According to NICE TA407 Secukinumab for active ankylosing spondylitis after treatment with non-steroidal anti-inflammatory drugs or TNF-alpha inhibitors.
• See NICE TA445 Certolizumab pegol and secukinumab for treating active psoriatic arthritis after inadequate response to DMARDs.

Tocilizumab (TLS Red)

• According to NICE TA247 (Rheumatoid Arthritis)
• According to NICE TA238 (Arthritis, juvenile idiopathic, systemic)
• May be used as monotherapy in adult patients with moderate/severe active rheumatoid arthritis who cannot take methotrexate (approved by the BNSSG JFG June 15)
• The subcutaneous preparation may be used in preference to the IV preparation in accordance with the NICE TAs 247 and also as monotherapy. Approved by the BNSSG JFG July 2015.
• According to NICE TA373 Abatacept, adalimumab, etanercept and tocilizumab for treating juvenile idiopathic arthritis
• See NICE guidance 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
• For Takayasu Arteritis see NHS England Clinical Commissioning Policy 16056/P
• According to NICE TA518 Tocilizumab for treating giant cell arteritis

Ustekinumab (TLS Red)

• According to NICE TA340 (Psoriatic Arthritis)

Sarilumab (TLS Red)

• As per NICE TA485 Sarilumab for moderate to severe arthritis

T-Cell Activation Inhibitors

Note on Biosimilars

When local procurement has been finalised and as per NICE’s biosimilar position statement, if the originator biologic product is on the BNSSG joint formulary, the new biosimilar product will also be included on the formulary in accordance with its UK licence when it becomes commercially available

Abatacept (TLS Red)

• According to NICE guidance TA195 Rheumatoid Arthritis - drugs for treatment after failure of a TNF inhibitor
• According to NICE guidance TA373 Abatacept, adalimumab, etanercept and tocilizumab for treating juvenile idiopathic arthritis
• See NICE guidance 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
• The subcutaneous preparation may be used in preference to the IV preparation in accordance with the NICE TAs 195 and 373 and 375. Approved by the BNSSG JFG June 2015.

Tumour Necrosis Factor Alpha (TNF-alpha) Inhibitors

See MHRA drug safety update Tumour necrosis factor alpha inhibitors: risk of tuberculosis

Note on Biosimilars

When local procurement has been finalised and as per NICE’s biosimilar position statement, if the originator biologic product is on the BNSSG joint formulary, the new biosimilar product will also be included on the formulary in accordance with its UK licence when it becomes commercially available

Adalimumab (TLS Red)

• Specify brand when prescribing Imraldi^® Amgevita^® , Humira^®
• See NICE guidance TA195 Rheumatoid Arthritis - drugs for treatment after failure of a TNF inhibitor
• See NICE guidance TA199 Psoriatic arthritis - treatment
• See NICE guidance TA373 Abatacept, adalimumab, etanercept and tocilizumab for treating juvenile idiopathic arthritis
• See NICE guidance 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
• See NICE guidance TA383 Ankylosing spondylitis and non-radiographic axial spondyloarthritis

Certolizumab pegol (TLS Red)

• See NICE guidance 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
• See NICE guidance TA383 Ankylosing spondylitis and non-radiographic axial spondyloarthritis
• See NICE guidance TA415 Certolizumab pegol for treating rheumatoid arthritis after inadequate response to a TNF-alpha inhibitor
• See NICE guidance TA445 Certolizumab pegol and secukinumab for treating active psoriatic arthritis after inadequate response to DMARDs

Etanercept (TLS Red)

• Specify brand when prescribing Benepali^®, Enbrel^® .
• See NICE guidance TA195 Rheumatoid arthritis - drugs for treatment after failure of a TNF inhibitor
• See NICE guidance TA199 Psoriatic arthritis - treatment
• See NICE guidance TA373 Abatacept, adalimumab, etanercept and tocilizumab for treating juvenile idiopathic arthritis
• See NICE guidance 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
• See NICE guidance TA383 Ankylosing spondylitis and non-radiographic axial spondyloarthritis

Golimumab (TLS Red)

• According to NICE TA220 (psoriatic arthritis)
• According to NICE TA225 (rheumatoid arthritis, after the failure of previous anti-rheumatic drugs)
• See NICE guidance 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
• See NICE guidance TA383 Ankylosing spondylitis and non-radiographic axial spondyloarthritis
• See NICE guidance TA497 for treating non-radiographic axial spondyloarthritis

Infliximab (TLS Red)

• Specify brand when prescribing - Remicade^®, Inflectra^®, Remsima^®.
• See NICE guidance TA195 Rheumatoid Arthritis - drugs for treatment after failure of a TNF inhibitor
• See NICE guidance TA199 Psoriatic arthritis - treatment
• See NICE guidance TA383 Ankylosing spondylitis and non-radiographic axial spondyloarthritis
• See NICE guidance 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
• Also commissioned for patients who have developed steroid resistant colitis secondary to ipilimumab treatment

Rituximab (TLS Red)

• See NICE guidance TA195 Rheumatoid Arthritis - drugs for treatment after failure of a TNF inhibitor.
• Rituximab may also be used in combination with Leflunomide in patients in whom methotrexate is not tolerated, in accordance with NICE TA195 - approved by the BNSSG JFG June 2015.
• Rituximab may also be used as monotherapy in RA in patients in whom methotrexate is not tolerated - approved by the BNSSG JFG July 2016
• For the treatment of Anti-neutrophil Cytoplasmic Autoantibody-Associated (ANCA) Vasculitis (AAV) see NHS England Commissioning Board Clinical Commissioning Policy A13/P/a (specialised rheumatology) and NICE guidance TA308 Rituximab in combination with glucocorticoids for treating anti-neutrophil cytoplasmic antibody associated vasculitis
• For the treatment of Systemic Lupus Erythematosus in adults see NHS England Board Clinical Commissioning Policy A13/PS/a (specialised rheumatology)

Protein Kinase Inhibitors

Baricitinib (TLS Red)

• See NICE guidance TA466 Baricitinib for moderate to severe rheumatoid arthritis

Tofacitinib (TLS Red)

• See NICE guidance TA480 Tofacitinib for moderate to severe rheumatoid arthritis
• See NICE guidance TA543 Tofacitinib for treating active psoriatic arthritis after inadequate response to DMARDs

Drugs affecting the immune response - for specialist use only

Azathioprine (TLS Amber) (SCP click here)

• Also see Azathioprine Rheumatology Monitoring Advice Sheet

Ciclosporin (TLS Red)

Cyclophosphamide (TLS Red)

Leflunomide (TLS Amber) (SCP click here)

• Also see Leflunomide Concise Monitoring Advice Sheet

Methotrexate (oral) 2.5mg tablets only - weekly dose (TLS Amber) (SCP click here)

• Also see Methotrexate Concise Monitoring Advice Sheet
• Please refer to NPSA guidance on reducing the risks of oral methotrexate. Patients should have patient held records while they are receiving treatment with any DMARD requiring regular monitoring (record cards and GP protocol advice available from rheumatology)

Methotrexate (parenteral) - weekly dose (TLS Amber) (SCP click here)

• The current recommended brand of subcutaneous methotrexate is Metoject^®
• All prescriptions in both primary and secondary care should state the generic and brand name
• Patients should remain on the same brand of methotrexate injection recommended by Rheumatology to prevent patients receiving a device that they cannot use to self-administer.
• Also see Methotrexate Concise Monitoring Advice Sheet

Mycophenolate (oral)  (TLS Amber 3 months) (SCP Click here)

• For use in rheumatological conditions- unlicensed indication

Other

Sulfasalazine (TLS Amber) (SCP click here)

• Also see Sulfasalazine Concise Monitoring Advice Sheet

Phosphodiesterase type-4 inhibitors

Apremilast (TLS Red)

• As per NICE TA419 Apremilast for treating moderate to severe plaque psoriasis
• As per NICE TA433 Apremilast for treating active psoriatic arthritis

Sildenafil (TLS Amber 3 months) (SCP click here)

• As per NHSE Clinical Commissioning- Sildenafil and bosentan for the treatment of digital ulceration in systemic sclerosis

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