[Skip to content]

Print this page
.

10.1.2 - 10.1.4 Corticosteroids, rheumatic disease suppressants, gout

Hydrocortisone acetate injection
Methylprednisolone acetate injection
Triamcinolone acetonide injection

 

10.1.3 Drugs which suppress the rheumatic disease process

Sulfasalazine enteric coated tablets click here for shared care
Methotrexate tablets, injection (see note)* click here for shared care
Leflunomide tablets (hospital specialist initiation only) click here for shared care
Penicillamine tablets click here for shared care
Hydroxychloroquine tablets

 

Immunosuppressants
Azathioprine tablets click here for shared care
Ciclosporin capsules, oral solution click here for shared care
Cyclophosphamide tables, IV Infusions (unlicensed indication)
Tacrolimus capsules

 

Cytokine modulators

All patients should be assessed for active and latent tuberculosis before starting anti-TNF treatment – see MHRA Drug Safety Update April 2014

Derbyshire commissioning guidance on biologic drugs for the treatment of
Rheumatoid arthritis (October 2014)
Ankylosing spondylitis (August 2011)
Psoriatic arthritis (April 2011)
 
Baricitib tablets – for moderate to severe rheumatoid arthritis. See NICE TA 466 
Tocilizumab infusion; s/c injection
Etanercept injection (specialist use only) - NICE Guidance is available for:
Rheumatoid arthritis - NICE TA 375
Severe active ankylosing spondylitis / non-radiographic axial spondyloarthritis - NICE TA 383
Psoriatic arthritis - NICE TA 199
Systemic juvenile idiopathic arthritis in children - NICE TA 373
Rheumatoid arthritis - drugs for treatment after failure of a TNF inhibitor - NICE TA 195
Takayasu vasculitis (in accordance with NHSE Commissioning Policy)

 

Golimumab injection - NICE Guidance is available for:
Psoriatic arthritis - NICE TA 225
Rheumatoid arthritis - NICE TA 375
Ankylosing spondylitis - NICE TA 383

 

Infliximab infusion (specialist use only) - NICE Guidance is available for:
Rheumatoid arthritis - NICE TA 375
Psoriatic arthritis - NICE TA 199
Rheumatoid arthritis - drugs for treatment after failure of a TNF inhibitor - NICE TA 195 
Ankylosing spondylitis - NICE TA 383

 

Adalimumab injection - NICE Guidance is available for:
Juvenile Idiopathic arthritis – NICE TA373
Rheumatoid arthritis - NICE TA 375
Ankylosing spondylitis / non-radiographic axial spondyloarthritis - NICE TA 383
Psoriatic arthritis - NICE TA 199
Rheumatoid arthritis - drugs for treatment after failure of a TNF inhibitor - NICE TA 195 

 

Abatacept infusion 
Juvenile Idiopathic arthritis – NICE TA373
Rheumatoid arthritis - drugs for treatment after failure of a TNF inhibitor - NICE TA 195

Rheumatoid arthritis - abatacept (2nd line) (rapid review of TA234) (TA280)

Abatacept may also be given by weekly subcutaneous injection as an alternative to other available subcutaneous biologics especially in patients at high risk of infection. This formulation is not currently supported by a NICE TA.

Tocilizumab infusion; s/c injection
Rheumatoid arthritis - NICE TA 375
Systemic juvenile idiopathic arthritis in children - NICE TA 373 
Ustekinumab injection

Psoriatic arthritis – NICE TA 313    
  
Certolizumab injection
Psoriatic arthritis – NICE TA 445 
Rheumatoid arthritis - NICE TA 415
Ankylosing spondylitis / non-radiographic axial spondyloarthritis – NICE TA383 

 

Rituximab - Truixma is the brand of choice for new patients requiring treatment with Rituximab. Mabthera brand is available for those patients already commenced on Rituximab and are unwilling to switch to Truximan
NICE Guidance is available for Severe acute rheumatoid arthritis (also see note)**
Rheumatoid arthritis - drugs for treatment after failure of a TNF inhibitor - NICE TA 195 
Dermatomyositis / polymyositis (in accordance with NHSE Commissioning Policy)

Secukinumab injection

Psoriatic arthritis – NICE TA 445 


Belimumab infusion - NICE Guidance is available for
Active autoantibody-positive systemic lupus erythematosus – TA 397

Ankylosing spondylitis – NICE TA407

Notes:

1. *Methotrexate should be prescribed on a ONCE WEEKLY basis along with Folic acid which is usually take one day a week, three days prior to methotrexate. Following several incidents when patients have taken ecessive doses it is recommended methotrexate be prescribed using 2.5mg tablets.

2. Hydroxychloroquine - patients should have a check for unusual impairment at their annual clinical review.

3. Tacrolimus- for hospital specialist initiation only, in patients who are intolerant of, or who have failed with, all other second line treatments. Prescribing should only be transferred to GPs under shared care arrangements once the patient has been stabilised for six months. Because of bioavailability differences between products, switching patients between different tacrolimus formulations is not recommended without careful therapeutic monitoring.

4. **Rituximab Infusion reserved for use in severe active Rheumatoid Arthritis with inadequate response or intolerance of other dmards, including one anti-TNF agent. Local agreement with the PCTs also allows the use as monotherapy in patients unable to take methotrexate, in patients with a proven malignancy in the last ten years (when anti-TNF therapy would be contraindicated) and in patients with significant pulmonary fibrosis (where anti-TNF may cause worsening of this condition).

 

10.1.4 Drugs for treatment of gout

Allopurinol tablets
Colchicine tablets
Febuxostat tablets - see NICE TA 164 
Sulfinpyrazone tablets
 
Hyperuricaemia associated with cytotoxic drugs 
Rasburicase

Benzbromarone tablets are unlicensed in the UK. They are a RED (hospital –only) medicine, reserved for use by rheumatology only, available via concession form, for patients who have contraindications to, or unable to tolerate, allopurinol or febuxostat.

Notes:

1. Allopurinol should be used with particular caution in renal impairment. Treatment should be started with a maximum dose of 100mg/day and increased only if the serum and/or urinary urate response is unsatisfactory. In severe renal insufficiency, it may be advisable to use less than 100mg or to use single doses of 100mg at longer intervals than one day.

2. Febuxostat is available for the management of chronic hyperuricaemia where crystal deposition has occurred. It is for specialist initiation, and is reserved for patients intolerant of or with contraindications to allopurinol.

There have been rare but serious reports of hypersensitivity reactions, including Stevens-Johnson syndrome and acute anaphylactic shock, with febuxostat (Adenuric). Febuxostat must be stopped immediately if hypersensitivity occurs, and must not be re-started in patients who have ever developed a hypersensitivity reaction to febuxostat.  Please refer to the Drug Safety Update for June 2012

 3. Prophylactic drugs should not be commenced until an acute attack has fully resolved as symptoms may be worsened. The introduction of allopurinol or probenecid for prophylaxis can increase the incidence of acute attacks during the first few months of treatment. Colchicine (500micrograms bd) or a NSAID (e.g. ibuprofen 400mg tds) given for 1-2 months helps to prevent this. Colchicine is to be preferred as it avoids the use of NSAIDs.

4. Rasburicase should be used in line with Derby Burton Cancer Network guideline for Tumour Lysis Syndrome