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10.1 Drugs used in Rheumatic Diseases and Gout

NICE Guidance Musculoskeletal Conditions

 10.1.1 Non-steroidal anti-inflammatory drugs

 Before prescribing a long term NSAID

  • Consider whether NSAID is necessary
  • Paracetamol is first line for osteoarthritis
  • All NSAIDs are associated with serious gastro-intestinal toxicity
  • Asthma may be worsened in patients with nasal polyps

 For patients <65 years with no CV or GI risk factors

 1st     IBUPROFEN (up to 2400mg daily)
 2nd    DICLOFENAC
 3rd    INDOMETACIN

 For patients with CV risk factors

MeReC guidance on the CV and GI risk associated with NSAIDs

 1st    IBUPROFEN <1200mg/day
 1st    NAPROXEN 1000mg/day

For patients >65 years with GI risk factors

GI risk factors for NSAIDs include:

  • Age over 65 years (more than 2 weeks treatment)
  • Past history of major gastro-intestinal events
  • Steroid
  • Anticoagulant
  • Aspirin
  • SSRI antidepressant
  • Long term high dose NSAID (more than two weeks)
  • Serious co-morbidity (e.g. cardiac, renal, and hepatic impairment)
 1st    NSAID + PPI
 1st    MELOXICAM + PPI
 2nd     CELECOXIB +PPI
 2nd    ETORICOXIB + PPI

 For patients >65 years with CV and GI risk factors

 1st    IBUPROFEN <1200mg/day + PPI
 1st    NAPROXEN 1000mg/day + PPI
     PARECOXIB (Theatres only)
     PIROXICAM MELT (For children only)
     MEFENAMIC ACID (Dysmenorrhoea and menorrhagia)
     ARTHROTEC (For continued treatment only)
     PHENYLBUTAZONE (Yellow) (Named patient only, for the treatment of ankylosing spondylitis)

Selective/Specific COX-2 inhibitors are not recommended fIrst line due to emerging safety concerns, and are now contraindicated in CVD. The same now applies to high doses of some standard NSAIDs, such as Ibuprofen and diclofenac in CVD.

 10.1.2 Corticosteroids

 10.1.2.1 Systemic corticosteroids

   

 PREDNISOLONE Oral

  • A steroid card should be given where appropriate.
  • Withdraw long term (>3 weeks) steroids gradually.
  • Offer prophylactic bone protection in patients likely to be on more than three months treatment.

  10.1.2.2 Local corticosteroid injections

 1st    METHYLPREDNISOLONE
 1st    METHYLPREDNISOLONE & LIDOCAINE
 2nd    HYDROCORTISONE ACETATE
 2nd    TRIAMCINOLONE
     SYNVISC (restricted indications - osteoarthritis of the knee)
     Intra-articular injections should not normally be administered to any one joint more than three times a year.

 10.1.3 Drugs which suppress the rheumatic disease process

Initiation by specialists ONLY

DMARD Shared Care Arrangement

     
  • All patients receiving these disease-modifiying drugs should be monitored before and during treatment.
  • DMARDS: 4-6 months of treatment is needed for full response.
  • NPSA document concerning oral methotrexate
   Gold  SODIUM AUROTHIOMALATE Injection (Yellow)
   Penicillamine  PENICILLAMINE (Yellow)
   Antimalarials  HYDROXYCHLOROQUINE (Yellow)

 Drugs affecting the immune response

     
     APREMILAST (Otezla) - NICE TA419
     AZATHIOPRINE (Amber)
     CICLOSPORIN (Amber)
     METHOTREXATE (Amber) (ONCE weekly)
     LEFLUNOMIDE (Amber)
     MYCOPHENOLATE MOFETIL (Amber)

 Sulfasalazine

     SULFASALAZINE (Amber)

Cytokine modulators

For use according to NICE guidance

     ADALIMUMAB
     CERTOLIZUMAB
     ETANERCEPT
     GOLIMUMAB
     INFLIXIMAB
   

 RITUXIMAB

Recommended option in psoriatic arthritis to etanercept, inflximab & adalimumab

     TOCILIZUMAB

 10.1.4 Gout and cytotoxic-induced hyperuricaemia

 Acute attacks of gout
  1st    NSAID (not aspirin)  - see Section 10.1.1
 2nd   

 COLCHICINE

Colchicine is limited by toxicity at higher doses, but is of value in patients with heart failure, and be given to patients on anticoagulants.

  Long-term treatment of gout

   

 ALLOPURINOL

 Do not start allopurinol during an acute attack of gout

     FEBUXOSTAT (For patients intolerant of allopurinol)
     PROBENECID

Hyperuricaemia associated with cytotoxic drugs

     RASBURICASE

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