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 Formulary Chapter 10: Musculoskeletal and joint diseases - Full Chapter
10.01  Drugs used in rheumatic diseases and gout
10.01  Rheumatoid arthritis and other inflammatory disorders
10.01  Osteoarthritis and soft-tissue disorders
10.01.01  Non-steroidal anti-inflammatory drugs
Ibuprofen
(Oral)
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First Choice
Green 1

Prescribing note: 1st line agent – preferred choice

 
Naproxen
View adult BNF View SPC online View childrens BNF
First Choice
Green 1

Prescribing note: 1st line agent

 
Celecoxib (Celebrex)
View adult BNF View SPC online View childrens BNF
Formulary
Green

Prescribe generically. See current guidance about the use of COX2 inhibitors. Please remember that COX2 inhibitors should not be used in patients with cardiovascular disease.

 
   
Diclofenac
View adult BNF View SPC online View childrens BNF
Formulary
Advice

Restricted: oral preparation not recommended for routine use. Please note: IM injection – maximum of 4 doses in 48 hours – see data sheet. Voltarol dispersible tablets are for patients who cannot swallow tablets.

See MHRA warning January 2015 and updated contra-indications – tablets not for new patients

 
   
Diclofenac with Misoprostol (Arthrotec 50 and 75)
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Restricted Drug Restricted
Advice

Not recommended for new patients

Restricted: Second line agent in patients with criteria to support the use of Misoprostol

 
   
Etodolac
View adult BNF View SPC online View childrens BNF
Formulary
Green 2

Note: Second line agent only

 
   
Indometacin
(Indometacin mr)
View adult BNF View SPC online View childrens BNF
Formulary
Green
 
   
Indometacin
View adult BNF View SPC online View childrens BNF
Formulary
Green
 
   
Ketoprofen
View adult BNF View SPC online View childrens BNF
Formulary
Green
 
   
Ketoprofen (Oruvail MR)
View adult BNF View SPC online View childrens BNF
Formulary
Green 2

Note: Second line agent only

 
   
Meloxicam
View adult BNF View SPC online View childrens BNF
Formulary
Green

See current guidance about the use of COX2 inhibitors. Please remember that COX2 inhibitors should not be used in patients with cardiovascular disease.

 
   
Nabumetone
View adult BNF View SPC online View childrens BNF
Restricted Drug Restricted
Amber

Restricted: For Consultant Rheumatologist use only

 
   
Piroxicam
View adult BNF View SPC online View childrens BNF
Restricted Drug Restricted
Advice

Restricted: Feldene Melts are available to patients whilst nil by mouth only. Once the patient is taking oral medication, an oral preparation should be used

 
   
Sulindac
View adult BNF View SPC online View childrens BNF
Restricted Drug Restricted

Restricted: Third line agent, for initiation by consultant rheumatologists only

 
   
10.01.01  Aspirin to top
10.01.02  Corticosteroids
10.01.02.01  Systemic corticosteroids
10.01.02.02  Local corticosteroids injections
Methylprednisolone Acetate (Depo-Medrone)
View adult BNF View SPC online View childrens BNF
Formulary
Green
 
   
Triamcinolone Acetonide (Adcorty')
View adult BNF View SPC online View childrens BNF
Formulary
Green

Intra-articular  /  Intradermal

 
   
Triamcinolone Acetonide (Kenalog)
View adult BNF View SPC online View childrens BNF
Formulary
Green
 
   
10.01.03  Drugs which suppress the rheumatic disease process
Baricitinib (Olumiant)
View adult BNF View SPC online View childrens BNF
Restricted Drug Restricted
Red
High Cost Medicine

For moderate to severe rheumatoid arthritis in line with TA466

 
   
Golimumab (Simponi)
(Axial spondyloarthritis)
View adult BNF View SPC online View childrens BNF
Restricted Drug Restricted
Red
High Cost Medicine

In line with NICE technology appraisals and local guidance

 
Link  NICE TA497: Golimumab for treating non-radiographic axial spondyloarthritis
   
Sarilumab (Kevzara)
View adult BNF View SPC online View childrens BNF
Restricted Drug Restricted
Red

 In line with NICE TA485

 
Link  NICE TA485: Sarilumab for moderate to severe rheumatoid arthritis
   
Tofacitinib citrate
(Xeljanz)
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Restricted Drug Restricted
Red
High Cost Medicine

For moderate to severe rheumatoid arthritis in line with TA480

 
Link  NICE TA480: Tofacitinib for moderate to severe rheumatoid arthritis
   
10.01.03  Gold to top
Soldium Aurothomalate (Myocrisin)
(Gold)
View adult BNF View SPC online View childrens BNF
Restricted Drug Restricted
Amber

Rheumatology - shared care

 

 
   
10.01.03  Penicillamine
Penicillamine
View adult BNF View SPC online View childrens BNF
Restricted Drug Restricted
Amber

Rheumatology shared care

 

 
   
10.01.03  Antimalarials
Chloroquine
View adult BNF View SPC online View childrens BNF
Restricted Drug Restricted
Amber
 
   
Hydroxychloroquine
(Rheumatology)
View adult BNF View SPC online View childrens BNF
Restricted Drug Restricted
Amber

Rheumatoid Arthritis Only

 

 
   
10.01.03  Drugs affecting the immune response
Abatacept (Orencia)
View adult BNF View SPC online View childrens BNF
Restricted Drug Restricted
Red
High Cost Medicine

 In line with NICE technology appraisals and local guidance

 
Link  NICE TA373: Abatacept, adalimumab, etanercept and tocilizumab for treating juvenile idiopathic arthritis
Link  NICE TA375: Rheumatoid arthritis not previously treated with DMARDs or after conventional DMARDs only have failed
   
Adalimumab (Humira)
(rheumatology)
View adult BNF View SPC online View childrens BNF
Restricted Drug Restricted
Red
High Cost Medicine

 In line with NICE technology appraisals and local guidance

 
Link  NICE TA195: Rheumatoid arthritis - after failure of a TNF inhibitor
Link  NICE TA199: Psoriatic arthritis
Link  NICE TA373: Abatacept, adalimumab, etanercept and tocilizumab for treating juvenile idiopathic arthritis
Link  NICE TA375: 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 TA455 : Adalimumab, etanercept and ustekinumab for treating plaque psoriasis in children and young peopl
Link  NICE TA460 : Adalimumab and dexamethasone for treating non-infectious uveitis
   
Cytotoxic Drug Azathioprine
(rheumatology)
View adult BNF View SPC online View childrens BNF
Restricted Drug Restricted
Amber
 
   
Certolizumab Pegol (Cimzia)
View adult BNF View SPC online View childrens BNF
Restricted Drug Restricted
Red
High Cost Medicine

 In line with NICE technology appraisals and local guidance

 
Link  NICE TA375: 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 DMARD
   
Ciclosporin
(Rhematology)
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Restricted Drug Restricted
Red Amber

Restricted: Consultant initiation only.

Hospital Only for new renal transplant patients

Prescribe by brand to ensure bioequivalence.

 
   
Cytotoxic Drug Cyclophosphamide
(Rheumatology)
View adult BNF View SPC online View childrens BNF
Restricted Drug Restricted
Amber

Immunosuppressant in Rheumatology - AMBER

 

 
   
Etanercept (Benepali)
(Biosimilar)
View adult BNF View SPC online View childrens BNF
Restricted Drug Restricted
Red

  In line with NICE technology appraisals and local guidance

 
Link  NICE TA35: Adult psoriasis
Link  NICE TA195: rheumatoid arthritis after the failure of a TNF inhibitor
Link  NICE TA199: Psoriatic arthritis
Link  NICE TA375: 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
   
Etanercept (Enbrel)
View adult BNF View SPC online View childrens BNF
Restricted Drug Restricted
Red
High Cost Medicine

 In line with NICE technology appraisals and local guidance

 
Link  NICE TA35: Adult psoriasis
Link  NICE TA195: Rheumatoid arthritis after the failure of a TNF inhibitor
Link  NICE TA199: Psoriatic arthritis
Link  NICE TA373: Abatacept, adalimumab, etanercept and tocilizumab for JIA
Link  NICE TA375: 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 TA455 : Adalimumab, etanercept and ustekinumab for treating plaque psoriasis in children and young people
   
Etanercept (Erelzi)
(Biosimilar)
View adult BNF View SPC online View childrens BNF
Restricted Drug Restricted
Red

 In line with NICE technology appraisals and local guidance

 
   
Golimumab (Simponi)
(Rheumatology)
View adult BNF View SPC online View childrens BNF
Restricted Drug Restricted
Red
High Cost Medicine

In line with NICE technology appraisals and local guidance

 
Link  NICE TA220: psoriatic arthritis
Link  NICE TA375: 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
   
Infliximab (Remicade)
View adult BNF View SPC online View childrens BNF
Restricted Drug Restricted
Red
High Cost Medicine

In line with NICE technology appraisals and local guidance

 
Link  NICE TA195: Rheumatoid arthritis (after failure of a TNF inhibitor)
Link  NICE TA199: Psoriatic arthritis
Link  NICE TA375: 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
   
Leflunomide
View adult BNF View SPC online View childrens BNF
Restricted Drug Restricted
Amber

Restricted: Consultant rheumatologist only

 
   
Cytotoxic Drug Methotrexate
(rheumatology)
View adult BNF View SPC online View childrens BNF
Restricted Drug Restricted
Amber

Restricted: Initiated by consultant specialist only.

Extreme care must be taken when prescribing methotrexate:

  • Only 2.5mg tablets may be prescribed. Ensure total dose and quantity of tablets is clearly written on the prescription
  • The frequency must state once weekly (unless higher dosing is not tolerated, and the weekly dose can then be split into 3 doses per week).
  • Patients must be counselled to ensure they understand a once weekly regime. NPSA guidelines must be followed
 
   
Methotrexate (Metoject)
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Restricted Drug Restricted
Red

Injectable product not suitable for primary care prescribing unless shared care available from out of County provider

 

 
   
Rituximab (Truxima)
(Rheumatology - biosimilar)
View adult BNF View SPC online View childrens BNF
Restricted Drug Restricted
Red
High Cost Medicine

In line with NICE and local guidance [for oncology/haematology use see ch.8]

 
   
Rituximab (rheumatology) (MabThera)
View adult BNF View SPC online View childrens BNF
Restricted Drug Restricted
Red
High Cost Medicine

In line with NICE and local guidance [for oncology/haematology use see ch.8]

 
Link  NICE TA195: Rheumatoid arthritis - after failure of a TNF inhibitor
   
Tocilizumab (RoActemra)
View adult BNF View SPC online View childrens BNF
Restricted Drug Restricted
Red
High Cost Medicine

In line with NICE technology appraisals and local guidance

 
Link  NICE TA247:Tocilizumab in RA
Link  NICE TA373: Abatacept, adalimumab, etanercept and tocilizumab for treating juvenile idiopathic arthritis
Link  NICE TA375: Rheumatoid arthritis not previously treated with DMARDs or after conventional DMARDs only have failed
Link  NICE TA518: Tocilizumab for treating giant cell arteritis
   
10.01.03  Cytokine modulators
10.01.03  Sulfasalazine to top
Sulfasalazine
View adult BNF View SPC online View childrens BNF
Restricted Drug Restricted
Amber

Induction and maintenance of remission of ulcerative colitis; treatment of active Crohn's Disease.

 

Use EC tablets for rheumatoid arthritis

 
   
Sulfasalazine EC (Salazopyrin EN-Tabs)
View adult BNF View SPC online View childrens BNF
Restricted Drug Restricted
Amber

Can be supplied via a WVT PGD for authorised rheumatology clinical specialists (supply and monitor the use of sulfasalazine).

 
   
10.01.04  Gout and cytotoxic-induced hyperuricaemia
10.01.04  Acute attacks of gout
Colchicine
View adult BNF View SPC online View childrens BNF
Formulary
Green
 
   
10.01.04  Long-term control of gout
Allopurinol
View adult BNF View SPC online View childrens BNF
Formulary
Green
 
   
Febuxostat (Adenuric )
View adult BNF View SPC online View childrens BNF
Formulary
Green 2

Febuxostat is recommended as an option for the management of chronic hyperuricaemia in gout only for people who are intolerant of allopurinol or for whom allopurinol is contraindicated in line with NICE TA164.

 
Link  NICE TA164: Hyperuricaemia - febuxostat
   
10.01.04  Hyperuricaemia associated with cytotoxic drugs
Rasburicase (Fastertec)
View adult BNF View SPC online View childrens BNF
Restricted Drug Restricted
Red
High Cost Medicine

For acute hyperuricaemia. Also approved for use in severe debilitating tophaceous gout (>3 tophi) by consultant rheumatologists

 
   
10.01.05  Other drugs for rheumatic diseases to top
10.02  Drugs used in neuromuscular disorders
10.02.01  Drugs which enhance neuromuscular transmission
10.02.01  Anticholinesterases
Edrophonium Chloride
View adult BNF View SPC online View childrens BNF
Restricted Drug Restricted
Amber

Unlicensed product.

Restricted for the diagnosis of myasthenia gravis.

 
   
Neostigmine
View adult BNF View SPC online View childrens BNF
Formulary
Green
 
   
Pyridostigmine Bromide (Mestinon)
View adult BNF View SPC online View childrens BNF
Formulary
Green
 
   
10.02.01  Immunosuppressant therapy
10.02.01  Acetylcholine-release enhancers to top
Amifampridine (Firdapse)
View adult BNF View SPC online View childrens BNF
Restricted Drug Restricted
Red
High Cost Medicine
NHS England
 
   
10.02.02  Skeletal muscle relaxants
Baclofen
View adult BNF View SPC online View childrens BNF
Formulary
Green
 
   
Dantrolene
View adult BNF View SPC online View childrens BNF
Formulary
Green
 
   
Diazepam
(muscle relaxant)
View adult BNF View SPC online View childrens BNF
Formulary
Green 2

Diazepam should not routinely be added to NSAIDs for the treatment of acute lower back pain.

10mg tablets should NOT be prescribed (make up the dose with 2mg and 5mg)

 
   
Tizanidine
View adult BNF View SPC online View childrens BNF
Restricted Drug Restricted
Amber

Restricted: Consultant Neurologist only

 
   
10.02.02  Other muscle relaxants
10.02.02  Nocturnal leg cramps
Quinine
(cramps)
View adult BNF View SPC online View childrens BNF
Formulary
Green

The BNF recommends a trial discontinuation with long-term use of quinine sulfate.
Treatment should be interrupted at intervals of 3 months to assess the need for further treatment.
 

 
   
10.03  Drugs for the treatment of soft-tissue disorders and topical pain relief
10.03  Extravasation to top
10.03.01  Enzymes
Collagenase (Xiapex)
View adult BNF View SPC online View childrens BNF
Restricted Drug Restricted
Red

Clostridium histolyticum 900 micrograms with solvent

▼For intralesional injection by trained specialists to treat Dupuytrens contracture in patients with a palpable cord.

 
Link  NICE TA459 : Collagenase clostridium histolyticum for treating Dupuytren’s contracture
   
10.03.02  Rubefacients, topical NSAIDs, capsaicin, and poultices
10.03.02  Topical NSAIDs and counter-irritants
Ibuprofen gel
View adult BNF View SPC online View childrens BNF
First Choice
Green 1
 
10.03.02  Capsaicin
Axsain
View adult BNF View SPC online View childrens BNF
Restricted Drug Restricted
Amber

Restricted: Consultant initiation only

 
   
Capsaicin
(Osteoarthritis)
View adult BNF View SPC online View childrens BNF
Restricted Drug Restricted
Amber

Restricted: Consultant initiation only

 
   
10.03.02  Poultices to top
 ....
 Non Formulary Items
Aceclofenac

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Non Formulary
 
Acelofenac  (Preservex)

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Non Formulary
 
Acemetacin  (Emflex)

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Non Formulary
 
Algesal
(Topical gel)

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Non Formulary
 
Allopurinol  (Zyloric)

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Non Formulary
 
Anakinra  (Kineret)

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Non Formulary
High Cost Medicine
 
Ataluren  (Translarna)

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Non Formulary
High Cost Medicine
 
Auranofin  (Ridaura)

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Non Formulary
 
Azapropazone  (Rheumox)

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Non Formulary
 
Baclofen  (Lioresal)

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Non Formulary
 
Belimumab  (Benlysta )

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Non Formulary
High Cost Medicine
Link  NICE TA397: Belimumab for treating active autoantibody-positive systemic lupus erythematosus
 
Betamethasone  (Betnesol)
(injection - local)

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Non Formulary
 
Controlled Drug  Cannabis extract  (Sativex)

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Non Formulary

Not recommended by NICE - see Herefordshire LPT

 

 
Capsaicin  (Qutenza)

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Non Formulary
 
Carisoprodol  (Carisoma)

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Non Formulary
 
Celecoxib  (Onsenal)

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Non Formulary
 
Dexamethasone
(joint injection)

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Non Formulary
 
Dexamethasone Phosphate

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Non Formulary
 
Dexibuprofen  (Seractil)

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Non Formulary
 
Dexketoprofen  (Keral)

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Non Formulary
 
Diclofenac

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Non Formulary
 
Dicolfenac Sodium  (Diclomax Retard)

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Non Formulary
 
Dicolfenac Sodium  (Diclomax SR)

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Non Formulary
 
Dicolfenac Sodium  (Motifene 75mg)

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Non Formulary
 
Dicolfenac Sodium  (Voltarol 75 mg SR)

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Non Formulary
 
Dicolfenac Sodium  (Voltarol Radid)

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Non Formulary
 
Dicolfenac Sodium  (Voltarol Retard)

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Non Formulary
 
Distigmine Bromide

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Non Formulary
 
Etodolac  (Lodine SR)

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Non Formulary
 
Etoricoxib  (Arcoxia)

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Non Formulary
 
Felbinac  (Traxam)

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Non Formulary
 
Fenbufen

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Non Formulary
 
Fenbufen  (Lederfen)

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Non Formulary
 
Fenoprofen  (Fenopron)

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Non Formulary
 
Flurbiprofen

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Non Formulary
 
Flurbiprofen  (Froben SR)

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Non Formulary
 
Flurbiprofen  (Froben)

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Non Formulary
 
Glucosamine

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Non Formulary

Low Value Medicine - see Herefordshire LPT

 
Hyaluronic acid  (Hyalgan)

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Non Formulary
 
Hyaluronidase  (Hyalase)

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Non Formulary
 
Hydrocortisone acetate  (Hydrocortistab)

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Non Formulary
 
Hylan G-F 20  (Synvisc)

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Non Formulary
 
Ibuprofen  (Brufen Retard)

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Non Formulary
 
Ibuprofen  (Brufen)

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Non Formulary
 
Ibuprofen  (Fenbid)

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Non Formulary
 
Ibuprofen 10% gel

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Non Formulary
 
Ibuprofen and famotidine  (Duexis)

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Non Formulary
 
Kaolin Poultice

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Non Formulary
 
Kaolin Poultice  (Kaolin Poultice K/L Pack)

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Non Formulary
 
Ketoprofen  (Axorid®)

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Non Formulary
 
Ketoprofen  (Orudis)

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Non Formulary
 
Ketoprofen  (Oruvail)

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Non Formulary
 
Ketoprofen 2.5%  (Oruvail , Powergel)

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Non Formulary
 
Lesinurad  (Zurampic)

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Non Formulary

NICE "do-not-do" recommendation

 

Link  NICE TA506: Lesinurad for treating chronic hyperuricaemia in people with gout
 
Lumiracoxib  (Prexige)

View adult BNF View SPC online View childrens BNF
Non Formulary
 
Mefenamic Acid

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Non Formulary
Not Recomended / Black

If an NSAID is required for dysmenorrhoea or menorrhagia, consider the use of ibuprofen or naproxen which is first choice/alternative NSAID on formulary rather than mefenamic acid which is increasingly expensive and has no evidence of superiority over other NSAIDs 

 
Mefenamic Acid  (Ponstan)

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Non Formulary
 
Meloxicam  (Mobic)

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Non Formulary
 
Methocarbamol  (Robaxin)

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Non Formulary
 
Methotrexate  (Ebetrex®)

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Non Formulary
 
Methylprednisolone Acetate  (Depo-Medrone with Lidocaine)

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Non Formulary
 
Movelat  (Topical gel / cream)

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Non Formulary
 
Nabumetone  (Relifex)

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Non Formulary
 
Naproxen  (Naprosyn)

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Non Formulary
 
Naproxen  (Synflex)

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Non Formulary
 
Naproxen & esomeprazole  (Vimovo)

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Non Formulary
 
Naproxen with Misoprostol  (Napratec)

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Non Formulary
 
Nusinersen  (Spinraza)

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Non Formulary
 
Piroxicam  (Brexidol)

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Non Formulary
 
Piroxicam  (Feldene)

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Non Formulary
 
Piroxicam  (Feldene)

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Non Formulary
 
Prednisolone Acetate  (Deltastab)

View adult BNF View SPC online View childrens BNF
Non Formulary
 
Sodium hyaluronate and triamcinolone hexacetonide  (Cingal)

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Non Formulary
 
Sulfinpyrazone

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Non Formulary
 
Sulindac  (Clinoril)

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Non Formulary
 
Tenoxicam  (Mobiflex)

View adult BNF View SPC online View childrens BNF
Non Formulary
 
Tiaprofenic Acid

View adult BNF View SPC online View childrens BNF
Non Formulary
 
Tiaprofenic Acid  (Surgam)

View adult BNF View SPC online View childrens BNF
Non Formulary
 
Transvasin

View adult BNF View SPC online View childrens BNF
Non Formulary
 
Triamcinolone Acetonide  (Adcortyl)

View adult BNF View SPC online View childrens BNF
Non Formulary
 
Triamcinolone hexacetonide

Non Formulary
 
  
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 children's 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

Green

Suitable for use in primary care  

Amber

Specialist initiation. Shared care in place  

Red

Red do not use..  

Advice

Some formulations restricted  

Black

NICE "Do not do"  

Green 1

1st line option  

Green 2

2nd line option  

Green 3

3rd line option only  

Not Recomended / Black

Low Value Medicine not recommended for use - see NHSE guidelines  

OTC

This preparation should be bought over the counter for self-care  

Red Amber

Check product description for traffic light status  

Red Black

Low Value Medicine  

netFormulary