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Milton Keynes Formulary
Milton Keynes University Hospital NHS Foundation Trust
Bedfordshire, Luton and Milton Keynes Clinical Commissioning Group
Milton Keynes Community Health Services
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 Formulary Chapter 10: Musculoskeletal and joint diseases - Full Chapter
10.01.03  Expand sub section  Drugs which suppress the rheumatic disease process
10.01.03  Expand sub section  Gold
10.01.03  Expand sub section  Penicillamine
10.01.03  Expand sub section  Antimalarials
10.01.03  Expand sub section  Drugs affecting the immune response to top
Cytotoxic Drug Methotrexate
(rheumatology)
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Third Choice
Amber SCG
Homecare

Tablets 2.5mg

Metoject Injection prefilled syringe 10mg, 15mg, 20mg, 25mg

1. CSM Warning – Methotrexate: In view of reports of blood dyscrasias (including
fatalities) and liver cirrhosis with low-dose methotrexate, the CSM has advised:
specific monitoring guidance (superseded by NPSA alerts and nGMS);
that patients should be advised to report all symptoms and signs suggestive of infection, especially sore throat.
2. Treatment with folinic acid (as calcium folinate) may be required in acute
toxicity.
3. The CSM has received reports of prescription and dispensing errors with
methotrexate, including fatalities. Attention should be paid to the strength of
methotrexate tablets prescribed and the frequency of dosing.
4. The label on prescribed/dispensed methotrexate should state the instructions
clearly, for example: ‘methotrexate 2.5mg tablets: (number of tablets) to be
taken as a single dose ONCE A WEEK on XXXDAY’.
5. Keep repeat prescriptions for methotrexate separate from others
6. In the treatment of non-cancer conditions (eg. rheumatology and
dermatology), methotrexate must be given once a week or once a month. Staff
that encounter methotrexate prescriptions must ensure the correct dosing
interval is given.
7. In patients who experience mucosal or gastrointestinal side effects with
methotrexate, folic acid 5mg each week (taken 48 hours after the methotrexate
dose) may be given. It may be given routinely to help reduce the frequency of
such side effects.
Methotrexate-induced mucositis or myelosuppression: folinic acid (given as
calcium folinate) is used to counteract the folate-antagonist action of
methotrexate and so facilitate recovery from methotrexate-induced mucositis or
myelosuppression.
8. Methotrexate and NSAIDs: if aspirin or other NSAIDs are given concurrently
the dose of methotrexate should be carefully monitored. Patients should be
advised to avoid self-medication with over-the-counter aspirin or ibuprofen.

 
Link  UKMI Q&A: Methotrexate and alcohol guidance
Link  NICE Q&A: Interaction between methotrexate and penicillins
   
Abatacept (Orencia®)
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Formulary
Red
High Cost Medicine

Orencia Intravenous infusion 250mg

 
Link  NICE TA195: Adalimumab, etanercept, infliximab, rituximab and abatacept for the treatment of rheumatoid arthritis after the failure of a TNF inhibitor
Link  NICE TA280: Abatacept for treating rheumatoid arthritis after the failure of conventional disease-modifying anti-rheumatic drugs
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
(rheumatology)
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Formulary
Red
High Cost Medicine
Homecare
  • Imraldi, Injection, 40mg/0.8mL prefilled pen or prefilled syringe
  • Amgevita, Injection, 20mg/0.4mL; 40mg/0.8mL prefilled pen or prefilled syringe
  • Humira, Injection, 40mg/0.4mL; 80mg/0.8mL prefilled pen or prefilled syringe
  • Humira, Injection, 20mg/0.2mL pre-filled syringe, 40mg/0.8mL solution in vial for first line use in paediatrics

Notes:
To be prescribed by brand.
1. First line brand in adults = Imraldi®
2. Second line brand in adults = Amgevita®
3. Third line brand in adults = Humira®

Hulio and Hyrimoz are non-formulary within Milton Keynes Healthcare.

 
Link  MHRA: Tuberculosis risk—screen patients before starting treatment
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
   
Anakinra (Kineret®)
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Formulary
Red
High Cost Medicine
BlueTeq

100mg/0.67 ml solution for injection in pre-filled syringe

To be prescribed in accordance with the NICE TA (see link below).

 
Link  NICE TA685: Anakinra for treating Still’s disease
Link  NHS England: Suggested Treatment Flow-chart for Juvenile idiopathic arthritis,JIA (Appendix A)
   
Cytotoxic Drug Azathioprine
(Rheumatology)
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Formulary
Amber SCG

Tablets 25mg, 50mg

 
   
Certolizumab Pegol (Cimzia®)
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Formulary
Red
High Cost Medicine

Cimzia® Solution for injection, 200mg in pre-filled pen or in pre-filled syringe

 
Link  MHRA: Tuberculosis risk—screen patients before starting treatment
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 DMARDs
Link  NICE TA574: Certolizumab pegol for treating moderate to severe plaque psoriasis
   
Ciclosporin
(Rheumatology)
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Formulary
Amber SCG
  • Capsules 10mg, 25mg, 50mg, 100mg
  • Oral solution 100mg/1ml

Notes:

  • Ciclosporin (Neoral) is licensed for severe active RA when conventional second-line therapy is inappropriate or ineffective.
  • It is contraindicated in abnormal renal function, uncontrolled hypertension, uncontrolled infections and malignancy.
  • Monitor hepatic function if concomitant NSAIDs given.
  • As there are differences in bioavailability, the brand of ciclosporin to be dispensed should be specified by the prescriber.
 
   
Etanercept (Benepali®)
(Biosimilar)
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Formulary
Red

50mg in 1ml pre-filled syringes

 
Link  NICE TA35: Adult psoriasis
Link  Benepali Patient Alert Card
Link  MHRA: Tuberculosis risk—screen patients before starting treatment
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®)
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Formulary
Red
High Cost Medicine
Homecare

25mg in 0.5ml pre-filled syringe, 25mg injection

 
Link  MHRA: Tuberculosis risk—screen patients before starting treatment
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
   
Golimumab (Simponi®)
(Rheumatology)
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Formulary
Red
High Cost Medicine

Simponi® 50mg in 0.5mL solution in pre-filled pen, 100mg in1mL solution in pre-filled pen

 
Link  MHRA: Tuberculosis risk—screen patients before starting treatment
Link  NICE TA220: psoriatic arthritis
Link  NICE TA225: Golimumab for the treatment of rheumatoid arthritis after the failure of previous disease-modifying anti-rheumatic drugs
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 TA497: Golimumab for treating non-radiographic axial spondyloarthritis
   
Infliximab
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Formulary
Red
High Cost Medicine

100mg vial powder for reconstition

 
Link  MHRA: Tuberculosis risk—screen patients before starting treatment
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
Link  NHS England: Suggested Treatment Flow-chart for JIA (Appendix A)
   
Leflunomide
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Formulary
Amber SCG

Tablets 10mg, 20mg

 
   
Rituximab
(Rheumatology)
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Formulary
Red
High Cost Medicine

Concentrate for iv infusion 100mg in 10ml, 500mg in 50ml

 

 
Link  NICE TA195: Rheumatoid arthritis - after failure of a TNF inhibitor
   
Tocilizumab (RoActemra®)
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Formulary
Red
High Cost Medicine
  • RoActemra® 162mg solution for injection in pre-filled pen or pre-filled syringe
  • RoActemra® Intravenous infusion 20mg in 1mL
 
Link  MHRA: rare risk of serious liver injury including cases requiring transplantation (2019)
Link  Appendix to Clinical Commissioning Policy Statement (NHS England E03/P/d)
Link  Clinical Commissioning Statement: Biologics for Juvenile Idiopathic Arthritis
Link  NICE TA238: Tocilizumab for the treatment of systemic juvenile idiopathic arthritis
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  Expand sub section  Cytokine modulators
10.01.03  Expand sub section  Sulfasalazine
 ....
 Non Formulary Items
Cytotoxic Drug  Cyclophosphamide
(Rheumatology)

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Non Formulary
 
Etanercept  (Erelzi®)
(Biosimilar)

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Non Formulary
Link  MHRA: Tuberculosis risk—screen patients before starting treatment
Link  NICE TA195: rheumatoid arthritis after the failure of a TNF inhibitor
Link  NICE TA199: Psoriatic arthritis
Link  NICE TA35: Adult psoriasis
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
 
Rituximab  (Truxima®)
(Rheumatology - biosimilar)

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Non Formulary
High Cost Medicine
Link  NHS England: Rituximab for ANCA-associated vasculitis in adults
Link  NHS England: Rituximab for immunoglobulin G4-related disease
Link  NHS England: Suggested Treatment Flow-chart for JIA (Appendix A)
Link  NICE TA195: Rheumatoid arthritis - after failure of a TNF inhibitor
 
  
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
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Link to adult BNF
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Link to children's BNF
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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

Routine prescribing within licensed indication  

Amber 1

Specialist recommendation followed by GP initiation and continuation  

Amber 2

Specialist or GP initiation in line with local guideline after 1st line failure followed by GP continuation   

Amber 3

Specialist initiation and stabilisation followed by GP continuation  

Amber SCG

Specialist initiation and stabilisation followed by GP continuation in line with an agreed shared care guideline  

Red

Hospital or specialist prescribing only  

Red Red

These medicines have been evaluated and rejected by MKPAG and are NOT approved for use within MK. They are not recommended for use because of lack of clinical effectiveness, cost effectiveness or safety.  

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