Please refer to the following protocols and guidance:

• NICE guideline NG100: Rheumatoid arthritis in adults: management
• NICE guideline NG65: Spondyloarthritis in over 16s: diagnosis and management

For DMARD monitoring protocols please refer to: DGRefHelp>Rheumatology>DMARD monitoring protocols

Safety considerations

• MHRA: Methotrexate once-weekly for autoimmune diseases: new measures to reduce risk of fatal overdose due to inadvertent daily instead of weekly dosing
• MHRA: Mycophenolate mofetil, mycophenolic acid: updated contraception advice for male patients Feb 2018
• MHRA: Mycophenolate mofetil, mycophenolic acid: new pregnancy-prevention advice for women and men Dec 2015
• MHRA DSU: Mycophenolate mofetil: pure red cell aplasia, July 2009
• MHRA DSU: Mycophenolate mofetil (CellCept) and mycophenolic acid: risk of hypogammaglobulinaemia and risk of bronchiectasis, January 2015
• MHRA DSU: Baricitinib (Olumiant▼): increased risk of diverticulitis, particularly in patients with risk factors
• MHRA DSU tofacitinib-new measures to minimise risk of major adverse cardiovascular events and malignancies October 2021

Rheumatoid arthritis – moderate to severe disease

Immunosuppressants - *Specialist Initiation Only*

DMARDs (all initiated in consultation with a specialist)

• Methotrexate ✓ Specialist Initiation Only (2.5mg tablets,once dose is stabilised, specialists may change to once weekly subcutaneous injection pre-filled pens (Metoject®)) Patient should stay on same brand they are used to. Prescribe MTX injection by brand.
• Hydroxychloroquine tablets ✓ Specialist Initiation Only
• Leflunimode tablets ✓ Specialist Initiation Only
• Sulphsalazine EC tablets ✓ Specialist Initiation Only
• Azathioprine tablets ✓ Specialist Initiation Only
• Ciclosporin capsules ✓ Specialist Initiation Only – patients should be maintained on the same brand
• Cyclophosphamide ✓ Specialist Initiation Only

Please note methotrexate should only be prescribed as multiples of the 2.5mg strength tablet once weekly

TNF-alpha inhibitors

• Adalimumab SC Injection – preferred biosimilar Amgevita® ✓ Specialist Initiation Only ✓ First Choice
• Infliximab IV/SC Injection - preferred biosimilar Remsima® ✓ Specialist Initiation Only
• Etanercept SC Injection– preferred biosimilar Benepali® ✓ Specialist Initiation Only
• Certolizumab SC Injection ✓ Specialist Initiation Only
• Golimumab SC Injection ✓ Specialist Initiation Only

CD-20 blocker

• Rituximab Infusion – preferred biosimilar Ruxience® ✓ Specialist Use Only

IL-6 inhibitors

• Sarilumab SC Injection ✓ Specialist Initiation Only
• Tocilizumab SC Injection - preferred biosimilar Tyenne® ✓ Specialist Initiation Only

CTLA-4 Blocker

• Abatacept SC Injection ✓ Specialist Initiation Only

JAK inhibitors

• Filgotinib tablets ✓ Specialist Initiation Only
• Upadacitinib tablets ✓ Specialist Initiation Only
• Baricitinib tablets ✓ Specialist Initiation Only
• Tofacitinib tablets ✓ Specialist Initiation Only

Psoriatic Arthritis

Immunosuppressants - *Specialist Initiation Only*

TNF-alpha inhibitors

• Adalimumab SC Injection – preferred biosimilar Amgevita® ✓ Specialist Initiation Only ✓ First Choice
• Infliximab IV/SC Injection - preferred biosimilar Remsima® ✓ Specialist Initiation Only
• Etanercept SC Injection– preferred biosimilar Benepali® ✓ Specialist Initiation Only
• Certolizumab SC Injection ✓ Specialist Initiation Only
• Golimumab SC Injection ✓ Specialist Initiation Only

IL-17 Inhibitors

• Secukinumab SC Injection
• Bimekizumab SC Injection
• Ixekizumab SC Injection

IL-12/23 inhibitors

• Ustekinumab SC Injection - preferred biosimilar Uzpruvo® ✓ Specialist Initiation Only
• Guselkumab SC Injection  ✓ Specialist Initiation Only

JAK inhibitors

• Upadacitinib tablets ✓ Specialist Initiation Only
• Tofacitinib tablets ✓ Specialist Initiation Only

PDE-4 inhibitor

• Apremilast tablets ✓ Specialist Initiation Only

Ankylosing spondylitis

• Naproxen
• Ibuprofen
• Paracetamol (+/- codeine) where NSAIDs are not suitable/tolerated

Immunosuppressants - *Specialist Initiation Only*

TNF-alpha inhibitors

• Adalimumab SC Injection – preferred biosimilar Amgevita® ✓ Specialist Initiation Only ✓ First Choice
• Infliximab IV/SC Injection - preferred biosimilar Remsima® ✓ Specialist Initiation Only
• Etanercept SC Injection– preferred biosimilar Benepali® ✓ Specialist Initiation Only
• Certolizumab SC Injection ✓ Specialist Initiation Only
• Golimumab SC Injection ✓ Specialist Initiation Only

IL-17 Inhibitors

• Secukinumab SC Injection
• Bimekizumab SC Injection

JAK inhibitors

• Upadacitinib tablets ✓ Specialist Initiation Only
• Tofacitinib tablets ✓ Specialist Initiation Only

Still's disease

• Anakinra SC injection ✓ Specialist Initiation Only as per SMC 2104

Giant cell arteritis

• Tocilizumab prefilled syringe/pen ✓ Specialist Initiation Only – as per SMC 2014

ANCA - Associated vasculitis

under specialist management

Induction:

• Glucocorticoids (prednisolone tablets, IV methylprednisolone),
• methotrexate,
• cyclophosphamide,
• Rituximab infusion – preferred biosimilar Ruxience®

Maintenance:

• prednisolone tablets,
• rituxamab infusion – preferred biosimilar Ruxience®,
• azathioprine,
• mycophenolate mofetil,
• methotrexate

See:

• DGRefHelp>Rheumatology>Gout
• British society for Rheumatology guidelines for the management of gout 2017
• NICE CKS guidelines https://cks.nice.org.uk/topics/gout/

Acute attacks

• Naproxen ✓ First Choice
• Ibuprofen
• Colchicine 500mcg tablets BD – QDS
  • Total dose per course should not exceed 6mg, do not repeat course within 3 days
  • Avoid Colchicine in those receiving (or recently prescribed if renal impairment) strong P-glycoprotein or CYP3A4 inhibitors eg clarithromycin. See SPC for colchicine
  • MHRA Colchicine: extremely toxic in overdose
• Prednisolone tablets 30mg ONCE daily for 5 days – if NSAID or colchicine contraindicated or cannot be tolerated

Longterm prophylaxis of gout

• Allopurinol tablets ✓ First Choice
• Febuxostat tablets

3.1 Muscular Dystrophy

See BNF for further information

3.2 Myasthenia gravis and Lambert-Eaton myasthenic syndrome

• Pyridostigmine tablets ✓ First Choice
• Neostigmine tablets

3.3 Myotonic disorders

See BNF for further information

3.4 Spasticity

• Baclofen tablets ✓ First Choice
• Diazepam tablets

Non-steroidal anti-inflammatory drugs

• Naproxen ✓ First Choice
• Ibuprofen

Safety considerations

• MHRA: Non-steroidal anti-inflammatory drugs: reminder on renal failure and impairment, May 2009
• MHRA: Non-steroidal anti-inflammatory drugs: cardiovascular risk, October 2012
• MHRA: NSAIDs and coxibs: balancing of cardiovascular and gastrointestinal risks, December 2007 *
• MHRA: Ketoprofen and ketorolac: gastrointestinal risk, December 2014 change to hyperlink

Systemic corticosteroids oral

• Prednisolone tablets ✓ First Choice if prescribing oral steroids please refer to the HIGH DOSE Steroid Pre- treatment checklist in the clinical handbook: https://www.nhsdghandbook.co.uk/medical-handbook/high-dose-steroid-pre-treatment- checklist/?handbook

Local corticosteroid injections

• Methylprednisolone acetate (Depo – Medrone)
• Triamcinolone acetonide (Kenalog)

Soft tissue disorders Rubefacients

• Ibuprofen 5%