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8: Malignant disease & immunosupression

Approved: 4 Oct 2017. Last amended: 1 Dec 2023.

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8.1 Cytotoxic drugs

Not currently included in Joint Formulary

8.2 Drugs affecting the immune response

8.2.1 Disease modifying therapies for Multiple Sclerosis

To be prescribed in line with NHS England Treatment Algorithm Multiple Sclerosis Disease-modifying Therapies criteria.

Consider patient choice and patient specific factors, including family planning, in treatment decisions.

Criteria for discussion in multi-disciplinary team (MDT) meeting:

  • For first line therapy if higher risk disease modifying therapies are proposed e.g. cladribine and monoclonal antibody therapies
  • All patients with rapidly evolving severe (RES) multiple sclerosis
  • For second- and third-line therapy (includes all patients with highly active relapsing remitting (RR) multiple sclerosis
  • Complex cases
  • Children

8.2.1.1 Interferons

  • Interferon beta 1a (Avonex®)

    30mcg pre-filled pen, pre-filled syringe

    Relapsing-remitting multiple sclerosis – NICE TA527

  • Interferon beta 1a (Rebif®)

    22mcg, 44mcg, pre-filled pen, pre-filled syringe, cartridge

    Relapsing-remitting multiple sclerosis – NICE TA527

  • Interferon beta 1b (Extavia®)

    300mcg (9.6 million IU) vial with pre-filled solvent syringe

    Relapsing-remitting multiple sclerosis – NICE TA527

    Secondary progressive MS with continuing relapses – NICE TA527

  • Peginterferon beta 1a (Plegridy®)

    125mcg pre-filled pen, pre-filled syringe

    Relapsing-remitting multiple sclerosis – NICE TA624

    • 8.2.1.2 Immunomodulatory

  • Dimethyl fumarate (Tecfidera®)

    120mg, 240mg capsules

    Relapsing-remitting multiple sclerosis – NICE TA320

  • Fingolimod

    0.5mg capsules

    Highly active relapsing-remitting multiple sclerosis – NICE TA254

  • Ponesimod (Ponvery®)

    20mg tablets, treatment initiation pack (2mg, 3mg, 4mg, 5mg, 6mg 7mg, 8mg, 9mg, 10mg)

    Relapsing-remitting multiple sclerosis – NICE TA767

  • Siponimod (Mayzent®)

    0.25mg, 2mg tablets

    Secondary progressive multiple sclerosis with evidence of disease activity – NICE TA656

    • Specific Indication

  • Diroximel fumarate (Vumerity®)

    231 mg capsules

    Relapsing–remitting multiple sclerosis – NICE TA794

    Restricted to patients for whom dimethyl fumarate is not tolerated

    • 8.2.1.3 Anti-lymphocyte monoclonal antibodies

  • Alemtuzumab (Lemtrada®)

    12mg concentrate for solution for infusion

    Highly active relapsing-remitting multiple sclerosis – NICE TA312

  • Natalizumab (Tyruko®)

    300mg concentrate for solution for infusion

    Highly active relapsing-remitting multiple sclerosis – NICE TA127

  • Ocrelizumab (Ocrevus®)

    300mg concentrate for solution for infusion

    Relapsing-remitting multiple sclerosis – NICE TA533

    Primary progressive multiple sclerosis – NICE TA585

  • Ofatumumab (Kesimpta®)

    20mg pre-filled pen

    Relapsing-remitting multiple sclerosis – NICE TA699

    • Specific Indication

  • Natalizumab (Tysabri®)

    150mg pre-filled syringe

    Highly active relapsing-remitting multiple sclerosis – NICE TA127

    Restricted to patients for whom intravenous natalizumab is unsuitable

    • 8.2.1.4 Pyrimidine synthesis inhibitors

  • Teriflunomide

    14mg tablets

    Relapsing-remitting multiple sclerosis – NICE TA303

    • 8.2.1.5 Antimetabolite

  • Cladribine (Mavenclad®)

    10mg tablets

    Highly active relapsing-remitting multiple sclerosis – NICE TA616

    • 8.2.1.6 Other

  • Glatiramer acetate (Copaxone®, Brabio®)

    20mg, 40mg pre-filled syringe

    Relapsing-remitting multiple sclerosis – NICE TA527

    • 8.2.2 Miscellaneous

  • Targeted-release budesonide (Kinpeygo®)

    Primary immunoglobulin A nephropathy, as per NICE TA937

    • 8.3 Sex hormones and hormone antagonists in malignant disease

    8.3.1 Oestrogens

    Not currently included in Joint Formulary

    8.3.2 Progestogens

    Not currently included in Joint Formulary

    8.3.3 Androgens

    Not currently included in Joint Formulary

    8.3.4 Hormone antagonists

    8.3.4.1 Breast Cancer

    Not currently included in Joint Formulary

    8.3.4.2 Gonadorelin analogues

    Recommended

  • Triptorelin (Decapeptyl® SR)

    3mg, 11.25mg, 22.5mg (22.5mg IM 6 monthly injection preferred)

    Shared Care Guideline

    • Alternative

  • Leuprorelin (Prostap®)

    3.75mg, 11.25mg

    Shared Care Guideline

  • Goserelin (Zoladex®)

    3.6mg, 10.8mg

    Shared Care Guideline

    • 8.3.4.3 Anti-androgens

    Specific Indication

  • Apalutamide
    • High-risk hormone-relapsed non-metastatic prostate cancer, NICE TA740
    • Hormone-sensitive metastatic prostate cancer, NICE TA741
  • Abiraterone
    • castration-resistant metastatic prostate cancer, as per NICE TA259
    • metastatic hormone-relapsed prostate cancer before chemotherapy is indicated, as per NICE TA387
    • newly diagnosed high-risk hormone-sensitive metastatic prostate cancer, as per NICE TA721
  • Enzalutamide
    • metastatic hormone relapsed prostate cancer previously treated with a docetaxel containing regimen, as per NICE TA316
    • metastatic hormone-relapsed prostate cancer before chemotherapy is indicated, as per NICE TA377
    • hormone-sensitive metastatic prostate cancer, as per NICE TA712

    • Recommended

  • Bicalutamide

    Shared Care Guideline

    • Alternative

  • Cyproterone

    • 8.3.4.4 Gonadotrophin-releasing hormone antagonists

  • Degarelix

    Advanced hormone-dependent prostate cancer in people with spinal metastases, as per NICE TA404

    Shared Care Guideline

    • 8.3.4.5 Somatostatin analogues

    Not currently included in Joint Formulary

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    Key

    Hospital / Specialist only

    Specialist initiated / advised (with Shared Care Guideline)

    Specialist initiated / advised (without Shared Care Guideline)

    Non-specialist or Specialist

    Treatment Guidelines

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