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8: Malignant disease & immunosupression

Approved: 4 Oct 2017. Last amended: 30 Jun 2025.

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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

  • Hospital or Specialist only
    Interferon beta 1a (Avonex®)

    30mcg pre-filled pen, pre-filled syringe

    Relapsing-remitting multiple sclerosis – NICE TA527

  • Hospital or Specialist only
    Interferon beta 1a (Rebif®)

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

    Relapsing-remitting multiple sclerosis – NICE TA527

  • Hospital or Specialist only
    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

  • Hospital or Specialist only
    Peginterferon beta 1a (Plegridy®)

    125mcg pre-filled pen, pre-filled syringe

    Relapsing-remitting multiple sclerosis – NICE TA624

    • 8.2.1.2 Immunomodulatory

  • Hospital or Specialist only
    Dimethyl fumarate

    120mg, 240mg capsules

    Relapsing-remitting multiple sclerosis – NICE TA320

  • Hospital or Specialist only
    Fingolimod

    0.5mg capsules

    Highly active relapsing-remitting multiple sclerosis – NICE TA254

  • Hospital or Specialist only
    Ponesimod

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

    Relapsing-remitting multiple sclerosis – NICE TA767

  • Hospital or Specialist only
    Siponimod

    0.25mg, 2mg tablets

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

    • Specific Indication

  • Hospital or Specialist only
    Diroximel fumarate

    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

  • Hospital or Specialist only
    Alemtuzumab (Lemtrada®)

    12mg concentrate for solution for infusion

    Highly active relapsing-remitting multiple sclerosis – NICE TA312

  • Hospital or Specialist only
    Natalizumab (Tyruko®)

    300mg concentrate for solution for infusion

    Highly active relapsing-remitting multiple sclerosis – NICE TA127

  • Hospital or Specialist only
    Ocrelizumab (Ocrevus®)

    300mg i.v. infusion, 920mg s.c. injection

    Relapsing-remitting multiple sclerosis – NICE TA533

    Primary progressive multiple sclerosis – NICE TA585

  • Hospital or Specialist only
    Ofatumumab (Kesimpta®)

    20mg pre-filled pen

    Relapsing-remitting multiple sclerosis – NICE TA699

  • Hospital or Specialist only
    Ublituximab

    Relapsing-remitting multiple sclerosis – NICE TA1025

    • Specific Indication

  • Hospital or Specialist only
    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

  • Hospital or Specialist only
    Teriflunomide

    14mg tablets

    Relapsing-remitting multiple sclerosis – NICE TA303

    • 8.2.1.5 Antimetabolite

  • Hospital or Specialist only
    Cladribine

    10mg tablets

    Relapsing-remitting multiple sclerosis – NICE TA616

    Active relapsing multiple sclerosis – NICE TA1053

    • 8.2.1.6 Other

  • Hospital or Specialist only
    Glatiramer acetate

    20mg, 40mg pre-filled syringe

    Relapsing-remitting multiple sclerosis – NICE TA527

    • 8.2.2 Miscellaneous

  • Hospital or Specialist only
    Targeted-release budesonide (Kinpeygo®)

    Primary immunoglobulin A nephropathy, as per NICE TA937

  • Hospital or Specialist only
    Leniolisib

    Activated phosphoinositide 3-kinase delta syndrome, as per NICE HST33

    • 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

  • Specialist initiated or advised (with Shared Care Guideline)
    Triptorelin (Decapeptyl® SR)

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

    Shared Care Guideline

    • Alternative

  • Specialist initiated or advised (with Shared Care Guideline)
    Leuprorelin (Prostap®)

    3.75mg, 11.25mg

    Shared Care Guideline

  • Specialist initiated or advised (with Shared Care Guideline)
    Goserelin (Zoladex®)

    3.6mg, 10.8mg

    Shared Care Guideline

    • 8.3.4.3 Anti-androgens

    Specific Indication

  • Hospital or Specialist only
    Apalutamide
    • High-risk hormone-relapsed non-metastatic prostate cancer, NICE TA740
    • Hormone-sensitive metastatic prostate cancer, NICE TA741
  • Hospital or Specialist only
    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
  • Hospital or Specialist only
    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

  • Specialist initiated or advised (with Shared Care Guideline)
    Bicalutamide

    Shared Care Guideline

    • Alternative

  • Specialist initiated or advised (without Shared Care Guideline)
    Cyproterone

    • 8.3.4.4 Gonadotrophin-releasing hormone antagonists

  • Specialist initiated or advised (with Shared Care Guideline)
    Degarelix

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

    Shared Care Guideline

  • Specialist initiated or advised (with Shared Care Guideline)
    Relugolix

    Hormone-sensitive prostate cancer: NICE TA995

    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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