Approved: 1 May 2013. Last amended: 29 Nov 2018.

10.1 Drugs used in rheumatic diseases and gout

NICE Guidance – Rheumatoid arthritis

NICE Guidance – Osteoarthritis

10.1.1 Non-steroidal anti-inflammatory drugs (NSAIDs)

  • Before prescribing an NSAID establish that the pain is not controlled by regular paracetamol 1g QDS, especially if chronic use is indicated and particularly in the elderly.
  • In osteoarthritis and soft tissue pain, NSAIDs should only be prescribed if simple analgesia (see section 4.7.1) and non-pharmacological treatment have failed.
  • All NSAIDs (including selective inhibitors of cyclo-oxygenase-2 [COX-2]) are contraindicated in patients with active gastro-intestinal ulceration or bleeding.
  • Non-selective NSAIDs are contraindicated in patients with a history of recurrent gastro-intestinal ulceration or haemorrhage (two or more distinct episodes), and in patients with a history of gastro-intestinal bleeding or perforation related to previous NSAID therapy.
  • NSAIDs should be used with caution in renal, cardiac and hepatic disease
  • For advice on NSAID allergy and NSAID-sensitive asthma see NICE CG183 (Drug allergy: diagnosis and management)

Cardiovascular events
Cyclo-oxygenase-2 selective (COX-2) inhibitors are associated with an increased risk of thrombotic events (e.g. myocardial infarction and stroke) and should not be used in preference to non-selective NSAIDs except when specifically indicated (i.e. for patients at a particularly high risk of developing gastroduodenal ulceration or bleeding) and after assessing their cardiovascular risk. COX-2 inhibitors are contraindicated in patients with existing cardiovascular disease.

Standard NSAIDs may also be associated with a increased risk of thrombotic events, particularly when used at high doses and for long-term treatment. Diclofenac appears to be associated with a similar excess risk to that of the COX-2 inhibitors, whereas naproxen and low dose ibuprofen (up to 1.2g/day) are associated with a lower thrombotic risk and should be used in preference to other NSAIDs in patients with cardiovascular disease.

Gastro-intestinal toxicity

All NSAIDs are associated with serious gastro-intestinal toxicity; the risk is higher in the elderly.

Low risk: Ibuprofen
Intermediate risk: Diclofenac, naproxen, ketoprofen, indometacin, piroxicam
High risk: Azapropazone

COX-2 inhibitors are associated with a lower risk of serious upper G.I. side effects than standard NSAIDs however this advantage may be lost in patients who require concomitant low-dose aspirin.

The lowest effective dose of NSAID should be prescribed for the shortest period to control symptoms and the need for long-term treatment should be reviewed periodically.

Concomitant gastroprotection should be prescribed where appropriate.

GHNHSFT Local Guideline: Oral PPI Guideline

10.1.1.1 Standard NSAIDs

Recommended

  • Ibuprofen

    (up to 1.2g/day)

  • Naproxen
  • Alternative

  • Meloxicam

    (COX-2 selective – see notes above)

  • Specific Indication

  • Etoricoxib

    (COX-2 inhibitor) only to be used in preference to a standard NSAID in patients with a history of gastroduodenal ulcer or perforation, or gastro-intestinal bleeding; or in patients at high risk of developing serious gastro-intestinal side-effects (e.g. those aged over 65 years). Contraindicated in patients with cardiovascular disease.

  • Diclofenac IV

    for use preoperatively or on the advice of the acute pain team only

  • Ketorolac
  • 10.1.2 Corticosteroids

    • Treatment with corticosteroids in rheumatic diseases should be reserved for specific indications e.g. when other anti-inflammatory drugs are unsuccessful.
    • Corticosteroids can induce osteoporosis; therefore, bone protection should be considered for patients on treatment for longer than 3 months. National Osteoporosis Guideline Group: Guideline for the diagnosis and management of osteoporosis (May 2013)
    • Enteric Coated (EC) prednisolone tablets are not recommended (UKMi advice)

    10.1.2.1 Systemic corticosteroids

    Recommended

  • Prednisolone
  • Methylprednisolone sodium succinate (Solu- Medrone®)

    Specialist use only

  • 10.1.2.2 Local corticosteroid injections

    Recommended

  • Hydrocortisone acetate (Hydrocortistab®)
  • Triamcinolone acetonide (Adcortyl®, Kenalog®)
  • Methylprednisolone acetate (Depo-Medrone®)
  • 10.1.3 Drugs which suppress the rheumatic disease process

    Disease-modifying antirheumatic drugs (DMARDs) should only be initiated by specialists.

    10.1.3.1 Gold

    Recommended

  • Sodium aurothiomalate
  • 10.1.3.2 Penicillamine

    Recommended

  • Penicillamine
  • 10.1.3.3 Antimalarials

    Recommended

  • Hydroxychloroquine
  • 10.1.3.4 Drugs affecting the immune response

    Only to be initiated by (or on the advice of) a Specialist

    Specific Indication

  • Azathioprine
  • Ciclosporin
  • Cyclophosphamide
  • Leflunomide
  • Methotrexate

    (oral) – weekly dose (NPSA Methotrexate Booklet)

  • Methotrexate

    (parenteral) – weekly dose

  • Mycophenolate
  • 10.1.3.5 Cytokine inhibitors

    Specialist use only

    Specific Indication

  • Abatacept
  • Adalimumab
  • Apremilast

    Psoriatic arthritis: NICE TA433

  • Baricitinib

    Rheumatoid arthritis NICE TA466

  • Belimumab

    Active autoantibody-positive systemic lupus erythematosus, as per NICE TA397

  • Certolizumab
  • Etanercept
  • Golimumab
  • Infliximab
  • Ixekizumab
  • Rituximab
  • Sarilumab

    rheumatoid arthritis, as per NICE TA485

  • Secukinumab
  • Tocilizumab
  • Tofacitinib
  • Ustekinumab

    Psoriatic arthritis: NICE TA340

  • 10.1.3.6 Sulfasalazine

    Specific Indication

  • Sulfasalazine EC

    Shared Care Guideline (intranet)

    See Section 1.5 for use in chronic bowel disorders

  • 10.1.4 Gout and cytotoxic-induced hyperuricaemia

    10.1.4.1 Acute attacks of gout

    Recommended

  • Naproxen
  • Specific Indication

  • Colchicine

    when NSAIDs not appropriate

  • Corticosteroids

    (oral, intra-articular or intramuscular) – when NSAIDs not appropriate

  • 10.1.4.2 Long-term control of gout

    Recommended

  • Allopurinol
  • Alternative

  • Sulfinpyrazone
  • Febuxostat

    as per NICE TA164

  • 10.1.4.3 Hyperuricaemia associated with cytotoxic drugs

    Specific Indication

  • Rasburicase

    Specialist use only

  • 10.1.5 Other drugs for rheumatic diseases

    None

    10.2 Drugs used in neuromuscular disorders

    10.2.1 Drugs which enhance neuromuscular transmission

  • Ataluren

    Duchenne muscular dystrophy with a nonsense mutation in the dystophin gene, as per NICE HST3

  • 10.2.1.1 Anticholinesterases: Diagnostic

  • Edrophonium
  • 10.2.1.2 Anticholinesterases: Treatment

  • Pyridostigmine
  • Neostigmine

    only on the recommendation of a Consultant Neurologist

  • 10.2.1.3 Immunosuppressant therapy

    Only on the recommendation of a specialist.

    Recommended

  • Corticosteroids
  • Azathioprine
  • Ciclosporin
  • Cyclophosphamide
  • Methotrexate

    (oral/parenteral) – weekly dose (NPSA Methotrexate Booklet)

  • Mycophenolate
  • 10.2.2 Skeletal muscle relaxants

    Recommended

  • Baclofen
  • Alternative

  • Dantrolene
  • Diazepam
  • Tizanidine
  • 10.2.2.1 Nocturnal leg cramps

    Recommended

  • Quinine sulphate

    300mg – only effective when used regularly. Refer to BNF for guidance.

  • 10.3 Drugs for the relief of soft-tissue inflammation

    10.3.1 Enzymes

    Specific Indication

  • Collagenase

    Dupuytren’s contracture: NICE TA459

  • Hyaluronidase

    Extravasation, hypodermoclysis

  • 10.3.2 Rubefacients and other topical antirheumatics

    10.3.2.1 Topical NSAIDs and counter-irritants

    Recommended

  • Ibuprofen gel

    review use after 14 day

  • Alternative

  • Piroxicam 0.5% gel

    review use after 14 days

  • Ketoprofen 2.5% gel

    review use after 14 days

  • Specific Indication

  • Capsaicin 0.025%

    (Zacin®) cream – symptomatic relief in osteoarthritis
    See section 4.7.3 for use of capsaicin in neuropathic pain

  • BEST CARE FOR EVERYONE