10: Musculoskeletal & joint diseases
Approved: 1 May 2013. Last amended: 6 Sep 2021.
10.1 Drugs used in rheumatic diseases and gout
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)
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.
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
(up to 1.2g/day)
(COX-2 selective – see notes above)
(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.
for use preoperatively or on the advice of the acute pain team only
- 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
Methylprednisolone sodium succinate (Solu- Medrone®)
Specialist use only
10.1.2.2 Local corticosteroid injections
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.
shared care guideline (intranet)
10.1.3.4 Drugs affecting the immune response
Only to be initiated by (or on the advice of) a Specialist
(oral) – weekly dose (NPSA Methotrexate Booklet)
(parenteral) – weekly dose
10.1.3.5 Cytokine inhibitors
Specialist use only
Still's disease: NICE TA685
Psoriatic arthritis: NICE TA433
Rheumatoid arthritis NICE TA466
Active autoantibody-positive systemic lupus erythematosus, as per NICE TA397
- Rheumatoid arthritis: NICE TA676
- Psoriatic arthritis: NICE TA711
- Rheumatoid arthritis, as per NICE TA485
- Rheumatoid arthritis NICE TA665
- Psoriatic arthritis: NICE TA340
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
when NSAIDs not appropriate
(oral, intra-articular or intramuscular) – when NSAIDs not appropriate
10.1.4.2 Long-term control of gout
as per NICE TA164
Where allopurinol and febuxostat are ineffective or unsuitable
10.1.4.3 Hyperuricaemia associated with cytotoxic drugs
Specialist use only
10.1.5 Other drugs for rheumatic diseases
10.2 Drugs used in neuromuscular disorders
10.2.1 Drugs which enhance neuromuscular transmission
Duchenne muscular dystrophy with a nonsense mutation in the dystophin gene, as per NICE HST3
10.2.1.1 Anticholinesterases: Diagnostic
10.2.1.2 Anticholinesterases: Treatment
only on the recommendation of a Consultant Neurologist
10.2.1.3 Immunosuppressant therapy
Only on the recommendation of a specialist.
(oral/parenteral) – weekly dose (NPSA Methotrexate Booklet)
10.2.2 Skeletal muscle relaxants
Sativex® Oromucosal Spray (cannabis extract)
Use is supported only for spasticity in patients with multiple sclerosis in accordance with NICE guidelines NG144.
Must be initiated and supervised by a physician with specialist expertise in treating spasticity due to multiple sclerosis.
10.2.2.1 Nocturnal leg cramps
300mg – only effective when used regularly. Refer to BNF for guidance.
10.3 Drugs for the relief of soft-tissue inflammation
Dupuytren’s contracture: NICE TA459
10.3.2 Rubefacients and other topical antirheumatics
10.3.2.1 Topical NSAIDs and counter-irritants
review use after 14 day
Piroxicam 0.5% gel
review use after 14 days
Ketoprofen 2.5% gel
review use after 14 days
(Zacin®) cream – symptomatic relief in osteoarthritis
See section 4.7.3 for use of capsaicin in neuropathic pain