Approved: 1 May 2013. Last amended: 2 Nov 2023.

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 Standard NSAIDs


  • 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.

  • Mefenamic acid

    Dysmenorrhoea / menorrhagia

  • Paracoxib

    Palliative care use only

  • 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) Systemic corticosteroids


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

    Specialist use only

  • 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. Gold


  • Sodium aurothiomalate
  • Penicillamine


  • Penicillamine
  • Antimalarials


  • Hydroxychloroquine
  • Drugs affecting the immune response

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

    Specific Indication

  • Cyclophosphamide
  • Azathioprine
  • Ciclosporin
  • Leflunomide
  • Methotrexate
  • Methotrexate

    (parenteral) – weekly dose. Shared Care Guideline

    • Metoject®
    • Nordimet® - restricted to Paediatric patients with needle phobia
  • Mycophenolate
  • Cytokine inhibitors

    Specialist use only

    Specific Indication

  • Abatacept
  • Adalimumab
  • Anakinra

    Still's disease: NICE TA685

  • Apremilast

    Psoriatic arthritis: NICE TA433

  • Avacopan

    Granulomatosis with polyangiitis or microscopic polyangiitis: NICE TA825

  • Baricitinib

    Rheumatoid arthritis NICE TA466

  • Belimumab

    Active autoantibody-positive systemic lupus erythematosus, as per NICE TA752

  • Bimekizumab
  • Certolizumab
  • Etanercept
  • Filgotinib
  • Golimumab
  • Guselkumab
  • Infliximab
  • Ixekizumab
  • Risankizumab
  • Rituximab
  • Sarilumab
  • Secukinumab
  • Tocilizumab
  • Tofacitinib
  • Upadacitinib
  • Ustekinumab
  • 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 Acute attacks of gout


  • Naproxen
  • Specific Indication

  • Colchicine

    when NSAIDs not appropriate

  • Corticosteroids

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

  • Long-term control of gout


  • Allopurinol
  • Alternative

  • Febuxostat

    as per NICE TA164

  • Specific Indication

  • Benzbromarone (unlicensed)

    Where allopurinol and febuxostat are ineffective or unsuitable

  • Hyperuricaemia associated with cytotoxic drugs

    Specific Indication

  • Rasburicase

    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

  • Ataluren

    Duchenne muscular dystrophy with a nonsense mutation in the dystrophin gene, as per NICE HST22

  • Onasemnogene abeparvovec

    Spinal muscular atrophy, as per NICE HST14, NICE HST24

  • Risdiplam

    Muscular atrophy, as per NICE TA755

  • Anticholinesterases: Diagnostic

  • Edrophonium
  • Anticholinesterases: Treatment

  • Pyridostigmine
  • Neostigmine

    only on the recommendation of a Consultant Neurologist

  • 10.2.2 Skeletal muscle relaxants


  • Baclofen
  • Alternative

  • Dantrolene
  • Diazepam
  • Tizanidine
  • Specific Indication

  • Pridinol

    Pain Team use only. For central and peripheral muscle spasms: lumbar pain, torticollis, general muscle pain, in adults where diazepam is not suitable i.e. in patients prone to respiratory depression due to neuromuscular weakness, patients with previous addiction to benzodiazepines, or in professions where benzodiazepine use may be dangerous (e.g. HGV Driver)

  • 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.

  • Nocturnal leg cramps


  • 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 Topical NSAIDs and counter-irritants


  • 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