Information on rheumatology medications

The types of medication prescribed by rheumatology include:

• Pain killers and non-steroidal anti-inflammatory drugs (NSAIDs)
• Disease-modifying anti-rheumatic drugs (DMARDs)
• Biologics and Biosimilars
• Corticosteroids
• Some osteoporosis medicines

More information is available at:

• Arthritis UK
• National Rheumatoid Artritis Society (NRAS)

Please do not alter your medication dose or frequency without discussing it with the rheumatology team first.

Pain killers and NSAIDs

These are usually prescribed by GPs.

These are used for most types of arthritis, including osteoarthritis. Examples include Paracetamol and mild opioids such as Codeine and Dihydrocodeine or combination products such as Paracetamol and Codeine (Co-codamol) or, Paracetamol and Dihydrocodeine (Co-dydramol). Tramadol is also sometimes prescribed. Very occasionally, stronger opioid analgesia such as morphine is required for very severe pain. This may be given in liquid or tablet/capsule form such as oramorph or MST. Very strong opioids are also available as patches e.g. Fentanyl.

Simple analgesia such as Paracetamol rarely causes any side effects and may be used safely with most other medication, however it is important not to exceed the maximum recommended dose of any medication. Opioid-based drugs may cause drowsiness in some people. if you are affected in this way you should avoid driving or operating machinery. Please read the information on the packaging or prescription.

Non-steroidal anti-inflammatory drugs (NSAIDs) are used to reduce inflammation as well as pain and may be prescribed for many types of arthritis. They are usually given in tablet or capsule form. NSAIDs may also be given in the form of suppositories or as gels and creams for topical application to the skin overlying affected areas. Examples of NSAIDs include Ibuprofen, Naproxen, Meloxicam, Etodolac, Celecoxib, Etoricoxib, Diclofenac and Nabumetone. There are many different brand names for some of these drugs.

NSAIDs may not be prescribed if you are taking certain other drugs such as blood thinners or if you have or have had gastric (stomach) ulcers in the past. If you are in any doubt, please discuss this with your GP or pharmacist. Should you experience dyspepsia (heartburn) or indigestion whilst taking NSAIDs you may require additional medication (PPIs) to protect your stomach. Again, you should discuss this with your GP or pharmacist. NSAIDs should not be taken on an empty stomach but always with, or immediately after, food.

Some NSAIDs are available over the counter as pain relief medications. Check you are not already taking a prescribed one before buying pain relievers.

Disease-modifying anti-rheumatic drugs (DMARDs)

A Disease-Modifying Anti-Rheumatic Drug (DMARD) is a medicine that can stop or slow down the damage caused by the progression of inflammatory diseases, for example, rheumatoid arthritis (RA) and psoriatic arthritis (PsA). DMARDs are not pain relief – they aim to slow down or stop disease- related tissue damage by reducing inflammation, but can also reduce pain, swelling, stiffness, fatigue and other symptoms. They are usually prescribed at or soon after diagnosis. Example of DMARDS include Methotrexate, Sulfasalazine, Leflunomide, Hydroxychloroquine, Azzthioprine.

DMARDs can help reduce inflammation, relieve pain, prevent and slow down tissue damage, reduce disability, and enable you to be as active as you can for as long as possible. Although there's no cure for conditions such as RA and PsA, early treatment can reduce the risk of permanent joint damage and limit the impact of the condition.

DMARDs are very effective drugs for treating many inflammatory diseases. DMARDs work by dampening down the patient’s immune system but as a result they can also weaken the body’s ability to fight infections. In addition, DMARDs can sometimes affect liver and kidney function, especially in those with history of impairment. Regular blood tests help.

The Rheumatology team will provide all prescriptions until we have confirmation from your GP that they are satisfied that you are stable enough for them to take over your care. This is normally after 12 weeks. You will receive a copy of our letter to your GP asking them to take over your prescription. Until you have received this letter, please request a repeat prescription by contacting the DMARDs team on ghn-tr.dmards.rheumatology@nhs.net Alternatively you can call the DMARD prescription order line number is 0300 422 8889 – available 24/7.There is only a facility to leave a message, it is not a phone number that will be answered.

All medications can have potential side effects. It may also be worth considering other causes of symptoms, such as allergies (hay fever, known food intolerance) and new washing detergents.

Some of our medications can cause side effects such as: nausea, diarrhoea, vomiting, headaches, dizziness, mouth ulcers, rashes, sore throat.

It is important that you report any side-effects (even if not listed above) and seek advice from your GP.

Rarely, patients can develop shortness of breath and/or a dry cough, which may require further investigation.

Here are some ways to help minimise potential side effects:

• Take your methotrexate at night time to minimise feelings of nausea
• Increase your folic acid to 6 out of 7 days avoiding the methotrexate day to help with methotrexate side effects
• Ask about a tablet to protect your stomach if you are taking oral steroids for a long period or a non-steroidal anti-inflammatory (ibuprofen).
• If you are having side effects from sulfasalazine, and have just started this, it might help to increase your sulfasalazine dose at a slower rate

Videos explaining your medication

Hydroxychloroquine

Methotrexate

Sulfasalazine

Subcutaneous methotrexate injections

For patients that are unable to tolerate methotrexate tablets due gastrointestinal upset we can switch the methotrexate to an injection once a week. We may also recommend switching to methotrexate injections if your tablets are not fully effective. The injections contain methotrexate in an injectable form and are administered once a week, and you will be expected to do your own injections.

We hold monthly group training sessions at CGH & GRH for patients to receive training on how to do the injections, and where to inject. In addition, there is also a video on the Medac website which is useful to watch.

If you are attending a group training session, you will receive written instructions on where and when to attend, and you will be asked that you arrive at 9:am and proceed to the Pharmacy prior to attending the training. This will be to collect your prescription.

However, if you already have your medication, please bring it with you and check in at the Outpatient Department waiting room. You may find it convenient to bring a carrier bag to carry everything home as you will also be receiving a sharps bin on the day.

Once all parties have arrived, the group training session will commence which will take approximately 1 hour, after which time you will have the opportunity to ask any questions.

You will then individually administer your first dose of Metoject on a one-to-one basis with me.

If you are already taking Methotrexate tablets, please stop taking these 7 days before and if you are taking Folic Acid do not take this on the day of your appointment.

You are also required to arrange a blood test at your GP Surgery approximately one week prior to having your first appointment and will receive a form for this.

Biologics (bDMARDs or tsDMARDs) and Biosimilars

What are bDMARDs?

bDMARDs are a group of medications that are used to treat arthritis (such as rheumatoid arthritis, psoriatic arthritis and ankylosing spondylitis).

These medicines can decrease the amount of inflammation you have and reduce the damaging effects of your arthritis on your joints.

There are now quite a few bDMARDs available to treat different types of arthritis; which medicine you have been prescribed may depend on the type of arthritis that you have or another medical condition at the same time as your arthritis that might make one treatment more appropriate than another.

At the time of writing, bDMARDs used for different conditions include:

• abatacept
• adalimumab
• anakinra
• belimumab
• bimzekizumab
• certolizumab pegol
• etanercept
• golimumab
• guselkumab
• infliximab
• ixekizumab
• risankizumab
• rituximab
• sarilumab
• secukinumab
• tocilizumab
• ustekinumab

However, more are becoming available very often.

bDMARDs can be given either as an injection into the layer of fat just underneath the surface of your skin (a subcutaneous injection) or by a drip into your vein (intravenous infusion).

If you have a subcutaneous injectable medication they will be delivered directly to you by a homecare delivery company, and you can be taught how to do this yourself at home or someone can be taught to give you the injections, such as a family member.

If you are having an intravenous infusion you will need to come to the Medical Day Care Unit in Cheltenham General Hospital which is located on Oakley ward.

What are Biosimilar Medicines?

Some of the bDMARD medicines listed above are now available in the UK as similar versions made by different companies, because the patent (allowing one company to make the product exclusively) has expired.

These different versions of existing bDMARDs are known as ‘biosimilars’ because they are deemed to be sufficiently similar (in terms of safety and effectiveness) to the original product.

Switching between biosimilar brands should not affect the safety or the effectiveness of your medicine.

Switching patients to the most cost-effective version of bDMARD allows the NHS to treat more patients with these expensive therapies.

NHS England may ask us to change the brand of bDMARD medication you are prescribed from time to time.

Injection-site reactions are a common adverse effect from injectable biologic medications:

To help minimise injection site reactions:

Injection site reactions are different to an allergic reaction they are generally mild and resolve after a few days. The symptoms can include mild swelling, itching, pain, redness, warmth, rash. To help with these symptoms some suggestions include:

• Please take injections out the fridge at least 30 minutes before use.
• Ensure you inject in the manner you have been taught by the nurses in your rheumatology team or home care provider.
• Use a cold pack before and after the injection
• Use pain relief such as a non-steroidal anti-inflammatory
• Take an Antihistamine
• Use over the counter hydrocortisone cream.

What are tsDMARDS?

tsDMARDs are targeted synthetic therapies.

Like biologic medicines, they target specific parts of the immune system, however they are not made from living cells. They are smaller chemical drugs and can usually be taken by mouth.

There are now quite a few tsDMARD medicines available to treat different types of arthritis; which medicine you have been prescribed may depend on the type of arthritis that you have or your other relevant medical conditions.

At the time of writing, this group of medicines include:

• apremilast
• baricitinib
• filgotinib
• tofacitinib
• upadacitinib

But others are going through approval steps so may be available soon.

How do we help you decide which b/tsDMARD is the best for you?

When your consultant or clinician decides it would be appropriate to start a b/tsDMARD therapy, we will usually invite you to a clinic appointment with the Rheumatology Specialist nurse/ specialist physiotherapist or Rheumatology Specialist Pharmacist to carry out your baseline assessments (this usually includes a joint examination and blood tests) and talk to you about your new treatment options.

The Nurse/ physio or Pharmacist will complete some paperwork with you and discuss the main symptoms associated with your condition, your other medical problems, previously tried therapies and any patient preferences you might have.

Once we have discussed your condition and preferences, we will look at the most cost-effective treatment to suit your needs.

We will support you to make a shared, informed decision about the most appropriate treatment for you.

If you have started a new biologic medication, please contact the Rheumatology Admin team at ghn-tr.rheumybloodsandbiologics@nhs.net to let us know so we can update our records.

Your prescription is managed by the Rheumatology nurses in conjunction with the delivery company. Usually, the delivery company asks the nurses for your repeat prescription to be renewed well before it is going to expire but occasionally this does not happen in time.

The Rheumatology nurses will renew your repeat prescription if you have attended your scheduled clinic appointments and had any relevant bloods or tests that have been asked for.

If you do not attend your appointments, or have regular blood tests as requested, your prescription for biologic drugs will be stopped. You may need to call the Rheumatology on ghn-tr.rheumybloodsandbiologics@nhs.net to discuss your repeat prescription.

My biologics medication has not been delivered. Who should I contact?

Please contact the company that delivers your medications to reorganise the delivery. Patient Enquiries telephone:

• Sciensus (Previously known as Healthcare At Home) : 0333 103 9499
• Lloyds Pharmacy Clinical Homecare : 0345 263 6135
• Healthnet: 0800 083 3060

If you have ongoing delivery problems cannot solve yourself with the company, please contact the Rheumatology Admin team at ghn-tr.rheumybloodsandbiologics@nhs.net

Corticosteroids

Corticosteroids are a group of medicines that control inflammation and regulate many of the human body’s normal functions. For the management of autoimmune conditions, this group of medications can be given intravenously (in a vein), intramuscularly (in a muscle), intraarticularly (injected in a joint) or orally (by mouth). Although they can be given topically, topical administration is primarily for skin disorders. Prednisone, Medrol, Depo-Medrol, Solu-Medrol, Kenalog, Celestone, methylprednisolone, hydrocortisone, triamcinolone, dexamethasone and others are all different types of corticosteroids used to treat a host of illnesses. Your doctor will pick the type of steroid and the method of administration according to your personal needs at the time of his or her assessment of your situation.

Corticosteroids are used in many ways. The goal in any of these treatments is to resolve the inflammation, joint swelling, pain and limitation. One way of using corticosteroids is a high dose, followed by a decreasing dose program to lower the dose gradually, eventually stopping the medication. Taper schedules are used when a high dose is continued for more than 5 days.

Corticosteroids can be injected into a joint to relieve inflammation: it will act locally, in the joint. Some patients will use a low dose for a longer period of time, until other medications start to control the disease. This is known as “bridge” therapy. On rare occasions, some patients continue a low dose of steroid for much longer, and even more rarely will remain on low doses of a corticosteroid as part of the regular therapy.

Corticosteroids can be of great benefit to patients but can have significant long-term side effects. These include but are not limited to skin thinning, easy skin bruising, purple skin streaking or striae, weight gain with increased abdominal girth (“belly” fat), progression to diabetes and bone loss that can lead to osteoporosis. Therefore, rheumatologists (and all physicians) make every effort to balance these risks against the benefits to health when prescribing or continuing corticosteroids.

If you are on steroids and become unwell, you may need to increase your steroid dose. The society for Endocrinology have produced some ‘Sick days rules’ to be followed if you are unwell.

Rheumatology medications that need to be stopped if you have an infection requiring antibiotics, as they suppress your immune system. Please note that some of these treatments have multiple brand names.