netFormulary Leicestershire Health Community NHS
Medicines Formulary  
 Formulary Chapter 10: Musculoskeletal and joint diseases - Full Chapter
10.01  Expand sub section  Drugs used in rheumatic diseases and gout
10.01  Expand sub section  Osteoarthritis and soft-tissue disorders
 note  Hyaluronic acid is not supported in NICE Clinical Guidelines for use in osteoarthritis of the knee.

At UHL it has been supported for pain relief in osteoarthritis of shoulder only. (Red traffic light status)
Clinical support has been given for use in specific patients with painful osteoarthritis who have exhausted other therapies, surgery is not appropriate and who have previously responded to treatment  but funding is still outstanding so not available for use in this group yet.
10.01.01  Expand sub section  Non-steroidal anti-inflammatory drugs
  • Use the lowest effective dose for the shortest period to control symptoms and review the need for long-term treatment periodically. Pain relief should start soon after taking the first dose but an anti-inflammatory effect may take up to 3 weeks.
  • NSAIDS are associated with an increased cardiovascular (CV) risk. Low-dose ibuprofen (≤ 1200mg daily) or naproxen ≤1000mg daily have the lowest CV risk.
  • Low dose ibuprofen is associated with the lowest risk of GI toxicity. However all NSAIDs are associated with serious GI toxicity and they should be used cautiously in patients who are at high risk including patients >65 years and those on long term therapy. Use of a proton-pump inhibitor (PPI) reduces the risk, and should routinely be co-prescribed for anyone with osteoarthritis or rheumatoid arthritis and those ≥ 45 years with chronic low back pain PLUS anyone else at high risk of GI toxicity.
  • Renal failure may be provoked by NSAIDs. Avoid in patients with pre-existing or risk factors for renal impairment.
  • Topical NSAIDs and/or paracetamol should be considered first for hand and knee OA
10.01.03  Expand sub section  Drugs which suppress the rheumatic disease process
  • Generally, when used alone immunosuppressants are not more effective than corticosteroids, but provide an alternative in selected cases. Immunosuppressants may be more effective in combination with steroids than treatment with a single drug and may allow a reduction in steroid dosage.
  • Methotrexate is suitable for moderate to severe active rheumatoid arthritis. Prescribers should be familiar with advice issued by the National Patient Safety Authority (NPSA) to reduce risk in prescribing of methotrexate.
  • The BNF recommends that only one strength of methotrexate tablet (usually 2.5 mg) is prescribed and dispensed.
  • Azathioprine, ciclosporin and cyclophosphamide are considered more toxic than methotrexate and are used in cases that have not responded to other disease modifying drugs. Ciclosporin is licensed for severe active rheumatoid arthritis when conventional second-line therapy is inappropriate or ineffective.
  • Disease-modifying drugs such as sulfasalazine, penicillamine, leflunomide, hydroxychloroquine and sodium aurothiomalate ('gold') may be used as alternatives to immunosuppressants in the management of rheumatoid arthritis.
  • Early treatment and control of inflammatory joint disease is essential to minimise joint damage and eventual disability. Prompt referral to a specialist is important. Patients with active rheumatoid disease should not be managed on non-steroidal anti-inflammatory drugs and/or corticosteroids in the long-term.
  • Response to all disease-modifying agents may be delayed for several months. Patients who fail to respond to one agent or suffer serious side effects may respond to another.
10.01.03  Expand sub section  Cytokine modulators to top
10.01.04  Expand sub section  Gout and cytotoxic-induced hyperuricaemia
10.01.04  Expand sub section  Acute attacks of gout
10.01.04  Expand sub section  Long-term control of gout
 note  Prophylaxis with allopurinol is necessary for recurrent acute attacks, chronic gout and symptomatic hyperuricaemia (with urate nephropathy). It may increase the incidence of acute attacks during the first few months of treatment therefore a NSAID e.g. ibuprofen 400mg three times daily should be given for 1-2 months (colchicine 500micrograms twice daily is suitable for patients that cannot take NSAIDs). Prophylactic drugs should never be commenced until an acute attack has fully resolved, as symptoms are likely to be worsened. 

10.01.04  Expand sub section  Hyperuricaemia associated with cytotoxic drugs
10.01.05  Expand sub section  Other drugs for rheumatic diseases to top
note Notes
Section Title Section Title (top level)
Section Title Section Title (sub level)
First Choice Item First Choice item
Non Formulary Item Non Formulary section
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Restricted Drug
Unlicensed Drug
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Traffic Light Status Information

Status Description


Drugs not recommended for use in the Leicestershire Health Community because of lack of evidence of clinical effectiveness, cost prioritization or concerns over safety. All new drugs will be black until they have been through the appropriate approval process - then they will appear as a specific entry   


Drugs which should be prescribed only by hospital specialists (clinical review by specialist as appropriate and annually as a minimum).  

Amber SCA

Drugs which would initially be prescribed by a hospital specialist and then by a GP where full agreement to share the care of each specific patient has been reached under a LMSG Shared Care Agreement (SCA). Specific patient monitoring or intervention required.   

Amber Simple

Drugs suitable to be initiated and prescribed in primary care only after specialist assessment and recommendation. A shared care agreement is not required.  

Green Conditional

Drugs for which GPs are able to take full responsibility for prescribing and monitoring subject to specified conditions e.g. prescribing in line with agreed LMSG guidance or able to demonstrate suitable competence see comments under individual entries.   


Drugs for which GPs would normally take full responsibility for prescribing and monitoring. Drugs included in this list have been specifically considered by LMSG.