10.1 Arthritis

Disease-modifying Anti-Rheumatic Drugs

Azathioprine (TLS Amber 1 month) (SCP click here)

Hydroxychloroquine (TLS Amber 1 month)

• Also licensed for active rheumatoid arthritis, systemic and discoid lupus erythematosus and dermatological conditions caused or aggravated by sunlight
• See Hydroxychloroquine Shared Care Protocol for rheumatology and dermatology here

Leflunomide (TLS Amber 1 month) (SCP click here)

Methotrexate (oral) 2.5mg tablets only - weekly dose (TLS Amber 1 month) (SCP click here)

• Patients should have patient held records while they are receiving treatment with any DMARD requiring regular monitoring (record cards and GP protocol advice available from rheumatology)

Methotrexate (parenteral) - weekly dose (TLS Amber 1 month) (SCP click here)

• The current recommended brand of subcutaneous methotrexate is Metoject^®
• All prescriptions in both primary and secondary care should state the generic and brand name
• Patients should remain on the same brand of methotrexate injection recommended by Rheumatology to prevent patients receiving a device that they cannot use to self-administer

Mycophenolate (oral) (TLS Amber 3 months) (SCP Click here)

• For use in rheumatological conditions- unlicensed indication

Penicillamine (TLS Amber 1 month) (SCP click here)

Sodium aurothiomalate (TLS Red) 

Sulfasalazine (TLS Amber 1 month) (SCP click here)

Interleukin Inhibitors

Note on Biosimilars

When local procurement has been finalised and as per NICE’s biosimilar position statement, if the originator biologic product is on the BNSSG joint formulary, the new biosimilar product will also be included on the formulary in accordance with its UK licence when it becomes commercially available

For use in Juvenile Idiopathic Arthritis (JIA) see NHS England policy E03/P/d Biologic Therapies for the treatment of Juvenile Idiopathic Arthritis (JIA)

Anakinra (TLS Red)

• NICE TA685 Anakinra for treating Still’s disease
• According to NHS Commissioning Policy for Adult-Onset Still's Disease

Bimekizumab (TLS Red)

• NICE TA916 Bimekizumab for treating active psoriatic arthritis
• NICE TA918 Bimekizumab for treating axial spondyloarthritis

Certolizumab pegol (TLS Red)

• For treatment of moderate RA as first line for patients who are actively planning to conceive or pregnant and are due to escalate to bDMARD therapy

Guselkumab (TLS Red)

• NICE TA815 Guselkumab for treating active psoriatic arthritis after inadequate response to DMARDs

Ixekizumab (TLS Red)

• NICE TA537 Ixekizumab for treating active psoriatic arthritis after inadequate response to DMARDs
• NICE TA718 Ixekizumab for treating axial spondyloarthritis

Risankizumab (TLS Red)

• NICE TA803 Risankizumab for treating active psoriatic arthritis after inadequate response to DMARDs

Rituximab (TLS Red)

• For treatment of moderate RA in patients for whom TNS inhibitor and JAK inhibitor are clinically contraindicated or not tolerated

Sarilumab (TLS Red)

• NICE TA485 Sarilumab for severe arthritis

Secukinumab (TLS Red)

• NICE TA407 Secukinumab for active ankylosing spondylitis after treatment with non-steroidal anti-inflammatory drugs or TNF-alpha inhibitors
• NICE TA445 Certolizumab pegol and secukinumab for treating active psoriatic arthritis after inadequate response to DMARDs
• NICE TA719 Secukinumab for treating non-radiographic axial spondyloarthritis

Tocilizumab (TLS Red)

• NICE TA247 Rheumatoid Arthritis
• NICE TA238 Arthritis, juvenile idiopathic, systemic
• May be used as monotherapy in adult patients with moderate/severe active rheumatoid arthritis who cannot take methotrexate (approved by the BNSSG JFG June 15)
• The subcutaneous preparation may be used in preference to the IV preparation in accordance with the NICE TAs 247 and also as monotherapy. Approved by the BNSSG JFG July 2015
• NICE TA373 Abatacept, adalimumab, etanercept and tocilizumab for treating juvenile idiopathic arthritis
• NICE TA375 Adalimumab, etanercept, infliximab, certolizumab pegol, golimumab, tocilizumab and abatacept for rheumatoid arthritis not previously treated with DMARDs or after conventional DMARDs only have failed
• For Takayasu Arteritis see NHS England Clinical Commissioning Policy 16056/P
• NICE TA518 Tocilizumab for treating giant cell arteritis

Ustekinumab (TLS Red)

• NICE TA340 Psoriatic Arthritis

T-Cell Activation Inhibitors

Note on Biosimilars

When local procurement has been finalised and as per NICE’s biosimilar position statement, if the originator biologic product is on the BNSSG joint formulary, the new biosimilar product will also be included on the formulary in accordance with its UK licence when it becomes commercially available

Abatacept (TLS Red)

• NICE TA195 Rheumatoid Arthritis - drugs for treatment after failure of a TNF inhibitor
• NICE TA373 Abatacept, adalimumab, etanercept and tocilizumab for treating juvenile idiopathic arthritis
• NICE TA375 Adalimumab, etanercept, infliximab, certolizumab pegol, golimumab, tocilizumab and abatacept for rheumatoid arthritis not previously treated with DMARDs or after conventional DMARDs only have failed
• The subcutaneous preparation may be used in preference to the IV preparation in accordance with the NICE TAs 195 and 373 and 375. Approved by the BNSSG JFG June 2015
• For treatment of severe treatment-resistant morphoea (localised scleroderma) as per NHS England Clinical Commissioning Policy
• NICE TA715 Adalimumab, etanercept, infliximab and abatacept for treating moderate rheumatoid arthritis after conventional DMARDs have failed

Tumour Necrosis Factor Alpha (TNF-alpha) Inhibitors

See MHRA drug safety update Tumour necrosis factor alpha inhibitors: risk of tuberculosis

Note on Biosimilars

When local procurement has been finalised and as per NICE’s biosimilar position statement, if the originator biologic product is on the BNSSG joint formulary, the new biosimilar product will also be included on the formulary in accordance with its UK licence when it becomes commercially available

Adalimumab (TLS Red)

• Specify brand when prescribing Imraldi^®, Hyrimoz^®, Amgevita^®, Humira^®
• NICE TA195 Rheumatoid Arthritis - drugs for treatment after failure of a TNF inhibitor
• NICE TA199 Psoriatic arthritis - treatment
• NICE TA373 Abatacept, adalimumab, etanercept and tocilizumab for treating juvenile idiopathic arthritis
• NICE TA375 Adalimumab, etanercept, infliximab, certolizumab pegol, golimumab, tocilizumab and abatacept for rheumatoid arthritis not previously treated with DMARDs or after conventional DMARDs only have failed
• NICE TA383 Ankylosing spondylitis and non-radiographic axial spondyloarthritis
• NICE TA715 Adalimumab, etanercept, infliximab and abatacept for treating moderate rheumatoid arthritis after conventional DMARDs have failed

Belimumab (TLS Red)

• NICE TA752 Belimumab for treating active autoantibody-positive systemic lupus erythematosus

Certolizumab pegol (TLS Red)

• NICE TA375 Adalimumab, etanercept, infliximab, certolizumab pegol, golimumab, tocilizumab and abatacept for rheumatoid arthritis not previously treated with DMARDs or after conventional DMARDs only have failed
• NICE TA383 Ankylosing spondylitis and non-radiographic axial spondyloarthritis
• NICE TA415 Certolizumab pegol for treating rheumatoid arthritis after inadequate response to a TNF-alpha inhibitor
• NICE TA445 Certolizumab pegol and secukinumab for treating active psoriatic arthritis after inadequate response to DMARDs

Etanercept (TLS Red)

• Specify brand when prescribing Benepali^®, Enbrel^®
• NICE TA195 Rheumatoid arthritis - drugs for treatment after failure of a TNF inhibitor
• NICE TA199 Psoriatic arthritis - treatment
• NICE TA373 Abatacept, adalimumab, etanercept and tocilizumab for treating juvenile idiopathic arthritis
• NICE TA375 Adalimumab, etanercept, infliximab, certolizumab pegol, golimumab, tocilizumab and abatacept for rheumatoid arthritis not previously treated with DMARDs or after conventional DMARDs only have failed
• NICE TA383 Ankylosing spondylitis and non-radiographic axial spondyloarthritis
• NICE TA715 Adalimumab, etanercept, infliximab and abatacept for treating moderate rheumatoid arthritis after conventional DMARDs have failed

Golimumab (TLS Red)

• NICE TA220 Psoriatic arthritis
• NICE TA225 Rheumatoid arthritis, after the failure of previous anti-rheumatic drugs
• NICE TA375 Adalimumab, etanercept, infliximab, certolizumab pegol, golimumab, tocilizumab and abatacept for rheumatoid arthritis not previously treated with DMARDs or after conventional DMARDs only have failed
• NICE TA383 Ankylosing spondylitis and non-radiographic axial spondyloarthritis
• NICE TA497 for treating non-radiographic axial spondyloarthritis

Infliximab (TLS Red)

• Specify brand when prescribing - Remicade^®, Inflectra^®, Remsima^®.
• NICE TA195 Rheumatoid Arthritis - drugs for treatment after failure of a TNF inhibitor
• NICE TA199 Psoriatic arthritis - treatment
• NICE TA383 Ankylosing spondylitis and non-radiographic axial spondyloarthritis
• NICE TA375 Adalimumab, etanercept, infliximab, certolizumab pegol, golimumab, tocilizumab and abatacept for rheumatoid arthritis not previously treated with DMARDs or after conventional DMARDs only have failed
• Also commissioned for patients who have developed steroid-resistant colitis secondary to ipilimumab treatment
• NICE TA715 Adalimumab, etanercept, infliximab and abatacept for treating moderate rheumatoid arthritis after conventional DMARDs have failed

Rituximab (TLS Red)

• NICE TA195 Rheumatoid Arthritis - drugs for treatment after failure of a TNF inhibitor.
• Rituximab may also be used in combination with Leflunomide in patients in whom methotrexate is not tolerated, in accordance with NICE TA195 - approved by the BNSSG JFG June 2015.
• Rituximab may also be used as monotherapy in RA in patients in whom methotrexate is not tolerated - approved by the BNSSG JFG July 2016
• For the treatment of Anti-neutrophil Cytoplasmic Autoantibody-Associated (ANCA) Vasculitis (AAV) see NHS England Commissioning Board Clinical Commissioning Policy A13/P/a (specialised rheumatology) and NICE TA308 Rituximab in combination with glucocorticoids for treating anti-neutrophil cytoplasmic antibody associated vasculitis
• For the treatment of Systemic Lupus Erythematosus in adults see NHS England Board Clinical Commissioning Policy A13/PS/a (specialised rheumatology)

Protein Kinase Inhibitors

Baricitinib (TLS Red)

• NICE TA466 Baricitinib for severe rheumatoid arthritis
• For use in monogenic interferonopathies as per NHS England Clinical Commissioning Policy

Filgotinib (TLS Red)

• NICE TA676 Filgotinib for treating moderate to severe rheumatoid arthritis

Tofacitinib (TLS Red)

• NICE TA480 Tofacitinib for severe rheumatoid arthritis
• NICE TA543 Tofacitinib for treating active psoriatic arthritis after inadequate response to DMARDs
• NICE TA920 Tofacitinib for treating active ankylosing spondylitis

Upadacitinib (TLS Red)

• NICE TA665 Upadacitinib for treating severe rheumatoid arthritis
• NICE TA744 Upadacitinib for treating moderate rheumatoid arthritis
• NICE TA829 Upadacitinib for treating active ankylosing spondylitis
• NICE TA861 Upadacitinib for treating active non-radiographic axial spondyloarthritis

Drugs affecting the immune response - for specialist use only

Ciclosporin (TLS Red)

Cyclophosphamide (TLS Red)

Voclosporin (TLS Red)

• NICE TA882 Voclosporin with mycophenolate mofetil for treating lupus nephritis

Phosphodiesterase type-4 inhibitors

Apremilast (TLS Red)

• NICE TA419 Apremilast for treating severe plaque psoriasis
• NICE TA433 Apremilast for treating active psoriatic arthritis

Sildenafil (TLS Amber Specialist Initiated)

• As per NHSE Clinical Commissioning Sildenafil and bosentan for the treatment of digital ulceration in systemic sclerosis

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