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BNSSG Adult Joint Formulary

10.3 Neuromuscular disorders

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Last edited: 17-07-2025

10.3.1 Myasthenia gravis and Lambert-Eaton myasthenic syndrome

First line drugs

Second line drugs

Specialist drugs

Secondary care drugs

Anticholinesterases

Neostigmine (TLS Green)

Only on the recommendation of a Consultant Neurologist

Pyridostigmine (TLS Green)

10.3.2 Nocturnal leg cramps

Quinine sulphate (TLS Green)

MHRA Drug Safety Update June 2010, Quinine is not a routine treatment for nocturnal leg cramps, and should only be tried when cramps regularly disturb sleep

10.3.3 Spasticity

Alpha 2 -Adrenoceptor Agonists

Tizanidine (TLS Green)

Only on the recommendation of a Neurologist or pain clinic
Caution in renal impairment

Gamma-Aminobutyric Acid Analogues and Derivatives

Baclofen (TLS Green)

Baclofen may lead to reversible neurological changes and coma in people with low kidney function. Start at very low doses at very long intervals in these patients and titrate to effect

Baclofen (intrathecal) (TLS Red)

Refer to the NHS England Policy D04/P/c: Intrathecal baclofen (ITB)

Muscle Relaxants

Dantrolene (TLS Green)

Diazepam (TLS Green)

See BNSSG Benzodiazepine and Z-drug Prescribing (including withdrawal) Support Document

Cannabis extract

Delta-9-tetrahydrocannabinol (THC) and cannabidiol (CBD) (Sativex^®) oromucosal spray (TLS Amber Specialist Initiated)

Sativex® contains cannabidiol 2.5mg and dronabinol 2.7mg per dose, administered as an oral spray with a maximum of 12 sprays per day.
Sativex® is restricted to use for moderate to severe spasticity in patients with multiple sclerosis in accordance with NICE guideline NG144.
It should only be initiated by a specialist with expertise in treating spasticity due to multiple sclerosis. The specialist is responsible for overseeing the titration period and assessing patient response.
After a successful initial trial period (usually 4-12 weeks), treatment can be continued indefinitely by primary care at the agreed dose.
Primary care does not need to carry out any additional monitoring. Patients will remain under specialist follow-up and the specialist team will review the patient's treatment at least once a year
Sativex® is a Schedule 4 Part 1 controlled drug

10.3.4 DMARDs

Disease Modifying Anti-Rheumatic Drugs (DMARDs)

Mycophenolate (TLS Amber 3 months) (SCP click here)

10.3.5 Other

Nusinersen (TLS Red)

NICE TA588 Nusinersen for treating spinal muscular atrophy

Risdiplam (TLS Red)

NICE TA755 Risdiplam for treating spinal muscular atrophy

Onasemnogene abeparvovec (TLS Red)

NHSE SSC 2504 Onasemnogene abeparvovec for treating pre-symptomatic spinal muscular atrophy

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