These are sometimes called disease modifying anti-rheumatic drugs (DMARDs). They are used when |
NSAIDs alone are not sufficient and they should only be initiated by a specialist. They require 4-6 |
months of treatment for a full response. If there is no benefit after 6 months they should be |
discontinued on specialist advice. |
|
AMBER SHARED CARE Azathioprine tablets 25mg, 50mg |
AMBER SHARED CARE Ciclosporin (Neoral®) |
capsules 25mg, 100mg |
oral solution 100mg/mL |
RED Cyclophosphamide injection 500mg, 1g |
AMBER Hydroxychloroquine tablets 200mg - see Prescriber Information Sheet |
AMBER SHARED CARE Leflunomide tablets 10mg, 20mg |
RED Leflunomide tablets 100mg (used for initial loading doses only) |
|
Secondary care will prescribe and supply leflunomide for the first three months, the primary care prescriber |
may then take over prescribing and the associated monitoring. |
|
Methotrexate |
All new patients started on methotrexate will be supplied with 2.5mg tablets only. Prescribers are |
reminded to follow the monitoring guidance outlined in the shared care protocol available here . |
|
AMBER SHARED CARE Methotrexate tablets 2.5mg only |
RED Methotrexate injection, for s/c or i/m use (Metoject®, Ebetrex®) |
|
Methotrexate should be prescribed once weekly as a single dose on the same day each week. |
Folic acid 5mg should normally be taken the day after methotrexate dosing. |
|
AMBER SHARED CARE Penicillamine tablets 125mg, 250mg |
AMBER SHARED CARE Sodium aurothiomalate injection 10mg, 20mg, 50mg |
AMBER SHARED CARE Sulfasalazine tablets e/c 500mg |
|
Cytokine modulators |
These drugs should be prescribed by specialists only, and in line with any relevant NICE guidance. |
|
Certolizumab, rituximab and tocilizumab (inc. Abatacept, Adalimumab, Etanercept, Golimumab and |
Infliximab) - NICE guidance for rheumatoid arthritis (TAG 130, 186, 195, 198, & 225). |
Treatment pathways for highly active rheumatoid arthritis in adults who have failed to respond to at |
least two standard disease modifying anti-rheumatic drugs (DMARDs) including methotrexate. These |
drugs should be prescribed according to the guidelines of the British Society for Rheumatology under |
the supervision of consultant rheumatologist. |
|
Please refer to the full guidelines for further information. |
|
Etanercept - NICE guidance for juvenile idiopathic rheumatoid arthritis (TAG 35) |
For children aged 4 to 17 years who have active JIA in at least five joints and whose condition has not |
responded adequately to or have been unable to tolerate treatment with methotrexate. Only a |
consultant who regularly sees children and young adults with JIA and who runs specialised paediatric |
rheumatology clinics should prescribe etanercept. |
|
Please refer to full guidelines for further information. |
|
Secukinumab is recommended, within its marketing authorisation, as an option for treating active |
ankylosing spondylitis in adults whose disease has responded inadequately to conventional therapy |
(non-steroidal anti-inflammatory drugs or TNF‑alpha inhibitors) as per NICE TA407 |
|
RED Secukinumab solution for injection 150mg/1mL |
|
Adalimumab, Certolizumab pegol , Etanercept, Golimumab and Infliximab - in line with NICE Guidance |
for Ankylosing spondylitis and non-radiographic axial spondyloarthritis (NICE TA383). |
(Replaces NICE technology appraisal guidance on adalimumab, etanercept and infliximab for ankylosing |
spondylitis (TA143) and golimumab for the treatment of ankylosing spondylitis (TA233). |
|
These drugs are for people with severe active ankylosing spondylitis or severe non‑radiographic axial |
spondyloarthritis who have tried non‑steroidal anti‑inflammatory drugs (NSAIDs), but they have not |
worked. |
|
RED Adalimumab pre-filled pen/syringe 40mg |
RED Certolizumab pegol pre-filled syringe 200mg |
RED Etanercept vial for injection 25mg |
pre-filled pen/syringe 25mg, 50mg |
RED Golimumab pre-filled pen/syringe 50mg,100mg |
RED Infliximab vial for infusion 100mg |
|
Golimumab for severe non-radiographic axial spondyloarthritis. |
This drug is for adults who have tried nonsteroidal anti-inflammatory drugs (NSAIDs), |
but they have not worked. Recommended as an option, within its marketing authorisation, as an |
option in NICE TA497 |
|
RED Golimumab 50 mg solution for injection in pre-filled pen (Simponi®) |
CCG Commissioned - BlueTeq Form |
|
Adalimumab, Etanercept, Infliximab, Certolizumab pegol, Golimumab, tocilizumab and abatacept - |
|
NICE Guidance for Rheumatoid arthritis not previously treated with DMARDS or after conventional |
DMARDS only have failed are recommended as an option by NICE. NICE TA375. |
Please refer to full guidelines for further information. |
|
Belimumab NICE TA752 -updates and replaces NICE TA397 | Recommended as an option as add-on treatment for active autoantibody-positive systemic lupus | erythematosus in people with high disease activity despite standard treatment, only if: | > high disease activity is defined as at least 1 serological biomarker (positive abti-double0strabded | DNA or low complement) and a SELENA-SLEDAI score of greater than or equal to 10 | > treatment is continued beyond 24 weeks only if the SELENA-SLEDAI score has improved by 4 points | or more | > the company [provides belimumab according to the commercial arrangement. | |
|
RED Belimumab ( Benlysta®) |
powder for concentrate for solution for infusion 120mg, 400mg |
NHS England Commissioned |
|
Adalimumab, Etanercept, Golimumab and Infliximab - NICE guidance for psoriatic |
arthritis (NICE TAG199 & 220) |
|
Treatment options for adults with severe active psoriatic arthritis who: |
|
> have peripheral arthritis with three or more tender joints, and |
> three or more swollen joints, and |
> other disease modifying anti-rheumatic drugs (DMARDs) administered individually or in |
combination have not worked. |
Please refer to the full guidelines for further information. |
|
|
Abatacept (Orencia), adalimumab (Humira), etanercept (Enbrel) and tocilizumab (RoActemra) are |
recommended as possible treatments for people with polyarticular juvenile idiopathic arthritis. Full |
guidance - NICE TA373 |
> Adalimumab and etanercept are recommended as possible treatments for people with |
enthesitis-related juvenile idiopathic arthritis. |
> Etanercept is recommended as a possible treatment for people with psoriatic juvenile |
idiopathic arthritis |
|
Abatacept |
Abatacept may be considered as a second line option for rheumatoid arthritis if either rituximab or |
methotrexate is contraindicated or an adverse reaction has been experienced (see NICE guidance). |
Infusion to be administered in hospital. (NICE TA195) |
|
Abatacept for treating Rheumatoid Arthritis after failure of conventional disease modifying anti- |
rheumatic drugs (NICE TAG280) (rapid review of TAG234) - recommended as an option by NICE in adults |
whose disease has responded inadequately to two conventional DMARD's including methotrexate if |
used in accordance with recommendations for other biologicals (TAG130) and PAS is provided |
|
RED Abatacept vial for infusion 250mg |
RED Abatacept pre-filled pen/syringe 125mcg |
|
Adalimumab |
Adalimumab is recommended either alone or in combination for the treatment of psoriatic arthritis |
and ankylosing spondylitis. It is also a treatment option for rheumatoid arthritis (see NICE guidance). |
Patients should be trained to self administer the injection. |
|
RED Adalimumab pre-filled pen/syringe 40mg |
|
Apremilast - NICE TA433 (relaces TA372) CCG Commissioned |
Apremilast, alone or in combination with disease-modifying antirheumatic drugs (DMARDs), is |
recommended as an option for treating active psoriatic arthritis in adults only if: |
¤ they have peripheral arthritis with 3 or more tender joints and 3 or more swollen joints and |
¤ their disease has not responded to adequate trials of at least 2 standard DMARDs, given either |
alone or in combination and |
¤ the company provides apremilast with the discount agreed in the patient access scheme |
|
RED Apremilast tablets 10mg, 20mg, 30mg (Otezla®) |
|
Certolizumab |
Certolizumab pegol in combination with methotrexate is indicated for the treatment of moderate |
to severe, active rheumatoid arthritisin adult patients when the response to conventional disease |
modifying anti-rheumatic drugs (DMARDs) including methotrexate, has been inadequate (see NICE |
guidance). Patients should be trained to self administer the injection. |
|
RED Certolizumab pre-filled syringe 200mg |
|
Certolizumab and Secukinumab as per NICE TA445 CCG Commissioned |
The response to certolizumab pegol and secukinumab should be assessed after 12 weeks and 16 weeks of |
treatment respectively and should only be continued if there is clear evidence of response as in NICE TA445. |
|
Certolizumab pegol alone, or in combination with methotrexate, is recommended as an option for |
treating active psoriatic arthritis in adults only if: |
|
> it is used as described in the NICE technology appraisal guidance on on etanercept, infliximab |
and adalimumab for the treatment of psoriatic arthritis (recommendations 1.1 and 1.2) or |
> the person has had a tumour necrosis factor (TNF)-alpha inhibitor but their disease has |
stopped responding after the first 12 weeks. |
Certolizumab pegol is only recommended if the company provides it as agreed in the patient access |
|
Secukinumab alone, or in combination with methotrexate, is recommended as an option for treating |
active psoriatic arthritis in adults only if: |
> it is used as described in the NICE technology appraisal guidance on etanercept, infliximab |
and adalimumab for the treatment of psoriatic arthritis (recommendations 1.2 and 1.2) or |
> the person has had a TNF‑alpha inhibitor but their disease has not responded within the first |
12 weeks or has stopped responding after 12 weeks or |
> TNF‑alpha inhibitors are contraindicated but would otherwise be considered (as described in |
NICE technology appraisal guidance on etanercept, infliximab and adalimumab for the |
treatment of psoriatic arthritis). |
Secukinumab is only recommended if the company provides it as agreed in the patient access |
scheme. |
|
RED Certolizumab pre-filled syringe 200mg |
RED Secukinumab pre-filled syringe 150mg/1mL |
|
Certolizumab |
Certolizumab is recommended for the treatment of adults withactive and progressive psoriatic arthritis |
in line with NICE TA199, that is when the person has peripheral arthritis with three or more tender |
joints and three or more swollen joints and their psoriatic arthritis has not responded to adequate trials |
of at least two standard disease-modifying antirheumatic drugs, administered either individually or in |
combination. |
Certolizumab should be used in combination with methotrexate where possible, however can be given |
as monotherapy in the case of intolerance to methotrexate or when continued treatment with |
methotrexate is inappropriate |
|
RED Certolizumab pre-filled syringe 200mg |
|
Certolizumab |
An option as as a second line anti-TNF (tumour necrosis factor) in psoriatic arthritis (PsA) following |
discontinuation of first anti-TNF due to an adverse event or primary or secondary inefficacy. |
|
RED Certolizumab pre-filled syringe 200mg |
|
Certolizumab |
Certolizumab pegol is licensed for the treatment of adults with severe active ankylosing spondylitis |
who have had an inadequate response to, or are intolerant to non-steroidal anti-inflammatory |
drugs (NSAIDs) (in line with NICE TA143) |
|
RED Certolizumab pre-filled syringe 200mg |
|
Certolizumab |
Certolizumab pegol is recommended as an option for treating rheumatoid arthritis after inadequate |
response to a TNF-alpha inhibitor - NICE TA415 |
|
RED Certolizumab pre-filled syringe 200mg CCG commissioned |
|
Etanercept |
Etanercept is recommended either alone or in combination with methotrexate for the treatment of |
active polyarticular juvenile idiopathic arthritis, psoriatic arthritis and ankylosing spondylitis. It is also a |
treatment option for rheumatoid arthritis (see NICE guidance). Patients should be trained to self |
administer the injection. |
|
RED Etanercept vial for injection 25mg |
pre-filled pen/syringe 25mg, 50mg |
|
Golimumab |
Treatment option for adults with severe active psoriatic arthritis only if used as described for other |
tumour necrosis factor (TNF) inhibitors and the manufacturer provides the 100mg dose of Golimumab |
at the same cost as the 50mg dose. |
Please refer to the full guidelines for further information. |
|
RED Golimumab pre-filled pen/syringe 50mg,100mg |
|
Infliximab |
Infliximab may be considered as an option to treat rheumatoid arthritis where: |
> certolizumab, adalimumab and etanercept are contraindicated, or |
> methotrexate is contraindicated or not tolerated, or |
> the patient cannot self inject (see NICE guidance). |
|
It is also a treatment option for psoriatic arthritis. Infusion to be administered in hospital. |
|
RED Infliximab vial for infusion 100mg |
|
Rituximab |
Rituximab in combination with methotrexate is recommended as a second line option for the treatment |
of adults with severe active rheumatoid arthritis who have had an inadequate response to, or are |
intolerant of, other disease modifying anti-rheumatic drugs (DMARDs), including at least one tumour |
necrosis factor (TNF) inhibitor. Treatment with rituximab should be given no more frequently than |
every 6 months (see NICE guidance). Infusion to be administered in hospital. |
|
Pre-medication 30-60 minutes before hand with methylprednisolone is necessary to reduce infusion- |
related reactions. Rituximab should be prepared by a pharmacist or healthcare professional observing |
aseptic techniques. As per BSR guidelines for anti-TNFs, treatment should be withdrawn following |
adverse events or where there is an inadequate response at 3 months following initiation of treatment. |
Rituximab should be funded via 'pass through funding' under payment by results, booked out to |
individual patients in pharmacy and recharged directly to the PCTs. A New Drug review for rituximab |
in rheumatoid arthritis is available - click here. |
|
RED Rituximab vial for infusion 100mg, 500mg |
|
Sarilumab - NICE guidance for moderate to severe rheumatoid arthritis (TA485) |
Sarilumab with methotrexate , is recommended as an option for treating active rheumatoid arthritis in |
adults whose disease has responded inadequately to intensive therapy with a combination of |
conventional disease- modifying antirheumatic drugs (DMARDs) - as per NICE TA485 |
CCG Commissioned (Blue Tec form required) |
|
Tocilizumab |
Tocilizumab in combination with methotrexate is recommended third line for the treatment of |
moderate to severe active rheumatoid arthritis in people whose condition (NICE TA198): |
> has responded inadequately to one or more tumour necrosis factor alpha (TNFα) |
inhibitors; and |
> has responded inadequately or are contraindicated to rituximab, or when rituximab is |
withdrawn because of an adverse effect as per NICE guidance. |
|
Tocilizumab in combination with methotrexate is recommended for some children with juvenile |
idiopathic arthritis where all other treatments have failed (NICE TA238). |
|
Infusion to be administered in hospital. |
RED Tocilizumab vial for infusion 80mg, 200mg, 400mg |
|
Subcutaneous Tocilizumab is recommended for use as an alternative to intravenous Tocilizumab |
providing the patient meets the prescribing criteria as set out in NICE technology appraisals for |
1st, 2nd and 3rd line use to treat active rheumatoid arthritis (RA) and the agreed Lancashire |
Rheumatology Alliance flex for use as monotherapy. CLICK here to link to the recommendation. |
|
RED Tocilizumab injection 162mg pre-filled syringe |
|
Tocilizumab is recommended as an option in treating Giant Cell Arteritis by NICE TA518, when used with |
a tapering course of glucocoticoids (and when used alone after glucocorticoids) only if: |
|
> they have relapsing or refractory disease |
> they have not already had |
> tocilizumab is stopped after 1 year of uninterrupted treatment at most and |
> the company provides it with the discount agreed in the patient access scheme |
|
RED Tocilizumab concentration for solution for infusion (RoActemra®) |
(NHS England Commissioned) |
|
Tofacitinib - Moderate to severe rheumatoid arthritis NICE TA480 |
Tofacitinib, with methotrexate, is recommended as an option for treating active rheumatoid arthritis in |
adults whose disease has responded inadequately to intensive therapy with a combination of |
conventional disease-modifying anti-rheumatic drugs (DMARDs), only if: |
|
> disease is severe (a disease activity score [DAS28] of more than 5.1) and |
> the company provides tofacitinib with the discoiunt agreed in the patient access scheme |
|
Tofacitinib with methotrexate, is recommended as an option for treating active rheumatoid arthritis in |
adults whose disease has responded inadequately to, or who cannot have, other DMARDs, including at |
least 1 biological DMARD, only if: |
|
> disease is severe (a DAS28 of more than 5.1) and |
> they cannot have rituximab |
> the company provides tofacitinib with the discount agreed in the patient access scheme |
|
Tofacitinib can be used as monotherapy for adults who cannot take methotrexate because it is |
contraindicated or because of intolerance, when the criteria in sections 1.1 and 1.2 are met. |
|
RED Tofacitinib |
tablets 5mg (Xeljanz®) (CCG Commissioned - Blue Teq form required) |
|