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10.3.1 Enzymes

[Collagenase clostridium hystolyticum  Discontinued by manufacturer]
Collagenase Clostridium histolyticum 900mcg (Xiapex®) *
* Xiapex® - Sobi has discontinued commercialisation of this product at the end of 2019 - see attached information
Used to render tissues more easily permeable to injected fluids i.e. in hypodermoclysis.
AMBER     Hyaluronidase injection 1500 unit

10.3.2 Rubefacients and other topical anti-rheumatics

Topical non-steroidal anti-inflammatory drugs (NSAIDs) are recommended by NICE as a first line treatment with or without regular paracetamol for

the management of osteoarthritis.        

GREEN      Ibuprofen gel 5%
GREEN      Ketoprofen gel 2.5% (licensed for up to 7 days use only)
Prescribers are reminded that photosensitivity reactions are an important side effect of Ketoprofen gel. Before prescribing
                    >     verify that the patient does not have any phototoxicity- or photoallergy-related contraindications.
                    >     explain to patients the steps they need to take to minimise the risk of photosensitivity reactions
                    >     check that patients understand the risk of photosensitivity and the steps they need to take to minimise this risk.
                           A prescriber checklist is available here 
If above agent/s are ineffective or insufficient then alongside other options (such as oral NSAIDs, oral opioids or intra-articular injections) consider
substitution or addition of topical capsaicin for hand/knee osteoarthritis.
Cautions Avoid contact with eyes, and inflamed or broken skin. Hands should be washed immediately after use. Not for use under tight bandages. Avoid  taking a hot shower or bath just before or after applying capsaicin—burning sensation enhanced.
Transient burning sensation can occur during initial treatment, particularly if too much cream is used, or if the frequency of administration 
is less than 3–4 times daily.
GREEN      Capsaicin cream 0.025% [Zacin®(for osteoarthritis of the hand and knee only- NOT for back pain)  
                   For general musculoskeletal pain advise to purchase a rubefacient product]  [Consider OTC/Self care]  
AMBER     Capsaicin cream 0.075% [Axsain®] (for post herpetic neuralgia & painful diabetic neuropathy)
For the use in specialist services, Transvasin® cream has been approved for off-licence use to improve the blood flow of the ear lobe prior to
measuring capillary ear lobe blood gases.
RED            Transvasin® cream
Information about changes to medicines or treatments on the NHS: Changes to rubefacients prescribing: Patient Information Leaflet