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 Formulary Chapter 10: Musculoskeletal and joint diseases - Full Chapter
10.01.01  Expand sub section  Non-steroidal anti-inflammatory drugs
Ibuprofen
(Tablet, Suspension)
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First Choice
OTC

  • Consider Self Care

  • First choice NSAID at doses up to 1200mg. If bigger doses are needed consider naproxen.

  • Usual dose 200-400mg prn up to 1200mg per day. 400mg qds acceptable in the short term. 2400mg per day is associated with CV risks similar to COX2s and diclofenac so try naproxen instead.

 
Naproxen
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Second Choice
Green

  • Suitable alternative to diclofenac when CV risk factors but it is associated with a higher GI risk.

  • May have a lower cardiovascular risk than other NSAIDs and COX2's. Good alternative if ibuprofen is not suitable.

  • EC tablets are non formulary: EC tablets are more expensive. No trial has shown a difference in ulcer rate and there is minimal difference in tolerability.

  • If needed tablets can be crushed and dispersed in water. unlicensed unlicensed

 
   
Celecoxib (Celebrex)
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Restricted Drug Restricted
Green

Routine use of Cox II selective inhibitors is not recommended.



  • Celecoxib should be used ONLY in patients who:
    1) Have severe disease uncontrolled by simple analgesics AND
    2) Are considered to be at high risk of gastrointestinal bleeding AND
    3) at least one of the following applies:

    • Are intolerant of NSAID + PPI because of GI symptoms

    • Are intolerant of PPIs (e.g. because of headaches / GI side-effects)

    • Have asthma that is exacerbated by conventional NSAIDs. [N.B. Many, but not all, patients with asthma will also fail to tolerate Cox-2 inhibitors]

    • Are on multiple medications and have problems with concordance that are likely to be exacerbated by the addition of two drugs rather than one

    • Are judged to be at VERY high risk of gastrointestinal complications (e.g. history of previous bleeds or ulcer complications) but have symptoms that cannot be adequately controlled without the use of anti-inflammatory drugs. In these cases a COX II selective inhibitor may be combined with a PPI on the advice of a specialist (but note that a robust evidence base for this is lacking).



 
   
Etodolac
(Tablets, Tablet MR)
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Restricted Drug Restricted
Amber No SCG

  • CUHFT: Restricted to rheumatology for patients intolerant of other NSAIDs.

  • Non formulary at all other Trusts

 
   
Etoricoxib (Arcoxia)
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Restricted Drug Restricted
Amber No SCG
  • Celecoxib is the COX II selective inhibitor of choice on the formulary.
  • Etoricoxib is only suitable for prescribing in Primary Care for patients with spondylarthritis who are unable to take formulary choice non-steroidal anti-inflammatory drugs (NSAIDs).
  • NON-FORMULARY - Etoricoxib is BLACK for all other indications in Primary or Secondary Care.
 
   
Indometacin
(Tablet, Capsule, )
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Restricted Drug Restricted
Amber No SCG

  • Oral treatments: restricted to rheumatology and neurology.


 



  • CUFHT only: To prevent heterotopic ossification three times a day for six weeks (Orthopaedic surgeons only) – HOSPITAL ONLY.


 



  • Injection: CUHFT only (Hospital only) unlicensed unlicensed. All other trusts non-formulary.


 



  • For use in neonatology and obstetrics see section 07.01.01.01.


 

 
   
Ketoprofen
(Injection)
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Restricted Drug Restricted
Red Hospital

  • CUHFT: A&E injection approved only.

  • Non formulary at all other Trusts

 
   
Mefenamic Acid
(Capsule, Tablet)
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Restricted Drug Restricted
Green

  • Restricted to use in gynaecology only

  • Licensed for menorrhagia, but naproxen (and maybe ibuprofen) are equally effective. See CKS review of evidence.

  • Not a first choice analgesic for any indication, and not good in overdose - See review

 
   
Meloxicam
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Restricted Drug Restricted
Green

  • Restricted to patients where standard NSAIDs have failed to control symptoms

  • NWAFT: non-formulary


 

 
   
Diclofenac sodium
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Restricted Drug Restricted
Red Hospital

  • Diclofenac is associated with an increased risk of thrombo-embolic events even when used short term in patients with no cardiovascular risk factors. This risk does not appear to be shared by low dose ibuprofen or naproxen.


 



  • CUHFT:



    • Diclofenac MR 100mg only tablets and 100mg suppositories to keep as a stat dose pre-med in surgery

    • Diclofenac suppositories for theatres and paediatric anaesthetist usage, head and neck oncologist usage (OP), Rosie theatres and for renal colic in EDDiclofenac, 25mg and 50mg E/C tabs, and 12.5mg, 25mg, 50mg supps, 50mg/5ml suspension (unlicensed) for paeds usage.Note suspension is not stocked and ordered on an adhoc basis only

    • Diclofenac 75mg/2ml injection for theatres, NCCU and ICU only although supply not always easy to obtain

    • All other oral prescribing is non-formulary 


  • NWAFT: Only injection and suppositories are formulary 

  • Non formulary at all other Trusts including Primary Care


 

 
Link  MHRA: Contraindications and warnings due to CV risk (2013)
Link  MHRA: Diclofenac no longer available OTC
Link  MHRA: patient information on CV risk (July 2013)
Link  NPC: Diclofenac and CV risk review (2010)
   
10.01.01  Expand sub section  Aspirin
Aspirin
(Tablets, Suppositories)
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Restricted Drug Restricted
Advice

  • Less suitable as an analgesic

  • CUHFT: Formulary

  • NWAFT: Suppositories and dispersible tablets only (post -stroke)

  • RPH: Non formulary

 
   
 ....
 Non Formulary Items
Aceclofenac

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Non Formulary
Grey

No formal submission

Link  MHRA: updated cardiovascular advice for aceclofenac
 
Acelofenac  (Preservex)

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Non Formulary
Grey
 
Acemetacin  (Emflex)

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Non Formulary
Grey
 
Dexibuprofen  (Seractil)

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Non Formulary
Grey

  • No advantage over parent drug ibuprofen

 
Dexketoprofen  (Keral)

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Non Formulary
Grey

  • No advantage over parent drug ibuprofen

 
Diclofenac with Misoprostol  (Arthrotec 50 and 75)

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Non Formulary
Grey

Tablet

 
Fenoprofen

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Non Formulary
Grey
 
Fenoprofen  (Fenopron)

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Non Formulary
Grey
 
Flurbiprofen

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Non Formulary
Grey
Link  Link to reviews
 
Ibuprofen  (Brufen Retard)

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Non Formulary
Grey
 
Ketoprofen / Omeprazole  (Axorid)

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Non Formulary
Grey
  • Capsules
  • Ketoprofen 100mg and omeprazole 20mg
  •  
    Nabumetone

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    Non Formulary
    Grey

    Tablet

     
    Naproxen / Esomeprazole  (Vimovo)

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    Non Formulary
    Grey
    Classified grey for patients requiring naproxen for osteoarthritis, rheumatoid arthritis, or ankylosing spondylitis, who are at risk of NSAID-associated duodenal or gastric ulcer and when treatment with lower doses of naproxen or other NSAIDs ineffective
     
    Naproxen / Misoprostol  (Napratec)

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    Non Formulary
    Grey

    • Tablets

    • Naproxen 500mg and misoprostol 200mcg.

     
    Piroxicam

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    Non Formulary
    Grey
     
    Sulindac

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    Non Formulary
    Grey
     
    Tenoxicam  (Mobiflex)

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    Non Formulary
    Grey
     
    Tiaprofenic Acid

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    Non Formulary
    Grey
     
      
    Key
    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
    Restricted Drug
    Restricted Drug
    Unlicensed Drug
    Unlicensed
    Track Changes
    Display tracking information
    click to search medicines.org.uk
    Link to adult BNF
    click to search medicines.org.uk
    Link to children's BNF
    click to search medicines.org.uk
    Link to SPCs
    SMC
    Scottish Medicines Consortium
    Cytotoxic Drug
    Cytotoxic Drug
    CD
    Controlled Drug
    High Cost Medicine
    High Cost Medicine
    Cancer Drugs Fund
    Cancer Drugs Fund
    NHSE
    NHS England
    Homecare
    Homecare
    CCG
    CCG

    Traffic Light Status Information

    Status Description

    OTC

    Available Over the Counter. Consider Self Care   

    Green

    Formulary - Can be prescribed in both secondary and primary care.   

    Advice

    Formulary - Specialist Advice, secondary care advice provided for primary care initiation.  

    Amber No SCG

    Formulary - Specialist initiation without shared care guidance.  

    Amber SCG

    Formulary - Specialist initiation with shared care guidance.  

    Red Hospital

    Restricted - Hospital only, not to be prescribed in primary care.  

    Switch

    Not recommended for prescribing. Switch to alternative cost-effective option.   

    Black

    Not recommended for prescribing in primary or secondary care.  

    Grey

    Not recommended as no formal application made for addition to the formulary. Contact relevant pharmacy team for further information.   

    Non Formulary

    Non-Formulary (category under review).  

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