| Formulary Chapter 10: Musculoskeletal and joint diseases - Full Chapter
|
| Notes: |
Coronavirus guidance
Guidance to support primary care prescribers and pharmacists is available from the MLCSU Coronavirus guidance resource page. Links are provided to national resources and regional documents produced by MLCSU, RDTC, and SPS for use by Pan Mersey APC, LSCMMG, and GMMMG.
The list of resources will be updated as new material becomes available so please check back regularly for updates.
The Pan Mersey APC supports the use of COVID-specific guidance issued by NICE, and NHS England and NHS Improvement. During the COVID pandemic this will supersede any APC advice.
Musculoskeletal and joint disease
Review date: October 2022
Non-formulary drugs: Any drug or formulation not listed in the formulary is deemed to be non-formulary.
Off-label use: Drugs are included in the formulary for their licensed indications – where inclusion of off-label use is considered to be included in the formulary this is specifically stated in the formulary entry for the drug N.B. also see Paediatrics note below.
Paediatrics: Drugs are included in the formulary for paediatric use for their BNF for Children recommended indications (indicated by symbol  ) which may be off-label, unless otherwise stated. All drugs are deemed to have the same RAG status as they have for adults unless stated otherwise.
NHS England Specialised Commissioning
Drugs carrying the NHS England logo are commissioned by them. Links to key documents, national programmes of care, and clinical reference groups are found below.
 NHS England Specialised Commissioning: Key documents
NHS England Specialised Commissioning: National programmes of care and clinical reference groups |
|
| Chapter Links... |
 NHSE. Specialised Commissioning: key documents |
| NHSE. Specialised Commissioning: national programmes of care and clinical reference groups |
| Details... |
| 10.02.02 |
Skeletal muscle relaxants |
|
|
|
Baclofen
|
Formulary
|
Tablets 10 mg: Liquid SF 5 mg/5mL  Paediatrics
 Intrathecal injection 500micrograms/ml and 2mg/ml – severe chronic spasticity e.g. with spinal cord injury, specialist use only. NB. Commissioned by NHS England
|
|
|
Diazepam
|
Formulary
|
Tablets 2 mg, 5 mg, 10 mg
Oral solution 2mg/5ml Paediatrics
|
|
|
Tizanidine
|
Formulary
|
Tablets 2 mg, 4 mg
Use after initiation by a specialist
Paediatrics: no BNFc entry - seek specialist advice
|
|
|
Cannabis extract (Sativex® oromucosal spray )
|
Formulary
|
Oromucosal spray - 2.7 mg delta-9-tetrahydrocannabinol (THC) and 2.5 mg cannabidiol (CBD) per 1 dose
To be prescribed in line with Prescribing Support Information as detailed below.
|
NICE CG186 (2014) Multiple sclerosis: management of multiple sclerosis in primary and secondary care
NICE NG144 (2019): Cannabis-based medicinal products
 Pan Mersey APC (2020): Cannabis Extract oromucosal spray (Sativex®) - Prescribing Support Information
|
Dantrolene
|
Formulary
|
Capsules 25 mg, 100 mg
Use after initiation by a specialist
|
|
|
Mexiletine (Namuscla®)
|
Formulary
|
Capsules 167mg
NHSE commissioned drug (non-dystrophic myotonia) - see Specialised Commissioning: Key documents
Paediatrics: no BNFc entry - seek specialist advice
|
|
|
Nusinersen
|
Formulary
|
12mg solution for injection
5q spinal muscular atrophy
NHSE commissioned drug - see Specialised Commissioning: Key documents
|
NICE TA588 (2019): Nusinersen for treating spinal muscular atrophy
|
Ataluren
|
Formulary
|
Granules 125mg, 250mg, 1g NHSE commissioned drug - see Specialised Commissioning: Key documents
|
|
|
Dantrolene
|
Formulary
|
Injection - powder for solution 20mg
|
|
|
Pridinol
|
Formulary
|
3mg tablets (Myopridin®)
|
Pan Mersey APC (2021): PRIDINOL tablets (Myopridin®) for central and peripheral muscle spasms
|
|
|
|
|
|
|
| 10.02.02 |
Other muscle relaxants |
|
|
Methocarbamol
|
Formulary
|
Tablets 750mg
BNF designates as "Less suitable for prescribing"
|
|
|
| 10.02.02 |
Nocturnal leg cramps |
|
|
 |
The MHRA recommends quinine is not a routine treatment for nocturnal leg cramps, and should only be considered when cramps cause regular disruption of sleep, are very painful or frequent; when other treatable causes of cramp have been ruled out; and when non-pharmacological measures have not worked (e.g, passive stretching exercises). After an initial trial of 4 weeks, treatment should be stopped if there is no benefit. |
|
Quinine
|
Second Choice
|
Tablets 200 mg, 300 mg
Paediatrics: no BNFc entry - seek specialist advice
|
|
|
| .... |
Key |
|
|
|
|
Cytotoxic Drug
|
|
|
Controlled Drug
|
|
High Cost Medicine
|
|
Cancer Drugs Fund
|
|
NHS England |
|
Homecare |
|
CCG |
|
Traffic Light Status Information
| Status |
Description |
|
Medicines considered suitable for non-specialist prescribing in primary or secondary care. |
|
Requires specialist assessment to enable patient selection. Amber Recommended medicines must meet criteria: (1) Requires specialist assessment to enable patient selection (2) Following specialist assessment, the medicine is suitable for prescribing in Primary Care. |
|
Amber Initiated. Requires specialist initiation of prescribing. Prescribing to be continued by the specialist until stabilisation of the dose is achieved and the patient has been reviewed. Amber Initiated medicines must meet criteria:
(1) Requires specialist assessment to enable patient selection
(2) Medicine is suitable for on-going prescribing in Primary Care
(3) Requires short to medium term specialist prescribing and monitoring of efficacy or toxicity until the patient’s dose and condition is stable
|
|
Amber Patient Retained. Requires specialist initiation of prescribing. Prescribing to be continued by specialist until stabilisation of the dose is achieved and the patient had been reviewed. Patient remains under the care of specialist (ie not discharged) as occasional specialist input may be required. Amber Patient Retained medicines must meet criteria:
(1)Requires specialist assessment to enable patient selection
(2)Medicine is suitable for on-going prescribing in Primary Care
(3) Requires short to medium term specialist prescribing and monitoring of efficacy or toxicity until the patient’s dose and condition is stable
(4) May require occasional specialist input indefinitely and therefore the patient should not be discharged from specialist care
|
|
Medicines recommended or initiated by specialists in primary or secondary care. Non-specialist prescribing in primary care may follow according the RAG criteria. In process of being superceded by Amber Recommended, Amber Initiated and Amber Patient Retained. |
|
Shared Care.
Medicines are considered suitable for Primary Care prescribing and/or management, following specialist initiation of therapy, with on-going communication between the Primary Care prescriber and specialist, within the framework of a Shared Care Agreement. Medicines designated as requiring Shared Care require on-going input from both Specialist and Primary Care clinicians and patients should not be discharged from Specialist care.
Where prescribing and monitoring are required under shared care, it is implicit that the responsibility for both of these tasks rests with the prescriber.
A Shared Care Agreement will always be available for Shared Care medicines and this document will include a Shared Care Agreement pro-forma which will be completed by all involved clinicians. This pro-forma will record agreement to take on defined aspects of care e.g. monitoring and/or on-going prescribing for the individual patients.
A policy detailing clinician responsibilities in Shared Care Agreements must be referred to in all cases of Shared Care.
All drugs to be included in this category must meet Shared Care criteria 1 to 3:
SC1 Requires specialist assessment to enable patient selection and also initiation, stabilisation and review of treatment and the patient`s condition.
SC2 Prescribing and/or management of the drug in Primary Care with specialist support and input, within the framework of the Shared Care Agreement is safe and convenient and that there is an appropriate mechanism for individual patient access in Primary Care.
SC3 Requires specific long-term monitoring (blood test or other measurement) for adverse effects and / or efficacy of the drug to be completed in Primary Care, and requires on-going specialist support for the dose changes or management of adverse effects. Monitoring is required on a regular basis (typically four times a year).
Implicit in any shared care agreement is the understanding that participation is at the discretion of the Primary Care prescriber subject to their clinical confidence.
|
|
Primary care prescribing of these medicines is NOT recommended. These treatments should be initiated by specialists only; ongoing prescribing is retained within secondary care. |
|
Not recommended for use. Deviation from the policy may be considered on an individual basis where exceptional circumstances exist. |
|
Not recommended for use at this time. Deviation from the policy may be considered on an individual basis where exceptional circumstances exist. Further guidance will be issued when more information or evidence is made available. |
|
|
|
