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Pan Mersey
Area Prescribing Committee
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 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 View childrens BNF) 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.

NHSE NHS England Specialised Commissioning: Key documents

NHSE NHS England Specialised Commissioning: National programmes of care and clinical reference groups

Chapter Links...
 Details...
10.02.02  Expand sub section  Skeletal muscle relaxants
 note 

Drug driving

Guidance for healthcare professionals on drug driving

Information for patients

Drugs and driving: blood concentration limits set for certain drugs

Baclofen
View adult BNF View SPC online View childrens BNF
Formulary
Green

Tablets 10 mg: Liquid SF 5 mg/5mL

Amber Recommended Paediatrics
 
 
RED 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
View adult BNF View SPC online View childrens BNF
Formulary
Green

Tablets 2 mg, 5 mg, 10 mg
Oral solution 2mg/5ml

Amber Recommended Paediatrics

 
   
Tizanidine
View adult BNF View SPC online
Formulary
Amber Retained

Tablets 2 mg, 4 mg

Use after initiation by a specialist

Paediatrics: no BNFc entry - seek specialist advice

 

 
   
Controlled Drug Cannabis extract (Sativex® oromucosal spray )
View adult BNF View SPC online
Formulary
Amber Retained

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.

 
Link  NICE CG186 (2014) Multiple sclerosis: management of multiple sclerosis in primary and secondary care
Link  NICE NG144 (2019): Cannabis-based medicinal products
Link  Pan Mersey APC (2020): Cannabis Extract oromucosal spray (Sativex®) - Prescribing Support Information
   
Dantrolene
View adult BNF View SPC online View childrens BNF
Formulary
Amber Retained

Capsules 25 mg, 100 mg

Use after initiation by a specialist

 
   
Mexiletine (Namuscla®)
View adult BNF View SPC online
Formulary
Red
NHS England

Capsules 167mg

NHSE commissioned drug (non-dystrophic myotonia) - see Specialised Commissioning: Key documents

Paediatrics: no BNFc entry - seek specialist advice

 
   
Nusinersen
View adult BNF View SPC online
Formulary
Red
NHS England

12mg solution for injection

5q spinal muscular atrophy

NHS NHSE commissioned drug - see Specialised Commissioning: Key documents 

 
Link  NICE TA588 (2019): Nusinersen for treating spinal muscular atrophy
   
Ataluren
View adult BNF View SPC online View childrens BNF
Formulary
Red

Granules 125mg, 250mg, 1g

NHS NHSE commissioned drug - see Specialised Commissioning: Key documents

 

 
   
Dantrolene
View adult BNF View SPC online View childrens BNF
Formulary
Red

Injection - powder for solution 20mg

 
   
Pridinol
View adult BNF
Formulary
Grey

3mg tablets (Myopridin®)

 
Link  Pan Mersey APC (2021): PRIDINOL tablets (Myopridin®) for central and peripheral muscle spasms
   
10.02.02  Expand sub section  Other muscle relaxants
Methocarbamol
View adult BNF View SPC online
Formulary
Black

Tablets 750mg

BNF designates as "Less suitable for prescribing"
 

 
   
10.02.02  Expand sub section  Nocturnal leg cramps
 note  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
View adult BNF View SPC online
Second Choice
Green
Tablets 200 mg, 300 mg

Paediatrics: no BNFc entry - seek specialist advice  
   
 ....
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

Green

Medicines considered suitable for non-specialist prescribing in primary or secondary care.  

Amber Recommended

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

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 Retained

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   

Amber

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.  

Purple

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.   

Red

Primary care prescribing of these medicines is NOT recommended. These treatments should be initiated by specialists only; ongoing prescribing is retained within secondary care.   

Black

Not recommended for use. Deviation from the policy may be considered on an individual basis where exceptional circumstances exist.   

Grey

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.  

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