10.1.3 Drugs that suppress the rheumatic disease process

Drugs used not listed here:

Penicillamine
  • Tablets 125mg, 250mg (£88.75 = 250mg 12 hourly)

Indications

  • Severe rheumatoid arthritis

Notes

  1. Refer to individual shared care guidelines for use in Rheumatology conditions
Hydroxychloroquine
  • Tablets 200mg (£3.40 = 200mg 12 hourly)

Indications

  • Treatment of adults with rheumatic disease, in particular systemic lupus erythematosus and rheumatoid arthritis

Notes

  1. Refer to individual shared care guidelines for use in Rheumatology conditions
  2. The Royal College of Ophthalmologists has issued updated guidance for monitoring for hydroxychloroquine retinopathy. The new guidance requires a consultant-led service. The CCG is working towards commissioning a service in Devon and will issue an updated shared care guideline when the service is in place
Leflunomide
  • Tablets 10mg, 20mg (£4.31 = 20mg daily)

Indications

  • Active rheumatoid arthritis
  • Active psoriatic arthritis

Notes

  1. Refer to individual shared care guidelines for use in Rheumatology conditions
Apremilast
  • Tablets 10mg, 20mg, 30mg

Notes

  1. For use in line with NICE TA419 Apremilast recommended for treating moderate to severe plaque psoriasis (November 2016)
  2. For use in line with NICE TA433 Apremilast for treating active psoriatic arthritis
Baricitinib
  • Tablets 2mg, 4mg

Notes

  1. NICE TA466: Baricitinib (Olumiant), 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), only when the criteria of the NICE TA are met (August 2017)
  2. MHRA Drug Safety Update (March 2020): Baricitinib (Olumiant): risk of venous thromboembolism.
    1. Use caution if considering baricitinib in patients with additional risk factors for deep vein thrombosis and pulmonary embolism, such as prior medical history of venous thromboembolism, surgery, immobilisation, older age, and obesity
    2. Discontinue baricitinib treatment permanently if clinical features of venous thromboembolism occur
    3. Advise patients undergoing treatment with baricitinib to seek urgent medical attention if they experience a painful swollen leg, chest pain, or shortness of breath
Tofacitinib
  • Tablets 5mg, 10mg

Notes

  1. NICE TA480: Tofacitnib for moderate to severe rheumatoid arthritis (October 2017):
    1. Tofacitnib (Xeljanz), 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 when the criteria of the NICE TA are met
    2. Tofacitinib (Xeljanz), 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 when the criteria of the NICE TA are met
    3. Tofacitinib can be used as monotherapy for adults who cannot take methotrexate because it is contraindicated or because of intolerance, when the criteria in of the NICE TA are met.
  2. NICE TA543: Tofacitnib (Xeljanz), with methotrexate, is recommended as an option for treating active psoriatic arthritis in adults, only when the criteria of the NICE TA are met (October 2018)
  3. NICE TA547: Tofacitinib ( Xeljanz) is recommended as an option for treating moderately to severely active ulcerative colitis in adults when conventional therapy or a biological agent cannot be tolerated or the disease has responded inadequately or lost response to treatment (November 2018)
  4. MHRA Drug Safety Update (March 2020): Tofacitinib (Xeljanz): new measures to minimise risk of venous thromboembolism and of serious and fatal infections.
    1. Tofacitinib is associated with a dose-dependent increased risk of serious venous thromboembolism
    2. Use caution in any patients with known risk factors for venous thromboembolism in addition to the underlying disease
    3. In patients with ulcerative colitis who have known risk factors for venous thromboembolism in addition to the underlying disease, use of 10mg twice daily tofacitinib for maintenance treatment is not recommended unless no suitable alternative treatment is available
    4. Do not exceed the recommended dose of 5mg twice daily for rheumatoid arthritis or 5mg twice daily for psoriatic arthritis in any patients
    5. Inform patients of the signs and symptoms of venous thromboembolism before they start tofacitinib and advise them to seek prompt medical help if they develop signs such as a painful swollen leg, chest pain, or shortness of breath
    6. Discontinue tofacitinib treatment permanently if signs of venous thromboembolism occur
    7. Patients older than 65 years of age are at an increased risk of serious infections and should be treated with tofacitinib only if there is no alternative treatment

Cytokine modulators

NICE TA375: Adalimumab, etanercept, infliximab, certolizumab pegol, golimumab, tocilizumab and abatacept are recommended for rheumatoid arthritis not previously treated with DMARDs or after conventional DMARDs only have failed (January 2016)

NICE TA383: TNF-alpha inhibitors for ankylosing spondylitis and non-radiographic axial spondyloarthritis (February 2016)

Abatacept
  • 250mg vial, powder for reconstitution
  • Injection 125mg pre-filled syringe

Notes

  1. NICE TA195: Adalimumab, etanercept, infliximab, rituximab, and abatacept are recommended for the treatment of rheumatoid arthritis after the failure of a TNF inhibitor (August 2010)
  2. NICE TA373: Abatacept, adalimumab, etanercept and tocilizumab are recommended as possible treatments for people with polyarticular juvenile idiopathic arthritis (NHS England Commissioned) (December 2015)
Adalimumab
  • Injection 40mg

Notes

  1. Prescribe by brand. A biosimilar medicine is a biological medicine that is highly similar and clinically equivalent (in terms of quality, safety, and efficacy) to an existing biological medicine however they cannot be considered generic equivalents of the originator biological medicine. Because they are not identical, biological medicines must be prescribed by brand. The decision which brand to prescribe rests with the responsible clinician in consultation with the patient. Automatic substitution of brands at the point of dispensing is not appropriate for biological medicines.
  2. NICE TA195: Adalimumab, etanercept, infliximab, rituximab, and abatacept are recommended for the treatment of rheumatoid arthritis after the failure of a TNF inhibitor (August 2010)
  3. NICE TA199: Psoriatic arthritis - etanercept, infliximab and adalimumab (August 2010)
  4. NICE TA373: Abatacept, adalimumab, etanercept and tocilizumab are recommended as possible treatments for people with polyarticular juvenile idiopathic arthritis. Adalimumab and etanercept are recommended as possible treatments for people with enthesitis-related juvenile idiopathic arthritis (NHS England Commissioned) (December 2015)
  5. NICE TA392: Adalimumab recommended for treating moderate to severe hidradenitis suppurativa (June 2016) (NHS England commissioned)
  6. NICE TA455: Adalimumab, etanercept and ustekinumab for treating plaque psoriasis in children and young people (July 2017)
  7. NICE TA460: Adalimumab and dexamethasone for treating non-infectious uveitis (July 2017)
Belimumab
  • Powder for solution for infusion 120mg vial, 400mg vial

Notes

  1. NICE TA397: Belimumab (Benlysta) is recommended as an option as add-on treatment for active autoantibody-positive systemic lupus erythematosus in adults only, only when the criteria of the NICE TA are met (June 2016)
  2. MHRA Drug Safety Update (April 2019): Belimumab (Benlysta): increased risk of serious psychiatric events seen in clinical trials
Certolizumab pegol
  • Prefilled syringe 200mg

Notes

  1. The commissioning of certolizumab is accepted in Devon as an alternative first line biological treatment option to NICE recommended tumour necrosis factor inhibitors for patients with ankylosing spondylitis who have had an inadequate response to NSAIDs. The patient's clinical condition and response to treatment should meet the criteria outlined in NICE TA383 (see Commissioning Policy for more details)
  2. NICE TA415: Certolizumab pegol (Cimzia), in combination with methotrexate, is recommended as an option for treating active rheumatoid arthritis in adults whose disease has responded inadequately to, or who cannot tolerate, other disease-modifying antirheumatic drugs (DMARDs) including at least 1 tumour necrosis factor‑alpha (TNF‑alpha) inhibitor, only when the criteria of the NICE TA are met (October 2016)
  3. NICE TA445: Certolizumab pegol and secukinumab for treating active psoriatic arthritis after inadequate response to DMARDs (May 2017):
    1. Certolizumab pegol (Cimzia) alone, or in combination with methotrexate, is recommended as an option for treating active psoriatic arthritis in adults, only when the criteria of the NICE TA are met
  4. NICE TA574: Certolizumab pegol (Cimzia) is recommended as an option for treating plaque psoriasis in adults, only when the criteria of the NICE TA are met (April 2019)
Etanercept
  • Paediatric injection 10mg vial with solvent
  • 25mg, 50mg vial with solvent
  • 25mg, 50mg prefilled syringe

Notes

  1. Prescribe by brand. A biosimilar medicine is a biological medicine that is highly similar and clinically equivalent (in terms of quality, safety, and efficacy) to an existing biological medicine however they cannot be considered generic equivalents of the originator biological medicine. Because they are not identical, biological medicines must be prescribed by brand. The decision which brand to prescribe rests with the responsible clinician in consultation with the patient. Automatic substitution of brands at the point of dispensing is not appropriate for biological medicines.
  2. Once commenced on therapy, etanercept should be brand prescribed to ensure continuity of supply for patients.
  3. NICE TA35: Arthritis (juvenile idiopathic), etanercept (March 2002)
  4. NICE TA195: Adalimumab, etanercept, infliximab, rituximab, and abatacept for the treatment of rheumatoid arthritis after the failure of a TNF inhibitor (August 2010)
  5. NICE TA199: Psoriatic arthritis - etanercept, infliximab and adalimumab (August 2010)
  6. NICE TA373: Abatacept, adalimumab, etanercept and tocilizumab are recommended as possible treatments for people with polyarticular juvenile idiopathic arthritis. Etanercept is recommended as a possible treatment for people with psoriatic juvenile idiopathic arthritis (NHS England Commissioned) (December 2015)
  7. NICE TA455: Adalimumab, etanercept and ustekinumab for treating plaque psoriasis in children and young people (July 2017)
Golimumab
  • Injection 50mg prefilled pen or prefilled syringe

Notes

  1. NICE TA220: Psoriatic arthritis – golimumab (April 2011)
  2. NICE TA225: Rheumatoid arthritis (after the failure of previous anti-rheumatic drugs) – golimumab (partially updated by TA375) (June 2011)
  3. NICE TA233: Ankylosing spondylitis – golimumab (August 2011)
  4. NICE TA497: Golimumab is recommended for treating severe non-radiographic axial spondyloarthritis (January 2018)
Infliximab
  • 100mg powder for reconstitution for intravenous infusion

Notes

  1. Prescribe by brand. A biosimilar medicine is a biological medicine that is highly similar and clinically equivalent (in terms of quality, safety, and efficacy) to an existing biological medicine however they cannot be considered generic equivalents of the originator biological medicine. Because they are not identical, biological medicines must be prescribed by brand. The decision which brand to prescribe rests with the responsible clinician in consultation with the patient. Automatic substitution of brands at the point of dispensing is not appropriate for biological medicines.
  2. Once commenced on therapy, infliximab should be brand prescribed to ensure continuity of supply for patients.
  3. NICE TA195: Adalimumab, etanercept, infliximab, rituximab, and abatacept for the treatment of rheumatoid arthritis after the failure of a TNF inhibitor (August 2010)
  4. NICE TA199: Psoriatic arthritis - etanercept, infliximab and adalimumab (August 2010)
  5. NICE TA329: Infliximab, adalimumab and golimumab for treating moderately to severely active ulcerative colitis after the failure of conventional therapy (including a review of TA140 and TA262)
Sarilumab
  • Solution for injection 150mg/1.14ml, 200mg/1.14ml

Notes

  1. NICE TA485: Sarilumab for moderate to severe rheumatoid arthritis (November 2017)
Tocilizumab
  • Solution for injection pre-filled syringes 180mg in 1ml
  • Concentrate for solution for infusion 20mg in 1ml

Notes

  1. The commissioning of tocilizumab subcutaneous injection is accepted in Devon as an alternative treatment option to tocilizumab intravenous infusion for the treatment of rheumatoid arthritis where use is in line with NICE guidance for tocilizumab (NICE TA247 and NICE TA375) (see Commissioning Policy for more details)
  2. NICE TA238: Tocilizumab (RoActemra) is recommended for the treatment of systemic juvenile idiopathic arthritis in children and young people aged 2 years and older whose disease has responded inadequately to non-steroidal anti-inflammatory drugs (NSAIDs), systemic corticosteroids and methotrexate (December 2011)
  3. NICE TA247: Tocilizumab (RoActemra) in combination with methotrexate is recommended as an option for the treatment of rheumatoid arthritis in adults, only when the criteria of the NICE TA are met (February 2012)
  4. NICE TA373: Abatacept (Orencia), adalimumab ( Humira), etanercept (Enbrel) and tocilizumab (RoActemra) are recommended as options for treating polyarticular juvenile idiopathic arthritis (JIA), including polyarticular‑onset, polyarticular‑course and extended oligoarticular JIA (December 2015)
  5. NICE TA375: Adalimumab (Humira), etanercept ( Enbrel), infliximab (Remicade, Remsima, Inflectra), certolizumab pegol (Cimzia), golimumab ( Simponi), tocilizumab (RoActemra) and abatacept ( Orencia), all in combination with methotrexate, are recommended as options for treating rheumatoid arthritis, only when the criteria of the NICE TA are met (January 2016)
  6. NICE TA518: Tocilizumab (RoActemra) when used with a tapering course of glucocorticoids (and when used alone after glucocorticoids), is recommended as an option for treating giant cell arteritis in adults, only when the criteria of the NICE TA are met (April 2018)
  7. MHRA Drug Safety Update (July 2019): Tocilizumab (RoActemra): rare risk of serious liver injury including cases requiring transplantation
Ustekinumab
  • Solution for injection pre-filled syringes and vials 45mg in 0.5ml
  • Concentrate for solution for infusion vials 130mg in 26ml

Notes

  1. NICE TA180: Ustekinumab is recommended for the treatment of adults with moderate to severe psoriasis (September 2009)
  2. NICE TA340: Ustekinumab is recommended for treating active psoriatic arthritis (June 2015)
  3. NICE TA456: Ustekinumab for moderately to severely active Crohn's disease after previous treatment (July 2017)
  4. NICE TA455: Adalimumab, etanercept and ustekinumab for treating plaque psoriasis in children and young people (July 2017)

 

Home > Formulary > Chapters > 10. Musculoskeletal & joint diseases > 10.1 Drugs used in rheumatic diseases and gout > 10.1.3 Drugs that suppress the rheumatic disease process

 

  • First line
  • Second line
  • Specialist
  • Hospital