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Nottinghamshire Area Prescribing Committee
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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
(Oral)
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First Choice
Green

Tablet, Suspension (100mg/5ml)

  • The MHRA advises that there is currently no strong evidence that ibuprofen can make coronavirus (COVID-19) worse. Patients who have confirmed COVID-19, or believe they have COVID-19, should take paracetamol in preference to ibuprofen. Those currently advised to use ibuprofen by their healthcare professional should not stop using them. See MHRA advice here.
  • Good first choice NSAID at doses up to 1200mg. If bigger doses are needed then naproxen is probably a better choice.
  • 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.
  • OTC
 
Naproxen
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First Choice
Green

Tablets, soluble tablets.

  • Good 2nd line choice after ibuprofen.
  • Usual dose: 250mg prn, max 5x a day (or 250-500mg bd)
  • May have a lower cardiovascular risk than other NSAIDs and COX2's. Good alternative if ibuprofen is not suitable.
  • EC tablets are more expensive (£20pm v £4). No trial has shown a difference in ulcer rate and there is minimal difference in tolerability [See trial data].
 
Celecoxib (Celebrex®)
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Formulary
Green
Cox-2 Inhibitor - osteoarthritis, rheumatoid arthritis Second line to patients unable to tolerate standard NSAID's.
 
Link  Link to reviews
   
Indometacin
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Formulary
Green

Tablet, Suppositories (100mg)

  • Option as a 3rd choice NSAID after ibuprofen and naproxen.
 
   
Nabumetone
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Formulary
Green
Tablet 
   
Diclofenac
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Restricted Drug Restricted
Green
  • Unless prescribed for agreed restricted patient groups (see below), tablets are non-formulary due to small cardiac risks with diclofenac. Ibuprofen (up to 1200mg/day) or naproxen should be considered instead. See links below.
  • Diclofenac suppositories are neither better tolerated nor more effective than oral NSAIDs
  • Suppositories available as: 12.5mg, 25mg, 50mg, 100mg. Avoid unless PR route is essential.
  • Injection 75mg in 3mL, (and Akis Injection 75mg/mL restricted at NUH for intra-operative analgesia)
  • Tablets 25mg, 50mg available for short term use in breastfeeding women (ibuprofen and diclofenac have the most reassurance of being ok in breastfeeding) and in renal colic.
  • NUH only: Tablets 25mg, 50mg available as a second line NSAID for paediatric patients.
  • Dispersible tablets now discontinued
 
Link  2018 (DTB): MI risk higher with diclofenac than naproxen (2018)
Link  2013 (MHRA): Contraindications and warnings due to CV risk
Link  2013 (MHRA): Patient information on CV risk
Link  2013 (UKMi): NSAID review - Naproxen or ibuprofen preferred
Link  NUH Medicines Matter Bulletin regarding diclofenac
Link  Relative strengths graph of analgesics
Link  SFH memo: Diclofenac vs naproxen
   
Flurbiprofen
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Restricted Drug Restricted
Amber 2

Tablet 50mg

  • May be used rarely by NUH ophthalmology consultants for ophthalmic scleritis if usual NSAIDs fail.
  • Costs £54pm for 100mg tds (Other NSAID costs here).
 
Link  Link to reviews
   
10.01.01  Expand sub section  Aspirin
 ....
 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
 
Azapropazone  (Rheumox®)

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Non Formulary
Red
Classified red for rheumatoid arthritis, ankylosing spondylitis and acute gout only when other NSAIDs have been tried and failed
 
Celecoxib  (Onsenal®)

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Non Formulary
Grey
Withdrawn from market August 2011
 
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
     
    Etodolac

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    Non Formulary
    Grey
  • Non formulary (grey) for new patients
  •  
    Etoricoxib

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    Non Formulary
    Grey
    Link  Link to reviews
    Link  MHRA Drug Safety Update (Oct 2016)
     
    Fenbufen

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    Non Formulary
    Grey
     
    Fenoprofen  (Fenopron®)

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    Non Formulary
    Grey
     
    Ibuprofen  (Brufen Retard®)

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    Non Formulary
    Grey
     
    Ibuprofen  (Nurofen® Joint & Muscular Pain Relief 200mg Medicated Plaster®)

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    Non Formulary
    Grey
    • Nurofen® Joint & Muscular Pain Relief 200mg Medicated Plaster 
    • OTC Patients should be advised to purchase over the counter
     
    Ibuprofen and famotidine  (Duexis®)

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    Non Formulary
    Grey
    Tablet
  • No formal submission
  •  
    Ketoprofen

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    Non Formulary
    Grey
     
    Ketoprofen  (Axorid®)

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    Non Formulary
    Grey
     
    Lumiracoxib  (Prexige®)

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    Non Formulary
    Grey
     
    Mefenamic Acid

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    Non Formulary
    Grey
    Link  Link to reviews
     
    Meloxicam

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    Non Formulary
    Grey
  • Non-formulary (grey) for new patients
  •  
    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
    Link  Link to reviews
     
    Naproxen with Misoprostol  (Napratec®)

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    Non Formulary
    Grey
     
    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

    Grey

    Grey / Non-Formulary: Medicines, which the Nottinghamshire APC has actively reviewed and does not recommend for use at present due to limited clinical and/or cost effective data.
    Grey / Non-Formulary (undergoing assessment): Work is ongoing and will be reviewed at a future APC meeting.
    Grey / Non-Formulary (no formal assessment): APC has not formally reviewed this medicine or indication because it had never been requested for formulary inclusion. Often used for drugs new to market.
      

    Red

    Medicines which should normally be prescribed by specialists only. eg hospital only.
    For patients already receiving prescriptions in primary care - continue. No new patients to receive prescriptions in primary care.
      

    Amber 1

    Medicines that should be initiated by a specialist and prescribed by primary care prescribers only under a shared care protocol, once the patient has been stabilised.
    Prior agreement must be obtained by the specialist from the primary care provider before prescribing responsibility is transferred. The shared care protocol must have been agreed by the relevant secondary care trust Drugs and Therapeutics Committee(s) (DTC) and approved by the Nottinghamshire APC.
      

    Amber 2

    Medicines suitable to be prescribed in primary care / general practice after specialist* recommendation or initiation.
    A supporting prescribing guideline may be requested which must have been agreed by the relevant secondary care trust DTCs and approved by the Nottinghamshire APC.
    *Specialist is defined by the APC as a clinician who has undertaken an appropriate formal qualification or recognised training programme within the described area of practice
      

    Amber 3

    Primary care/ non specialist may initiate as per APC guideline.
    The supporting prescribing guideline must have been agreed by the relevant secondary care trust D&TC(s) and approved by the Nottinghamshire APC.
      

    Green

    Medicines suitable for routine use within primary care.
    Can be initiated within primary care within their licensed indication, in accordance with nationally recognised formularies, for example the BNF, BNF for Children, Medicines for Children or Palliative Care Formulary. Primary care prescribers take full responsibility for prescribing.   

    OTC

      

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