Drugs That Suppress the Rheumatic Disease Process

NHSL Medicines Guidance
NHS Lanarkshire

General Notes

Please refer to NHS Lanarkshire Guidelines Prescribing Information for Disease-Modifying Anti-Rheumatic Drugs (DMARDs) for Healthcare Professionals on prescribing of these drugs.

FirstPort: Primary Care Support Services page (NHSL Staff Access Only) provides information on enhanced services for medicines monitoring in primary care.

Please refer to the EMC (Electronic Medicines Compendium) for associated risk minimisation materials e.g. patient alert cards.

Disease-Modifying Anti-Rheumatic Drugs (DMARDs)

Specialist initiation (S1)

AZATHIOPRINE

CICLOSPORIN (Neoral®)

  • Must be prescribed by brand name as bioavailability differs between brands.
  • Neoral® is the preferred brand in NHS Lanarkshire for rheumatologic indications.

HYDROXYCHLOROQUINE

LEFLUNOMIDE

METHOTREXATE 2.5mg tablets

  • METHOTREXATE should be taken as a single weekly dose taken on the same day each week. Only the 2.5mg tablets should be prescribed to avoid patient confusion.
  • Folic acid supplementation reduces the toxicity of METHOTREXATE. Folic acid supplementation should be avoided on the day of METHOTREXATE in case it adversely affects absorption.

METHOTREXATE (Metoject®) pre-filled pen

  • Metoject® is the preferred brand in NHS Lanarkshire for rheumatologic indications.

PENICILLAMINE

SULFASALAZINE enteric coated tablets

  • The enteric coated tablets are the only preparation licensed for use in rheumatologic indications.

 

Specialist use only (S2)

CYCLOPHOSPHAMIDE

Phosphodiesterase Type-4 Inhibitors

Specialist use only (S2)

APREMILAST (Otezla®)

  • Indication: Specialist use in adult patients with active psoriatic arthritis who have had an inadequate response with at least two prior DMARD therapies or who are intolerant to such therapies. Please refer to the SMC Advice: Apremilast (Otezla®) June 2015.

JAK Inhibitors

Specialist use only (S2)

BARICITINIB (Olumiant®)

  • Indication: Specialist use for rheumatoid arthritis in patients with severe disease (a disease activity score [DAS28] greater than 5.1) that has not responded to intensive therapy with a combination of conventional DMARDs. In patients with severe disease inadequately controlled by a tumour necrosis factor (TNF) antagonist, it may be used in patients ineligible to receive rituximab. Please refer to the SMC Advice: Baricitinib (Olumiant®) September 2017.

TOFACITINIB (Xeljanz®)

  • Indication: Specialist use for rheumatoid arthritis in patients with severe disease (a disease activity score [DAS28] greater than 5.1) that has not responded to intensive therapy with a combination of conventional DMARDs. In patients with severe disease inadequately controlled by a TNF antagonist, it may be used in patients ineligible to receive rituximab. Please refer to the SMC Advice: Tofacitinib Citrate (Xeljanz®) February 2018.
  • Indication: Specialist use for psoriatic arthritis in patients whose disease has not responded adequately to at least two conventional DMARDs, given either alone or in combination. Tofacitinib is only licensed for use in combination with methotrexate (MTX) for psoriatic arthritis. Please refer to the SMC Advice: Tofacitinib (Xeljanz®) January 2019.

UPADACITINIB (Rinvoq®)

  • Indication: Specialist use for the treatment of rheumatoid arthritis in adult patients with severe disease (a disease activity score [DAS28] greater than 5.1) that has not responded to intensive therapy with a combination of conventional DMARDs, and in patients with severe disease inadequately controlled by a TNF antagonist when rituximab is not appropriate. Upadacitinib may be used as monotherapy or in combination with methotrexate. Please refer to SMC Advice: Upadacitinib (Rinvoq®) February 2021.
  • Indication: Specialist use for the treatment of rheumatoid arthritis in adult patients with moderate disease (a disease activity score [DAS28] of 3.2 to 5.1) when intensive therapy with 2 or more conventional DMARDs has not controlled the disease well enough. Upadacitinib may be used as monotherapy or in combination with methotrexate. Please refer to SMC Advice: Upadacitinib (Rinvoq®) December 2022.
  • Indication: Specialist use for the treatment of active psoriatic arthritis in adult patients who have responded inadequately to, or who are intolerant to one or more DMARDs. UPADACITINIB may be used as monotherapy or in combination with methotrexate. Restricted to use in patients with psoriatic arthritis whose disease has not responded adequately to at least two conventional DMARDs, given either alone or in combination. Please refer to the SMC Advice: Upadacitinib (Rinvoq®) May 2021. 

FILGOTINIB (Jyseleca®)

  • Indication: Specialist use for the treatment of moderate to severe active rheumatoid arthritis in adult patients who have responded inadequately to, or who are intolerant to one or more disease-modifying anti-rheumatic drugs (DMARDs). Filgotinib may be used as monotherapy or in combination with methotrexate (MTX) in patients with severe disease (a disease activity score [DAS28] greater than 5.1) that has not responded to intensive therapy with a combination of conventional DMARDs and in patients with severe disease inadequately controlled by a TNF antagonist in whom rituximab is not appropriate. Please refer to the SMC Advice: Filgotinib (Jyseleca®) September 2021.

T-Cell Activation Inhibitors

Specialist use only (S2)

ABATACEPT (Orencia®)

Indication: Specialist use for rheumatoid arthritis, in line with the NICE Guidance [TA375, January 2016] / HIS: NICE (Multiple) Technology Appraisal Guidance No 375.

Tumour Necrosis Factor Alpha (TNF-α) Inhibitors

Specialist use only (S2)

ADALIMUMAB (Amgevita®)

CERTOLIZUMAB PEGOL (Cimzia®)

ETANERCEPT (Benepali®)

GOLIMUMAB (Simponi®)

INFLIXIMAB (Remsima®)

CD-20 Inhibitors

Specialist use only (S2)

RITUXIMAB (Truxima®)

  • Rituximab should be prescribed by brand name. Truxima® is the preferred biosimilar.
  • Indication: Specialist use for rheumatoid arthritis after the failure of a TNF inhibitor - NICE Guidance [TA195, August 2010].

Interleukin Inhibitors

Specialist use only (S2)

ANAKINRA (Kineret®)

  • Indication: Specialist use for the treatment of Still’s disease, as monotherapy or in combination with other anti-inflammatory drugs and disease-modifying anti-rheumatic drugs - SMC Advice: Anakinra (Kineret®) October 2018.

SARILUMAB (Kevzara®)

  • Indication: Specialist use for rheumatoid arthritis in patients with severe disease (a disease activity score [DAS28] greater than 5.1) that has not responded to intensive therapy with a combination of conventional DMARDs. In patients with severe disease inadequately controlled by a TNF antagonist, it may be used in patients ineligible to receive rituximab - SMC Advice: Sarilumab (Kevzara®) April 2018.

SECUKINUMAB (Cosentyx®)

  • Indication: Specialist use for the treatment of active and progressive psoriatic arthritis for patients with peripheral arthritis with three or more tender joints and three or more swollen joints, and the psoriatic arthritis has not responded to adequate trials of at least two standard DMARDs, administered either individually or in combination or the patient has had a TNF-alpha inhibitor but their disease has stopped responding after the first 12 weeks or TNF-alpha inhibitors are contraindicated but would otherwise be considered - NICE Guidance [TA445, May 2017] / HIS: NICE (Multiple) Technology Appraisal Guidance No 445.
  • Indication: Specialist use in treatment of active ankylosing spondylitis in adults who have responded inadequately to conventional therapy - SMC Advice: Secukinumab (Cosentyx®) July 2016.
  • Indication: Specialist use for treatment of active non-radiographic axial spondyloarthritis with objective signs of inflammation as indicated by elevated C-reactive protein and/or magnetic resonance imaging evidence in adults who have responded inadequately to NSAIDs - SMC Advice: Secukinumab (Cosentyx®) January 2021.

TOCILIZUMAB (RoActemra®)

IXEKIZUMAB (Taltz®)

  • Indication: Specialist use for active psoriatic arthritis, in patients whose disease has not responded adequately to at least two conventional DMARDs given either alone or in combination, and who have had an inadequate response to a TNF inhibitor - SMC Advice: Ixekizumab (Taltz®) October 2018.

USTEKINUMAB (Stelara®)

  • Indication: Specialist use in patients with active psoriatic arthritis, alone or in combination with methotrexate, when the response to previous non-biological disease-modifying anti-rheumatic drug therapy has been inadequate, who have failed on, or are unsuitable for, treatment with an anti-TNF drug - SMC Advice: Ustekinumab (Stelara®) March 2015.

GUSELKUMAB (Tremfya®)

  • Indication: Specialist use, alone or in combination with methotrexate (MTX) for the treatment of active psoriatic arthritis in adult patients who have had an inadequate response or who have been intolerant to a prior disease-modifying antirheumatic drug (DMARD) therapy.

    Restricted to use in:

    (i) patients whose disease has not responded adequately or who have been intolerant to two previous conventional disease-modifying antirheumatic drug (DMARD) therapies but have not received biologic DMARD therapy (biologic-naïve population);

    (ii) patients whose disease has not responded adequately to conventional DMARDs and one or more tumour necrosis factor (TNF) inhibitors (biologic-experienced population);

    and (iii) patients in whom TNF inhibitors are contraindicated or not tolerated. [SMC Advice: Guselkumab (Tremfya® )August 2021]. 

NHSL Joint Adult Formulary Key

To indicate the category of a formulary medicine, updated sections adopt the following key:

Preferred list (P): First-line formulary choices.

Total list (T): Alternative choices when preferred list options not effective/not tolerated, or not indicated.

Specialist initiation (S1): Specialist initiation, or on the advice of a Consultant or Specialist Practitioner in this therapeutic area. Continuation in primary care is acceptable.

Specialist use only (S2): Supply via hospital, Homecare Service or a hospital based prescription (HBP) for dispensing by community pharmacy. Not prescribed in primary care setting.

Editorial Information

Last reviewed: 31/01/2022

Next review date: 31/01/2025

Author(s): NHSL.

Version: Please refer to the introduction section for an explanation of the review dates above.

Approved By: ADTC

Reviewer name(s): ADTC.