Additional Notes – Chapter 10 BNF chapter 10 Musculoskeletal and joint diseases Section 10.1 Drugs used in rheumatic diseases and gout Subsection 10.1.1 Non-steroidal anti-inflammatory drugs Both NICE CG177 and CG79 recommend that when prescribing a NSAID it should be co-prescribed with a proton pump inhibitor (PPI), choosing the one with the lowest acquisition cost. Subsection 10.1.2 Corticosteroids Systemic corticosteroids The general actions, uses, and cautions of corticosteroids are described in BNF section 6.3. Corticosteroids can induce osteoporosis, and prophylaxis should be considered for patients on long-term treatment. Local corticosteroid injections Additional notes Corticosteroid injections are also injected into soft tissues for the treatment of skin lesions (see BNF section 13.4). Occasionally an acute inflammatory reaction develops after an intra-articular or soft-tissue injection of a corticosteroid. This may be a reaction to the microcrystalline suspension of the corticosteroid used, but must be distinguished from sepsis introduced into the injection site Hydrocortisone acetate or one of the synthetic analogues is generally used for local injection. Intra-articular corticosteroid injections can cause flushing and may affect the hyaline cartilage. Each joint should usually be treated no more than 4 times in one year. Consider referral for specialist opinion. Subsection 10.1.3 Drugs that suppress the rheumatic disease process DMARDS Additional notes Early combination treatment with DMARDs is recommended, using the DAS28 score for disease remission as evidenced by a score of less than 2.4 i.e.' Treat to Target ' recommendations apply. Folic acid is often given 2 to 3 days after methotrexate (minimum of 24 hours after methotrexate dose). The folic acid dose can be increased if necessary to reduce the side effects of methotrexate. Cytokine Modulators Additional notes None Subsection 10.1.4 Gout and cytotoxic induced hyperuricaemia Acute attack and Long-term control of gout Additional notes Allopurinol, febuxostat, and uricosurics are not effective in treating an acute attack and may prolong it indefinitely if started during the acute episode. (Extract from BSR Guideline for the Management of Gout) Affected joints should be rested and analgesic, anti-inflammatory drug therapy commenced immediately, and continued for 1–2 weeks. Fast-acting oral NSAIDs at maximum doses are the drugs of choice when there are no contraindications. In patients with increased risk of peptic ulcers, bleeds or perforations, coprescription of gastro-protective agents should follow standard guidelines for the use of NSAIDs and Coxibs. Colchicine can be an effective alternative but is slower to work than NSAIDs. In order to diminish the risks of adverse effects (especially diarrhoea) it should be used in doses of 500microgramms twice to four times a day. Allopurinol should not be commenced during an acute attack but in patients already established on allopurinol, it should be continued and the acute attack should be treated conventionally. Opiate analgesics can be used as adjuncts. Intra-articular corticosteroids are highly effective in acute gouty monoarthritis and i.a, oral, i.m or i.v corticosteroids can be effective in patients unable to tolerate NSAIDs, and in patients refractory to other treatments. If diuretc drugs are being used to treat hypertension, an alternative antihypertensive agent should be considered, but in patients with heart failure, diuretic therapy should not be discontinued. Subsection 10.1.5 Other drugs for rheumatic diseases Additional notes None Section 10.2 Drugs used in neuromuscular disorders Subsection 10.2.1 Drugs that enhance neuromuscular transmission Additional notes Pyridostigmine is less powerful and slower in action than neostigmine but it has a longer duration of action. It is preferable to neostigmine because of its smoother action and the need for less frequent dosage. Neostigmines pronounced muscarinic action is a disadvantage, and simultaneous administration of an antimuscarinic drug such as atropine or propantheline may be required to prevent colic, excessive salivation, or diarrhoea. Subsection 10.2.2 Skeletal muscle relaxants Additional Notes These drugs are used for the relief of chronic muscle spasm or spasticity associated with multiple sclerosis or other neurological damage; they are not indicated for spasm associated with minor injuries. Baclofen, diazepam, and tizanidine act principally on the central nervous system. Dantrolene has a peripheral site of action. Dantrolene acts directly on skeletal muscle and produces fewer central adverse effects making it a drug of choice. The dose should be increased slowly. Diazepam can also be used. Sedation and occasionally extensor hypotonus are disadvantages. Baclofen inhibits transmission at spinal level and also depresses the central nervous system. The dose should be increased slowly to avoid the major sideeffects of sedation and muscular hypotonia (other adverse events are uncommon). Tizanidine is an alpha2-adrenoceptor agonist indicated for spasticity associated with multiple sclerosis or spinal cord injury. Section 10.3 Drugs for the relief of soft-tissue inflammation Subsection 10.3.1 Enzymes Additional Notes: None Subsection 10.3.2 Rubefacients and other topical antirheumatics Rubefacients The evidence available does not support the use of topical rubefacients in acute or chronic musculoskeletal pain and thus they are not recommended within this formulary. If clinicians do decide to prescribe they should ensure they choose the cheapest product available. Topical NSAIDS Additional Notes: Topical NSAIDs may provide some relief of pain in musculoskeletal conditions; they can be considered as an adjunctive treatment in knee or hand osteoarthritis. Cautions must be observed - Apply with gentle massage only. Avoid contact with eyes, mucous membranes, and inflamed or broken skin; discontinue if rash develops. Hands should be washed immediately after use. Not for use with occlusive dressings. Topical application of large amounts can result in systemic effects including hypersensitivity and asthma (renal disease has also been reported). Not generally suitable for children. Patient packs carry a warning to avoid during pregnancy or breast-feeding. Patients should be advised against excessive exposure to sunlight of area treated in order to avoid possibility of photosensitivity; patients using preparations containing ketoprofen should be advised to avoid exposure to sunlight of the area treated, and for two weeks after stopping treatment. When prescribed the cheapest available product should be selected and prescribing should always be generic. Capsaicin Additional Notes: A preparation containing capsaicin 0.025% can be considered as an adjunct in hand or knee osteoarthritis. It may need to be used for 1–2 weeks before pain is relieved. A capsaicin 0.075% cream is licensed for the symptomatic relief of postherpetic neuralgia after lesions have healed, and for the relief of painful diabetic neuropathy. Cautions must be observed - Apply with gentle massage only. Avoid contact with eyes, mucous membranes, and inflamed or broken skin; discontinue if rash develops. Hands should be washed immediately after use. Not for use with occlusive dressings.