Additional Notes

Additional Notes – Chapter 10
Musculoskeletal and joint diseases
Drugs used in rheumatic diseases and gout
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.
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.
10.1.3 Drugs that suppress the rheumatic disease process
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
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.
10.1.5 Other drugs for rheumatic diseases
Additional notes
Drugs used in neuromuscular disorders
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
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
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
Tizanidine is an alpha2-adrenoceptor agonist indicated for spasticity associated
with multiple sclerosis or spinal cord injury.
Drugs for the relief of soft-tissue inflammation
10.3.1 Enzymes
Additional Notes:
10.3.2 Rubefacients and other topical antirheumatics
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
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.
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
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.