10.1.3 Drugs that suppress the rheumatic disease process

The following drugs are AMBER, i.e. may be prescribed by GPs under a shared care agreement. Shared care guidelines are available here

Azathioprine

Cyclophosphamide

Ciclosporin

Hydroxychloroquine

Leflunomide

Methotrexate

Mycophenolate

Penicillamine

Sodium aurothiomalate

Sulfasalazine

Prescribing Notes

  • Refer to the following websites for further information and guidelines: NICE Rheumatoid Arthritis Pathway and British Society for Rheumatology.
  • All patients with suspected inflammatory joint disease should be referred to a specialist as soon as possible to confirm diagnosis and evaluate disease activity; early initiation of DMARDs is recommended to control the signs and symptoms, and to limit joint damage. Refer to the rheumatology shared care guidelines.
  • Methotrexate tablets should be prescribed in 2.5mg strength only. The MHRA has received reports of prescription and dispensing errors for methotrexate that have resulted in serious and fatal adverse reactions. The prescribed dose for methotrexate in non-malignant conditions is usually once a week. Tablets should be taken together, at the same time of day. Prescribers must specify the day of the week on which the dose is to be taken, avoiding Monday – this is to avoid ‘Monday’ being misread as ‘morning’ on prescriptions. The 10mg strength should not be used since they may be confused with the 2.5mg tablets. For further information see MHRA, NPSA ‘Improving compliance with oral methotrexate’ guidelines and Northern Ireland ‘Policy for the safe use of oral methotrexate in secondary care’.
  • Providing monitoring procedure is followed, NSAIDs may be prescribed with methotrexate.
  • Folic acid 5mg should be prescribed weekly, one to two days after methotrexate to reduce toxicity.

Cytokine Modulators

  • Cytokine modulators (biologics) are not addressed in the NI Formulary. Patients who may require access to these drugs should be assessed in secondary care.
Specific commissioning arrangements are in place for biologics for the management of patients with Inflammatory Arthritis. Clinicians should consult their respective HSC Trusts for further guidance on approved commissioning arrangements.