Rheumatoid Arthritis
For older patients and other patients at high risk of gastro-intestinal adverse events, see prescribing notes. Consider the use of paracetamol prior to commencing an NSAID.
Initially 200-400mg 3-4 times a day; increased if necessary up to 600mg 4 times a day; maintenance 200-400mg 3 times a day, may be adequate.
Initially 200-400mg 3-4 times a day; increased if necessary up to 600mg 4 times a day; maintenance 200-400mg 3 times a day, may be adequate.
Initially 200-400mg 3-4 times a day; increased if necessary up to 600mg 4 times a day; maintenance 200-400mg 3 times a day, may be adequate.
Initially 200-400mg 3-4 times a day; increased if necessary up to 600mg 4 times a day; maintenance 200-400mg 3 times a day, may be adequate.
For older patients and other patients at high risk of gastro-intestinal adverse events, see prescribing notes.
Orally 75-150mg daily in 2-3 divided doses.
Orally 75-150mg daily in 2-3 divided doses.
Orally 75mg twice daily.
0.5-1g daily in 1-2 divided doses.
0.5-1g daily in 1-2 divided doses.
Prescribing Notes:
For older patients and other patients at high risk of gastro-intestinal adverse events:
- Prescribe a NSAID (as shown in this pathway) + omeprazole or lansoprazole (see ‘NSAID-associated ulcers and dyspepsia’ pathway in the Gastro-intestinal chapter of the formulary).
Additional prescribing notes:
- Patients that require NSAIDs should be prescribed them at the lowest effective dose and long term use should be avoided if possible.
- Diclofenac is contraindicated in those with ischaemic heart disease, peripheral arterial disease, cerebrovascular disease or established heart failure. The arterial thrombosis risk with diclofenac is similar to that of the COX-2 inhibitors.
- Low dose ibuprofen is considered to have the most favourable thrombotic cardiovascular safety profile.
- For patients with cardiovascular and cerebrovascular disease, current evidence suggests that the risk of heart failure is increased with all NSAIDs. The risk of myocardial infarction is also increased with most NSAIDs, with the possible exception of naproxen. The risk of stroke is increased with most NSAIDs with the possible exception of low dose (<200mg daily) celecoxib.
- Contra-indications to NSAIDs include proven hypersensitivity to aspirin or any NSAID, severe heart failure and active gastrointestinal bleeding. They should be used with caution in patients with mild-moderate heart failure, renal impairment and history of peptic ulceration.
- NSAIDs may worsen asthma; they are contra-indicated if aspirin or any other NSAID has precipitated attacks of asthma.
- Long-term use of high dose ibuprofen may interfere with the cardioprotective effects of low dose aspirin. Naproxen may be a suitable alternative.
- Patients at high risk of gastrointestinal (GI) adverse effects should be prescribed NSAID + PPI, see the ‘NSAID-associated ulcers and dyspepsia’ pathway in the Gastro-intestinal chapter of the formulary. Risk factors for GI adverse effects include previous peptic ulcer, previous GI bleed, alcohol excess, systemic corticosteroids, anticoagulants, SSRIs, age>65 years, high dose NSAIDs.
- Oral NSAIDs are excluded from the inpatient analgesic strategy for severe or distressing acute musculoskeletal pain in patients aged >65years. This is due to increased risk of serious GI toxicity and perforation, increased risks of renal impairment and increased cardiovascular risks. Topical NSAIDs may be appropriate, see the ‘Treatment of musculoskeletal pain’ pathway.
- Intramuscular or intravenous diclofenac must only be used for up to 2 days due to the risk of tissue necrosis: if necessary, treatment can be continued with tablets or suppositories.
- During long term use of NSAIDs ensure appropriate monitoring and regular re-evaluation of clinical need.
- Modified release preparations should not be prescribed as initial treatment but may be of benefit in patients with inflammatory arthritis who remain symptomatic on standard preparations e.g. the treatment of night-time pain or early morning stiffness.
- Patients should be advised against excessive exposure to sunlight of areas treated with topical NSAIDs in order to avoid the possibility of photosensitivity.
- If pain is the only symptom without signs of inflammation then consider non-drug treatments (TENS, acupuncture, physiotherapy) or an appropriate analgesic.
History Notes
18/05/2022
East Region Formulary content agreed.
Oral.
Dose as per specialist advice.
Dose as per specialist advice.
Dose as per specialist advice.
Intravenous injection.
Slow intravenous injection or infusion, initially 10-500mg.
Slow intravenous injection or infusion, initially 10-500mg.
Slow intravenous injection or infusion, initially 10-500mg.
Slow intravenous injection or infusion, initially 10-500mg.
Intramuscular depot injection.
Deep intramuscular injection, initially 40-120mg, then 40-120mg after 2-3 weeks if required, to be injected into the gluteal muscle.
Deep intramuscular injection, initially 40-120mg, then 40-120mg after 2-3 weeks if required, to be injected into the gluteal muscle.
Deep intramuscular injection, initially 40-120mg, then 40-120mg after 2-3 weeks if required, to be injected into the gluteal muscle.
Prescribing Notes:
- Corticosteroids should ideally only be commenced after liaison with a rheumatologist, and a steroid card given when appropriate.
- Patients should be provided with written information (e.g. the Versus Arthritis leaflet on steroids) and given the opportunity to discuss the benefits and risks of long-term corticosteroids before treatment is commenced.
- Prophylactic bone protection should be considered in patients anticipated to receive any dose of prednisolone daily for longer than 3 months. See 'Corticosteroid-induced osteoporosis (treatment and prevention)' pathway.
- Bone loss is related to the cumulative dose of glucocorticoids and preventative measures should therefore be considered in patients receiving >7.5mg daily for 3 months or longer, or intermittent courses of prednisolone resulting in a cumulative dose of 250mg or more in 3 months (or equivalent dose of other glucocorticoid).
- For patients with swallowing difficulties prednisolone oral solution or soluble tablets may be considered. Prednisolone tablets may be dispersed in water as an alternative to soluble tablets or oral solution preparations. This is an off-label use but more cost-effective option. Refer to local board policies on the use of unlicensed (and off-label) medicines for further guidance.
- Long-term steroids should be withdrawn gradually.
- Intra-articular steroids should be used judiciously and ideally any one joint should not be injected more than 3 times in 1 year.
- Intramuscular methylprednisolone 80-120mg can be given in the community as an interim measure in patients with a flare of rheumatoid arthritis.
History Notes
28/11/2024
Removal of 'Prednisolone 5mg soluble tablets' and updates to associated prescribing notes - ERFC Dec 2024.
18/05/2022
East Region Formulary content agreed.
Soft tissue injection.
Intrasynovial injection, 5-50mg, select dose according to size of patient and joint; where appropriate dose may be repeated at intervals of 21 days. No more than 3 joints should be treated on any one day, for details consult product literature.
Intra-articular injection (must only be administered by appropriately trained staff).
Intra-articular injection, 4-80mg, select dose according to size; where appropriate dose may be repeated at intervals of 7-35 days, for details consult product literature.
Intra-articular injection, 4-80mg, select dose according to size; where appropriate dose may be repeated at intervals of 7-35 days, for details consult product literature.
Intra-articular injection, 4-80mg, select dose according to size; where appropriate dose may be repeated at intervals of 7-35 days, for details consult product literature.
By intra-articular injection, 5-40mg adjusted according to size; max per dose 80mg.
By intra-articular injection, 2-20mg, adjusted according to size of joint, where appropriate, may be repeated at intervals of 3-4 weeks.
Prescribing Notes:
- Intra-articular steroids should be used judiciously and ideally any one joint should not be injected more than 3 times in 1 year.
- Intramuscular methylprednisolone 80-120mg can be given in the community as an interim measure in patients with a flare of rheumatoid arthritis.
- Hydrocortisone is the preferred agent for injections for structures lying superficially.
- In inflammatory conditions of the joints, particularly rheumatoid arthritis, an intra-articular injection of methylprednisolone or triamcinolone may be used to reduce pain and increase mobility.
History Notes
18/05/2022
East Region Formulary content agreed.
Initiated in consultation with a specialist. A combination of these drugs may be used as guided by specialists.
7.5mg once weekly, adjusted according to response; maximum 20mg per week.
Initially 7.5mg once weekly, then increased in steps of 2.5mg once weekly, adjusted according to response; maximum 25mg per week.
Initially 7.5mg once weekly, then increased in steps of 2.5mg once weekly, adjusted according to response; maximum 25mg per week.
Initially 7.5mg once weekly, then increased in steps of 2.5mg once weekly, adjusted according to response; maximum 25mg per week.
Initially 7.5mg once weekly, then increased in steps of 2.5mg once weekly, adjusted according to response; maximum 25mg per week.
Initially 7.5mg once weekly, then increased in steps of 2.5mg once weekly, adjusted according to response; maximum 25mg per week.
Initially 7.5mg once weekly, then increased in steps of 2.5mg once weekly, adjusted according to response; maximum 25mg per week.
Initially 7.5mg once weekly, then increased in steps of 2.5mg once weekly, adjusted according to response; maximum 25mg per week.
Initially 7.5mg once weekly, then increased in steps of 2.5mg once weekly, adjusted according to response; maximum 25mg per week.
Initiated in consultation with a specialist. A combination of these drugs may be used as guided by specialists.
200-400mg daily, daily maximum dose to be based on ideal body-weight; maximum 6.5 mg/kg per day.
200-400mg daily, daily maximum dose to be based on ideal body-weight; maximum 6.5 mg/kg per day.
Initially 100mg once daily for 3 days, then reduced to 10-20mg once daily.
Initially 100mg once daily for 3 days, then reduced to 10-20mg once daily.
Initially 500mg daily, increased in steps of 500mg every week, increased to 2-3g daily in divided doses.
Initially 500mg daily, increased in steps of 500mg every week, increased to 2-3g daily in divided doses.
Initiated in consultation with a specialist. A combination of these drugs may be used as guided by specialists.
Initially up to 2.5mg/kg daily in divided doses, adjusted according to response, rarely more than 3mg/kg daily; maintenance 1-3mg/kg daily, consider withdrawal if no improvement within 3 months.
Initially up to 2.5mg/kg daily in divided doses, adjusted according to response, rarely more than 3mg/kg daily; maintenance 1-3mg/kg daily, consider withdrawal if no improvement within 3 months.
Initially 1.5mg/kg twice daily, increased if necessary up to 2.5mg/kg twice daily after 6 weeks, dose increases should be made gradually, for maintenance treatment, titrate dose individually to the lowest effective dose according to tolerability, treatment may be required for up to 12 weeks.
Initially 1.5mg/kg twice daily, increased if necessary up to 2.5mg/kg twice daily after 6 weeks, dose increases should be made gradually, for maintenance treatment, titrate dose individually to the lowest effective dose according to tolerability, treatment may be required for up to 12 weeks.
Initially 1.5mg/kg twice daily, increased if necessary up to 2.5mg/kg twice daily after 6 weeks, dose increases should be made gradually, for maintenance treatment, titrate dose individually to the lowest effective dose according to tolerability, treatment may be required for up to 12 weeks.
Initially 1.5mg/kg twice daily, increased if necessary up to 2.5mg/kg twice daily after 6 weeks, dose increases should be made gradually, for maintenance treatment, titrate dose individually to the lowest effective dose according to tolerability, treatment may be required for up to 12 weeks.
Dose advised by specialists.
Dose advised by specialists.
Prescribing Notes:
- Risks/benefits of disease modifying antirheumatic drugs (DMARDs) should be discussed with patients before commencing using a written information sheet available from Versus Arthritis.
- DMARDs are appropriate for shared care arrangements to facilitate the seamless transfer of individual patient care from secondary care to general practice.
- The MHRA has received reports of prescription and dispensing errors for methotrexate that have resulted in serious and fatal adverse reactions. Methotrexate tablets should be prescribed in 2.5mg strength only. The 10mg strength should not be used since they may be confused with the 2.5mg tablets.
- Patients who have a partial response to or intolerance of oral methotrexate may be switched to subcutaneous methotrexate under the guidance of a rheumatologist.
- Providing monitoring procedure is followed, NSAIDs may be prescribed with methotrexate.
- Folic acid 5mg should be prescribed weekly, 24 hours after methotrexate to reduce toxicity. This can be increased to daily (apart from day of methotrexate) if side effects are troublesome.
- Ciclosporin should be prescribed by brand name as there are differences in the bioavailability between different brands.
- Early aggressive treatment with a combination of disease modifying agents can prevent progression of the disease.
- Patients who do not respond to at least 2 DMARDs at therapeutic doses, one of which should be methotrexate, within 6 months will be considered for biologic therapy.
- Disease-modifying anti-rheumatic drugs (DMARDs) can affect the progression of disease but may require 2-6 months of treatment for a full therapeutic response.
- The use of oral methotrexate for non-malignant conditions such as rheumatoid arthritis has been highlighted nationally as a potential risk for fatal medication errors. New measures have been implemented to prompt healthcare professionals to record the day of the week for intake and to remind patients of the dosing schedule and the risks of overdose due to continued reports of inadvertent overdose. For further advice see MHRA Drug Safety Update September 2020.
History Notes
18/05/2022
East Region Formulary content agreed.
40 mg every 2 weeks, then increased if necessary to 40 mg once weekly, alternatively 80 mg every 2 weeks, dose to be increased only in patients receiving adalimumab alone, review treatment if no response within 12 weeks.
40 mg every 2 weeks, then increased if necessary to 40 mg once weekly, alternatively 80 mg every 2 weeks, dose to be increased only in patients receiving adalimumab alone, review treatment if no response within 12 weeks.
40 mg every 2 weeks, then increased if necessary to 40 mg once weekly, alternatively 80 mg every 2 weeks, dose to be increased only in patients receiving adalimumab alone, review treatment if no response within 12 weeks.
40 mg every 2 weeks, then increased if necessary to 40 mg once weekly, alternatively 80 mg every 2 weeks, dose to be increased only in patients receiving adalimumab alone, review treatment if no response within 12 weeks.
40 mg every 2 weeks, then increased if necessary to 40 mg once weekly, alternatively 80 mg every 2 weeks, dose to be increased only in patients receiving adalimumab alone, review treatment if no response within 12 weeks.
40 mg every 2 weeks, then increased if necessary to 40 mg once weekly, alternatively 80 mg every 2 weeks, dose to be increased only in patients receiving adalimumab alone, review treatment if no response within 12 weeks.
40 mg every 2 weeks, then increased if necessary to 40 mg once weekly, alternatively 80 mg every 2 weeks, dose to be increased only in patients receiving adalimumab alone, review treatment if no response within 12 weeks.
40 mg every 2 weeks, then increased if necessary to 40 mg once weekly, alternatively 80 mg every 2 weeks, dose to be increased only in patients receiving adalimumab alone, review treatment if no response within 12 weeks.
40 mg every 2 weeks, then increased if necessary to 40 mg once weekly, alternatively 80 mg every 2 weeks, dose to be increased only in patients receiving adalimumab alone, review treatment if no response within 12 weeks.
50mg once weekly, review treatment if no response within 12 weeks of initial dose.
50mg once weekly, review treatment if no response within 12 weeks of initial dose.
200mg once daily, for dose adjustments consult product literature. For patients over 65 years, the recommended dose is 100mg once daily.
200mg once daily, for dose adjustments consult product literature. For patients over 65 years, the recommended dose is 100mg once daily.
For intravenous infusion; 1g, then 1g after 2 weeks, consult product literature for information on retreatment.
For intravenous infusion; 1g, then 1g after 2 weeks, consult product literature for information on retreatment.
8mg/kg body weight (BW), given once every four weeks (max. per dose 800mg) - consult product literature for dose adjustments.
8mg/kg body weight (BW), given once every four weeks (max. per dose 800mg) - consult product literature for dose adjustments.
8mg/kg body weight (BW), given once every four weeks (max. per dose 800mg) - consult product literature for dose adjustments.
162mg once weekly by subcutaneous injection - consult product literature for dose adjustments.
162mg once weekly by subcutaneous injection - consult product literature for dose adjustments.
4mg once daily. For patients over 65 years, the recommended dose is 2mg once daily - consult product literature of dose adjustments.
4mg once daily. For patients over 65 years, the recommended dose is 2mg once daily - consult product literature of dose adjustments.
Consult product literature for dosing information.
Consult product literature for dosing information.
Consult product literature for dosing information.
200mg every 2 weeks, for dose adjustments consult product literature.
200mg every 2 weeks, for dose adjustments consult product literature.
200mg every 2 weeks, for dose adjustments consult product literature.
15mg once daily.
50mg once a month for 3-4 doses, dose may be increased if inadequate response and body-weight above 100kg. For dose adjustments, consult product literature.
50mg once a month for 3-4 doses, dose may be increased if inadequate response and body-weight above 100kg. For dose adjustments, consult product literature.
3mg/kg given as an intravenous infusion followed by additional 3mg/kg infusion doses at 2 and 6 weeks after the first infusion, then every 8 weeks thereafter.
See product literature for subcutaneous loading doses and maintenance doses or if switching from intravenous loading doses of infliximab to subcutaneous doses.
Prescribing Notes:
- Biologic therapies or targeted synthetic DMARDs may be initiated by rheumatologists in patients who have not responded to conventional DMARDs in line with British Society for Rheumatology guidance and East Region Formulary Decisions i.e. locally approved health technology assessment approvals and restrictions in line with national guidance.
- All biosimilar medicines should be prescribed by brand name in line with national guidance for the use of biosimilar medicine.
- Monitoring guidance for individual agents can be found in the unit protocols and is included in patient correspondence.
- Discontinue baricitinib treatment permanently if clinical features of deep vein thrombosis or pulmonary embolism occur. Prescribers are reminded to use caution if using baricitinib in patients with risk factors for deep vein thrombosis or pulmonary embolism in addition to rheumatoid arthritis. For further advice see MHRA Drug Safety Update, March 2020.
- If the original form of biologic prescribed is not tolerated, consider switching biosimilar brand.
History Notes
06/02/2025
Addition of new amgevita formulations, ERWG Jan 24.
29/07/2024
Inclusion of Tocilizumab: Tyenne, and Infliximab: Remsima, updated prescribing information, ERWG July 24.
04/04/2023
Pathway title and prescribing notes updated, ERWG March 23.
18/05/2022
East Region Formulary content agreed.
Loading dose 400mg every 2 weeks for 3 doses, then maintenance 200mg every 2 weeks, alternatively maintenance 400mg every 4 weeks, review treatment if no response within 12 weeks.
Prescribing Notes:
- Biologics are reserved for specialist use for patients with severe rheumatoid arthritis, psoriatic arthritis and ankylosing spondylitis. These are available from rheumatology. There are other biologic medicines that can be used after third choice products.
- All biosimilar medicines should be prescribed by brand name in line with national guidance for the use of biosimilar medicine.
- Monitoring guidance for individual agents can be found in the unit protocols and is included in patient correspondence.
History Notes
18/05/2022
East Region Formulary content agreed.