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 Formulary Chapter 10: Musculoskeletal and joint diseases - Full Chapter
10.02  Expand sub section  Drugs used in neuromuscular disorders
Mexiletine (Namuscla®)
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Red
High Cost Medicine
BlueTeq

  • Approved for the treatment of myotonia in patients with non-dystrophic myotonic disorders in line with NICE and NHSE commissioning policy (SSC2001). 


 

 
Link  NICE TA748: Mexiletine for treating the symptoms of myotonia in non-dystrophic myotonic disorders
 
Nusinersen (Spinraza®)
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Red
High Cost Medicine
  • 12mg solution for injection
  • Approved as an option for treating 5q spinal muscular atrophy (SMA) types 1, 2 or 3 in line with NICE.

 

 
Link  NHS England Urgent Clinical Commissioning Policy Statement (170018/P)
Link  NICE TA588: Nusinersen for treating spinal muscular atrophy
 
RisdiplamBlack Triangle (Evrysdi®)
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Red
  • 0.75mg/1ml oral solution
  • Approved for treating spinal muscular atrophy in line with NICE
  • To be provided by Newcastle Hospitals homecare service only 
 
Link  NICE TA755: Risdiplam for treating spinal muscular atrophy
 
VamoroloneBlack Triangle (Agamree®)
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Red
High Cost Medicine
NHS England
  • 40 mg/ml oral suspension
  • Approved for treating Duchenne muscular dystrophy in people 4 years and over in line with NICE
 
Link  NICE TA1031:Vamorolone for treating Duchenne muscular dystrophy in people 4 years and over
 
10.02.01  Expand sub section  Drugs used in neuromuscular disorders
Ataluren (Translarna®)
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Red
  • Approved as an option for treating Duchenne muscular dystrophy resulting from a nonsense mutation in the dystrophin gene in people 2 years and over who can walk - in line with NICE HST22.
 
Link  NICE HST22: Ataluren for treating Duchenne muscular dystrophy with a nonsense mutation in the dystrophin gene
 
10.02.01  Expand sub section  Anticholinesterases
Edrophonium Chloride
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Red 		 
 
Neostigmine
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Green plus
  • 2.5mg in 1ml injection
 
 
Pyridostigmine Bromide
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Green plus 		 
 
10.02.01  Expand sub section  Immunosuppressant therapy
10.02.01  Expand sub section  Acetylcholine-release enhancers to top
10.02.02  Expand sub section  Skeletal muscle relaxants
Baclofen
(Tablets, SF liquid & injection)
View adult BNF View SPC online View childrens BNF 		First Choice
Green
  • The following baclofen intrachecal injections (unlicensedunlicensed) are also approved; 36mg in 12ml, and 72mg in 12ml intrathecal injections.Red Traffic Light
 
 
Diazepam
(Tablets, solution, syrup, injection)
View adult BNF View SPC online View childrens BNF 		First Choice
Green
  • Note: diazepam 10mg tablets are no longer on the formulary. 
 
 
Controlled Drug Cannabis extract (Sativex®)
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Amber
  • cannabidiol 2.5mg/dronabinol 2.7mg per dose oromucosal spray
  • approved to treat moderate to severe spasticity in adults with multiple sclerosis in line with NICE Amber
 
Link  NENC Shared Care Protocol: Sativex (delta-9-tetrahydrocannabinol / cannabidiol) Oromucosal Spray
Link  NICE NG144: Cannabis-based medicinal products
 
Dantrolene
(Capsules)
View adult BNF View SPC online View childrens BNF 		Alternatives
Green 		 
 
Tizanidine
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Green plus
  • Approved for use on advice from neurologists when other treatments are unsuitable.
 
 
10.02.02  Expand sub section  Other muscle relaxants
10.02.02  Expand sub section  Nocturnal leg cramps
Quinine sulfate
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Green
  • 200mg & 300mg tablets
  • Approved for nocturnal leg cramps in accordance with MHRA advice
 
 
 ....
 Non Formulary Items
Ravulizumab  (Ultomiris®)

View adult BNF View SPC online View childrens BNF 		Non Formulary
Not Recomended
  • 300mg/30ml and 110mg/11ml concentrate for solution for infusion
  • Not recommended for treating generalised myasthenia gravis in adults in line with NICE
  • Not recommended for treating AQP4 antibody-positive neuromyelitis optica spectrum disorder in adults in line with NICE
Link  NICE TA940: Ravulizumab for treating generalised myasthenia gravis (terminated appraisal)
Link  NICE TA941: Ravulizumab for treating AQP4 antibody-positive neuromyelitis optica spectrum disorder (terminated appraisal)
Satralizumab  (Enspryng®)

View adult BNF View SPC online View childrens BNF 		Non Formulary
Not Recomended
  • Not recommended for preventing relapses in neuromyelitis optica spectrum disorder in line with NICE
Link  NICE TA960: Satralizumab for preventing relapses in neuromyelitis optica spectrum disorders
  
Key
Restricted Drug Restricted Drug
Unlicensed Drug Unlicensed
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 Link to adult BNF
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Cytotoxic Drug
 Cytotoxic Drug
CD
 Controlled Drug
High Cost Medicine
 High Cost Medicine
NHSE
 NHS England
Homecare
 Homecare
CCG
 ICB
Green Low Carbon

Low carbon footprint
Amber Medium Carbon

Medium carbon footprint
Red High carbon footprint

High carbon footprint
Status Description

Red

 Drugs for hospital use only. The responsibility for initiation and monitoring treatment should rest with an appropriate hospital clinician and the drug should be supplied through the hospital throughout the duration of treatment. In some very exceptional circumstances (e.g. due to distance from the hospital, storage, supply or mobility/transport problems) it may be appropriate for the GP to be asked to prescribe a Red drug. This should be negotiated on an individual patient basis and should only be done with the GP’s prior informed agreement where the roles of the GP and hospital services are clearly defined and agreed. The GP should not feel under pressure to prescribe in these circumstances. For all RED drugs automatically added to the formulary in response to a positive NICE TA: Prescribers need to ensure that local Trust new drug governance procedures and pharmacy processes are followed before any prescribing.   

Amber

 Drugs initiated by hospital specialist, but where continuing treatment by GPs may be appropriate under a shared care arrangement. These medicines are considered suitable for primary care prescribing following specialist initiation of therapy and stabilisation, with ongoing communication between the primary care prescriber and specialist as set out in the associated shared care guideline (SCG). Shared care should be initiated by the specialist, which includes consultant, suitably trained specialist non-medical prescriber or GPwER within a secondary, tertiary, or primary care clinic. The specialist should send the primary care prescriber a copy of the NENC Clinical Effectiveness and Governance (CEG) Subcommittee approved SCG to sign. The primary care prescriber should sign the SCG or indicate reasons why they are unable to accept the agreement and return a copy back to the specialist, as soon as possible. SCGs are available or are being developed for most of the drugs listed as AMBER.   

Green plus

 Drugs normally recommended or initiated by a hospital specialist who is a prescriber, a GP with an extended role [GPwER], or a specialist within primary care which can be safely maintained in primary care and monitored in primary care. In some cases, a further restriction for use may be defined. The primary care prescriber must be familiar with the drug to take on prescribing responsibility or must obtain the required information from the specialist. Therefore, provision of additional information, or an information leaflet, may be appropriate in some cases to facilitate continuing treatment by primary care prescriber or provide information re stopping criteria. These are considered suitable for primary care prescribing following specialist assessment and recommendation of therapy, with ongoing communication between the primary care prescriber and specialist, if necessary. In some case these drugs require specialist initiation and short to medium term monitoring of efficacy or toxicity until the patient’s dose is stable. Following specialist review the patient may be transferred to primary care for ongoing prescribing. Ongoing prescribing by primary care can include, if required, additional dose titrations and assessment of efficacy, with ongoing communication between the primary care prescriber and specialist, if necessary. If the drug requires urgent initiation, it is expected that the specialist undertakes the initial prescribing responsibility for an appropriate period of time, usually a minimum of 28 days. A GREEN+ drug can only be recommended to primary care for initiation if does not need to be initiated within 28 days.  

Green

 Medicines suitable for initiation, ongoing prescribing and discontinuation in all care settings, subject to appropriate communication between those responsible.  

Brown

 UNDER REVIEW: drugs whose current formulary status or RAG status is currently under review.  

Not Recomended

 Drugs that have been considered by the NENC Clinical Effectiveness and Governance (CEG) Subcommittee (or other approved body) and are not approved for prescribing within the North East and North Cumbria ICS. These may also include all medicines with a “not NHS” or “DLCV” classification in the BNF, those agents as included within the NICE “Do not do” list, and those agents included with the NHS England: Items which should not routinely be prescribed in primary care.  

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