NICE NG100: Rheumatoid arthritis in adults: management
The County Durham & Darlington or Tees DO NOT PRESCRIBE List can be accessed online at: http://medicines.necsu.nhs.uk/guidelines/durhamdarlington or
https://medicines.necsu.nhs.uk/guidelines/tees-guidelines/
The County Durham & Darlington or Tees GREY List – items to be prescribed in certain specific circumstances only can be accessed online at: http://medicines.necsu.nhs.uk/guidelines/durham-darlington or https://medicines.necsu.nhs.uk/guidelines/tees-guidelines/
CD&D Patient Decision Aids Resource available at: http://medicines.necsu.nhs.uk/guidelines/durham-darlington/
NHS England Guidance on “Conditions for which over the counter items should not routinely be prescribed” available at: https://www.england.nhs.uk/medicines/conditions-for-which-over-the-counter-items-should-not-routinely-be-prescribed/
Prescribing of medicines available to purchase over the counter for self-care
NSAIDs and cardiovascular events
All NSAID use (including cyclo-oxygenase-2 selective inhibitors) can, to varying degrees, be associated with a small increased risk of thrombotic events (e.g. myocardial infarction and stroke) independent of baseline cardiovascular risk factors or duration of NSAID use; however, the greatest risk may be in those receiving high doses long term. Cyclo-oxygenase-2 selective inhibitors , diclofenac (150 mg daily) and ibuprofen (2.4 g daily) are associated with an increased risk of thrombotic events. The increased risk for diclofenac is similar to that of licensed doses of etoricoxib . Naproxen (1 g daily) is associated with a lower thrombotic risk, and low doses of ibuprofen (1.2 g daily or less) have not been associated with an increased risk of myocardial infarction.
The lowest effective dose of NSAID should be prescribed for the shortest period of time to control symptoms and the need for long-term treatment should be reviewed
periodically. (from BNF 66.)
The following NSAIDs should be the preferred choices for those starting treatement. Existing patients on alternate NSAIDs should be reviewed as appropriate, but can remain on a non-formulary NSAID if deemed appropriate.
Preferred Drugs
Long Term use: Ibuprofen low dose – First line treatment
Naproxen low dose – Second line treatment
Naproxen high dose – Third line treatment
CD&D APC Grey List: Short courses of analgesics for acute common ailments can be purchased by
the patient under self-care with community pharmacist support. Continue to prescribe for children and when required for chronic conditions although patients should be reminded that these medications are also available to purchase. Prescribing short courses of pain relief for acute conditions costs the NHS more than the equivalent products purchased over the counter (prescription fees, GP consultation time
etc.)
200mgOTC, 400mgOTC & 600mg tablets
100mg in 5ml sugar-free suspensionOTC
MHRA Drug Safety Update (June 2015): High-dose ibuprofen (≥2400mg/day): small increase in cardiovascular risk.
25mg & 50mg capsules; 75mg m/r capsules
25mg in 5ml suspension; 100mg suppositories
The County Durham & Darlington or Tees DO NOT PRESCRIBE List can be accessed online at: http://medicines.necsu.nhs.uk/guidelines/durhamdarlington or
https://medicines.necsu.nhs.uk/guidelines/tees-guidelines/
The County Durham & Darlington or Tees GREY List – items to be prescribed in certain specific circumstances only can be accessed online at: http://medicines.necsu.nhs.uk/guidelines/durham-darlington or https://medicines.necsu.nhs.uk/guidelines/tees-guidelines/
The County Durham & Darlington or Tees DO NOT PRESCRIBE List can be accessed online at: http://medicines.necsu.nhs.uk/guidelines/durhamdarlington or
https://medicines.necsu.nhs.uk/guidelines/tees-guidelines/
The County Durham & Darlington or Tees GREY List – items to be prescribed in certain specific circumstances only can be accessed online at: http://medicines.necsu.nhs.uk/guidelines/durham-darlington or https://medicines.necsu.nhs.uk/guidelines/tees-guidelines/
See section 6.3
1ml injection - methylprednisolone acet. 40mg + lidocaine 1%
2ml injection - methylprednisolone acet. 80mg + lidocaine 1%
40mg in 1ml & 80mg in 2ml intramuscular/ intra-articular injections
10mg in 1ml & 50mg in 5ml intradermal/intra-articular injections
Shared care guidelines for DMARDs can be found here:
Area Prescribing Committee website
25mg & 50mg tablets;
50mg in 5ml suspension
For non Cancer indications
Shared care guidelines for DMARDs can be found here:
10mg, 25mg, 50mg & 100mg capsules
Prescribe by brand name to ensure continuity
Shared care guidelines for DMARDs can be found here:
Tablets - 200mg
Shared care guidelines for DMARDs can be found here:
Tablets - 10mg, 20mg, 100mg
Shared care guidelines for DMARDs can be found here:
Tablets - 2.5mg
Injection – for non cancer indications
Shared care guidelines for DMARDs can be found here:
Area Prescribing Committee website
Methotrexate Subcutaneous = RED drug in Tees
250mg capsules; 500mg tablets
Shared care guidelines for DMARDs can be found here:
Area Prescribing Committee website
MHRA Drug Safety Update (Jan 2015): Mycophenolate mofetil (CellCept) and mycophenolic acid: risk of hypogammaglobulinaemia and risk of bronchiectasis
MHRA Drug Safety Update (Dec 2015): Mycophenolate mofetil, mycophenolic acid: new pregnancy-prevention advice for women and men
MHRA Drug Safety Update (Feb 2018): Mycophenolate mofetil, mycophenolic acid: updated contraception advice for male patients
Tablets - 125mg, 250mg
Shared care guidelines for DMARDs can be found here:
500mg e/c tablets
Shared care guidelines for DMARDs can be found here: APC Website CDDFT Intranet
MHRA Drug Safety Update (April 2014): Tumour necrosis factor alpha inhibitors ): risk of tuberculosis—screen all patients before starting treatment and monitor them closel.
NTAG September 2015: The Northern (NHS) Treatment Advisory Group recommends that the sequential use of TNF inhibitors can be considered in the case of failure due to inefficacy or adverse effects (AEs) and if the patient still has
active disease. Sequential use must be assessed and reviewed by a multidisciplinary team within the Trust and patients must continue to fulfil the NICE ‘start-stop’ criteria when prescribing a TNF inhibitor for psoriatic arthritis.
250mg injection
125mg injection (prefilled syringe)
Commissioner: CCGs – Adults
Commissioner: NHS England – Paediatrics Only
Drug protocol: abatacept (CDDFT intranet access only)
Approved for use in accordance with the following NICE TAs:
Not approved in accordance with the following NICE TAs:
40mg injection (prefilled syringe)
Commissioner: CCGs – Adults NICE TA199, NICE TA187, NICE TA195, NICE TA383, NICE TA130 NICE TA375
Commissioner: NHS England – Paediatrics Only NICE TA130, NICE TA143, NICE TA199, NICE TA187, NICE TA146, NICE TA373
NHS England: Not routinely commissioned - Uveitis in Paediatric
100mg injection (prefilled syringe)
The APC approved anakinra for acute refractory or difficult gout requiring hospitalisation. It was noted this is an UNLICENSED INDICATION, supported by the APC.
NHS England: Not routinely commissioned - Adult indications - Paediatric indications
NHS England - Cryopyrin Associated Periodic Syndrome – only via specialised services commissioned by NHS England.
10mg, 20mg and 30mg tablets
MHRA Drug Safety Update (Jan 2017): Apremilast (Otezla ▼): risk of suicidal thoughts and behaviour
Apremilast for treating active psoriatic arthritis (NICE TA433)
2mg and 4mg tablets
Baricitinib for moderate to severe rheumatoid arthritis - See NICE TA466
MHRA Drug Safety Update (Mar 2020): Baricitinib (Olumiant▼): risk of venous thromboembolism
120mg and 400mg IV infusion
Belimumab for treating active autoantibody-positive systemic lupus erythematosus see NICE TA397
MHRA Drug Safety Update (April 2019: Belimumab (Benlysta▼): increased risk of serious psychiatric events seen in clinical trials
Each pre-filled syringe contains 200 mg certolizumab pegol in one ml
NHS England – Not routinely commissioned - Paediatric indications
NTAG September 2015: The Northern (NHS) Treatment Advisory Group recommends the use of certolizumab pegol as an option in those patients who fulfil NICE criteria for use of TNF Inhibitor therapy in psoriatic arthritis.
However other more established, NICE approved treatment options would remain first line choices in this patient group.
Commissioner: CCGs – Adults NICE TA375 NICE TA415 NICE TA445
10mg (Enbrel®), 25mg injection (Enbrel® & Benapali®▼)
Commissioner: NHS England – Paediatrics Only NICE TA199, NICE TA383, NICE TA130, NICE TA103, NICE TA373
Commissioner: NHS England – Juvenile arthritis - NICE TA35
Commissioner: CCGs – Adults NICE TA199, NICE TA143, NICE TA130, NICE TA375, NICE TA195
Tertiary Centre Only: NICE TA35
NTAG April 2016: The Northern (NHS) Treatment Advisory Group recommends the use of etanercept biosimilar Benepali® as an option for use in adults where the originator product (Enbrel®) would normally be prescribed.
50mg injection (prefilled pen & syringe)
Commissioner: CCGs - Adults NICE TA233, NICE TA225, NICE TA220 NICE TA375, NICE TA497
Commissioner: NHS England – Paediatrics Only - NICE TA220, NICE TA383
100mg injection (Remicade® , Inflectra®▼ & Remsima®▼)
Commissioner: CCGs – Adults NICE TA199, NICE TA187, NICE TA143, NICE TA130 NICE TA375, NICE TA195
Commissioner: NHS England – Paediatrics Only NICE TA130, NICE TA134, NICE TA140, NICE TA383, NICE TA163, NICE TA199
Commissioner: NHS England – Crohn’s disease in children - NICE TA187
NHS England: Not routinely commissioned for - Connective tissue disease-interstital lung disease – Renal - Sarcoidosis - Uveitis in Paediatric
Drug protocol: infliximab – rheumatology (CDDFT intranet access only)
NTAG September 2015: The Northern (NHS) Treatment Advisory Group recommends the use of infliximab biosimilars as an option where the originator product (Remicade®) would normally be prescribed.
80mg/ml pre-filled syringe or pen
Approved for use in accordance with the following NICE TAs:
100mg in 10ml & 500mg in 50ml concentrate for IV infusion
Commissioner: NHS England – Paediatrics Only - TA195, NHS England Policy
Commissioner: NHS England – ANCA-positive vasculitis - Policy - A13/P/a
Commissioner: NHS England – SLE - Policy - A13/PS/a
NHS England: Not routinely commissioned for - Connective tissue disease–interstitial lung disease - Haemophilia – Nephritis
NTAG recommendation: Recommends rituximab in combination with methotrexate
as first-line biological therapy in cases where there is an absolute contraindication to tumour necrosis factor inhibitor
NTAG June 2017: The Northern (NHS) Treatment Advisory Group recommends the use of
rituximab biosimilars as an option for use in adults where the originator
product (MabThera®) would normally be prescribed.
Drug protocol: rituximab – rheumatology (CDDFT intranet access only)
150mg pre-filled syringe or pen
200mg pre-filled syringe or pen
Commissioner: CCG - NICE TA485
150mg/ml injection
Secukinumab is recommended, within its marketing authorisation, as an option for treating active ankylosing spondylitis in adults whose disease has responded inadequately to conventional therapy (non-steroidal anti-inflammatory drugs or TNF‑alpha inhibitors). NICE TA407
For treating active psoriatic arthritis after inadequate response to DMARDs – see NICE TA445
80mg in 4ml, 200mg in 10ml & 400mg in 20ml concentrate for IV infusion
162 mg solution for injection in pre-filled syringe or pre-filled pen for subcutaneous injection.
Tertiary Centre Only: NICE TA247, NICE TA238, NICE TA518
Commissioner: NHS England – Paediatrics Only - NICE TA247
Commissioner: NHS England – Juvenile arthritis - NICE TA238, NICE TA373
Commissioner: CCGs – Adults NICE TA375
NTAG recommendation: Recommended as an alternative treatment to anakinra for systemic onset juvenile idiopathic arthritis. Not recommended for polyarticular juvenile idiopathic arthritis. (Tertiary centres)
162mg SC injection is approved:
Drug protocol: tocilizumab – rheumatology (CDDFT intranet access only)
MHRA Drug Safety Update (July 2019): Tocilizumab (RoActemra): rare risk of serious liver injury including cases requiring transplantation
5mg tablets
Commissioner CCGs - adults
Approved for use in accordance with the following NICE TAs:
MHRA Drug Safety Update (May 2019): Tofacitinib (Xeljanz▼): restriction of 10 mg twice-daily dose in patients at high risk of pulmonary embolism while safety review is ongoing
MHRA Drug Safety Update (Mar 2020): Tofacitinib (Xeljanz▼): new measures to minimise risk of venous thromboembolism and of serious and fatal infections
45mg vial
Ustekinumab (Stelara®) is recommended as a possible treatment, alone or with a drug called methotrexate, for adults with active psoriatic arthritis when treatment with non-biological disease-modifying antirheumatic drugs (or DMARDS) has not worked well enough if:
•treatment with tumour necrosis factor (TNF) alpha inhibitors is not suitable for them, or
•the person has had a TNF alpha inhibitor before.
Acute Attacks
NSAIDs
– see section 10.1.1
Colchicine
Long-term Control of Gout
First Choice = Allopurinol
Alternatives =
Febuxostat
For use in accordance with NICE guidance in patients where allopurinol is not tolerated or contraindicated (SPC)
NICE TA164
Hyperuricaemia Associated with Cytotoxic Drugs
First Choice =
Allopurinol
Alternative =
• Rasburicase
Prophylactic use in high risk patients only
Commissioner: NHS England
Tablets - 100mg, 300mg
Serious interaction with azathiopurine concurrent use should be avoided
Tablets - 500microgram
6mg course length when used in acute gout
Longterm low dose only on rheumatology advice
Tablets - 80mg , 120mg
For use in accordance with NICE guidance in patients where allopurinol is not tolerated or contraindicated (SPC)
Approved for use in accordance with the following NICE TAs:
MHRA Drug Safety Update (July 2019): Febuxostat (Adenuric): increased risk of cardiovascular death and all-cause mortality in clinical trial in patients with a history of major cardiovascular disease
NICE TA506 - Lesinurad for treating chronic hyperuricaemia in people with gout.
NICE did not recommend
1.5mg & 7.5mg vials
Prophylactic use for hyperuricaemia associated with cytotoxic drugs in high risk patients only.
Commissioning: NHS England - Tertiary Centres only
TA508 - Autologous chondrocyte implantation using chondrosphere for treating symptomatic articular cartilage defects of the knee
The County Durham & Darlington or Tees DO NOT PRESCRIBE List can be accessed online at: http://medicines.necsu.nhs.uk/guidelines/durhamdarlington or
https://medicines.necsu.nhs.uk/guidelines/tees-guidelines/
The County Durham & Darlington or Tees GREY List – items to be prescribed in certain specific circumstances only can be accessed online at: http://medicines.necsu.nhs.uk/guidelines/durham-darlington or https://medicines.necsu.nhs.uk/guidelines/tees-guidelines/
Anticholinesterases
Edrophonium
Neostigmine
Pyridostigmine
LEMS
Amifampridine Phosphate ▼
Commissioner: NHS England – not routinely commissioned see Policy - D04/PS/a
Multiple Sclerosis
Fampridine ▼
Commissioner: NHS England - not routinely commissioned see Policy - D04/PS/d
60mg tablets & 60mg/5ml suspension
Initiated by neurology only
Tablets can be halved
See section 4.1.2
N.B. Diazepam 10mg tablets are no longer included in the formulary
Short courses only
Tablets - 2mg
For use on advice from neurologists when other treatments are unsuitable.
Oromucosal Spray.
Each single 100 microlitre spray contains: 2.7 mg delta-9-tetrahydrocannabinol (THC) and 2.5 mg cannabidiol (CBD) from Cannabis sativa L.
Cannabis-based medicinal products NICE guideline [NG144] Published date: November 2019 – change in NICE recommending use for spasticity in MS
NICE have recommended that use in MS related spasticity will be initiated by specialists but may be transferred to primary care for prescribing under a shared care agreement.
Interim position should be that Sativex® for spasticity in MS is RED until shared care in place as per current North of Tyne APC position.
Ataluren approved in line with NICE recommendation https://www.nice.org.uk/guidance/hst3
Injection
Commissioner: NHS England
Approved for use in accordance with the following NICE TAs:
Topical rubefacient preparations may contain nicotinate and salicylic acid compounds, essential oils, capsicum, and camphor which are all irritant
The evidence available does not support the use of topical rubefacients in acute or chronic musculoskeletal pain. Rubefacients should not be offered to treat osteoarthritis. Stop any prescribing.
NICE states that capsaicin patches should not be used for neuropathic pain in non-specialist settings, unless advised by a specialist.
PrescQIPP briefing 114: Rubefacients
The County Durham & Darlington or Tees DO NOT PRESCRIBE List can be accessed online at: http://medicines.necsu.nhs.uk/guidelines/durhamdarlington or
https://medicines.necsu.nhs.uk/guidelines/tees-guidelines/
The County Durham & Darlington or Tees GREY List – items to be prescribed in certain specific circumstances only can be accessed online at: http://medicines.necsu.nhs.uk/guidelines/durham-darlington or https://medicines.necsu.nhs.uk/guidelines/tees-guidelines/
Gel - 5%OTC
Algesal may be considered as an alternative product that may be purchased in the community cheaper than topical NSAIDs.
0.075% cream
For use with specialist advice in post-herpetic neuralgia & severe neuropathic pain mainly in diabetes patients.
0.025% cream
For symptomatic relief in osteoarthritis.
Topical rubefacient preparations may contain nicotinate and salicylic acid compounds, essential oils, capsicum, and camphor which are all irritant.
The evidence available does not support the use of topical rubefacients in acute or chronic musculoskeletal pain. Rubefacients should not be offered to treat osteoarthritis. Stop any prescribing.
The County Durham & Darlington or Tees DO NOT PRESCRIBE List can be accessed online at: http://medicines.necsu.nhs.uk/guidelines/durhamdarlington or
https://medicines.necsu.nhs.uk/guidelines/tees-guidelines/
The County Durham & Darlington or Tees GREY List – items to be prescribed in certain specific circumstances only can be accessed online at: http://medicines.necsu.nhs.uk/guidelines/durham-darlington or https://medicines.necsu.nhs.uk/guidelines/tees-guidelines/
Topical rubefacient preparations may contain nicotinate and salicylic acid compounds, essential oils, capsicum, and camphor which are all irritant.
The evidence available does not support the use of topical rubefacients in acute or chronic musculoskeletal pain. Rubefacients should not be offered to treat osteoarthritis. Stop any prescribing.
The County Durham & Darlington or Tees DO NOT PRESCRIBE List can be accessed online at: http://medicines.necsu.nhs.uk/guidelines/durhamdarlington or
https://medicines.necsu.nhs.uk/guidelines/tees-guidelines/
The County Durham & Darlington or Tees GREY List – items to be prescribed in certain specific circumstances only can be accessed online at: http://medicines.necsu.nhs.uk/guidelines/durham-darlington or https://medicines.necsu.nhs.uk/guidelines/tees-guidelines/
Topical rubefacient preparations may contain nicotinate and salicylic acid compounds, essential oils, capsicum, and camphor which are all irritant.
The evidence available does not support the use of topical rubefacients in acute or chronic musculoskeletal pain. Rubefacients should not be offered to treat osteoarthritis. Stop any prescribing.
The County Durham & Darlington or Tees DO NOT PRESCRIBE List can be accessed online at: http://medicines.necsu.nhs.uk/guidelines/durhamdarlington or
https://medicines.necsu.nhs.uk/guidelines/tees-guidelines/
The County Durham & Darlington or Tees GREY List – items to be prescribed in certain specific circumstances only can be accessed online at: http://medicines.necsu.nhs.uk/guidelines/durham-darlington or https://medicines.necsu.nhs.uk/guidelines/tees-guidelines/
Topical rubefacient preparations may contain nicotinate and salicylic acid compounds, essential oils, capsicum, and camphor which are all irritant.
The evidence available does not support the use of topical rubefacients in acute or chronic musculoskeletal pain. Rubefacients should not be offered to treat osteoarthritis. Stop any prescribing.
The County Durham & Darlington or Tees DO NOT PRESCRIBE List can be accessed online at: http://medicines.necsu.nhs.uk/guidelines/durhamdarlington or
https://medicines.necsu.nhs.uk/guidelines/tees-guidelines/
The County Durham & Darlington or Tees GREY List – items to be prescribed in certain specific circumstances only can be accessed online at: http://medicines.necsu.nhs.uk/guidelines/durham-darlington or https://medicines.necsu.nhs.uk/guidelines/tees-guidelines/
Topical rubefacient preparations may contain nicotinate and salicylic acid compounds, essential oils, capsicum, and camphor which are all irritant.
The evidence available does not support the use of topical rubefacients in acute or chronic musculoskeletal pain. Rubefacients should not be offered to treat osteoarthritis. Stop any prescribing.
The County Durham & Darlington or Tees DO NOT PRESCRIBE List can be accessed online at: http://medicines.necsu.nhs.uk/guidelines/durhamdarlington or
https://medicines.necsu.nhs.uk/guidelines/tees-guidelines/
The County Durham & Darlington or Tees GREY List – items to be prescribed in certain specific circumstances only can be accessed online at: http://medicines.necsu.nhs.uk/guidelines/durham-darlington or https://medicines.necsu.nhs.uk/guidelines/tees-guidelines/
Topical rubefacient preparations may contain nicotinate and salicylic acid compounds, essential oils, capsicum, and camphor which are all irritant.
The evidence available does not support the use of topical rubefacients in acute or chronic musculoskeletal pain. Rubefacients should not be offered to treat osteoarthritis. Stop any prescribing.
The County Durham & Darlington or Tees DO NOT PRESCRIBE List can be accessed online at: http://medicines.necsu.nhs.uk/guidelines/durhamdarlington or
https://medicines.necsu.nhs.uk/guidelines/tees-guidelines/
The County Durham & Darlington or Tees GREY List – items to be prescribed in certain specific circumstances only can be accessed online at: http://medicines.necsu.nhs.uk/guidelines/durham-darlington or https://medicines.necsu.nhs.uk/guidelines/tees-guidelines/
Topical rubefacient preparations may contain nicotinate and salicylic acid compounds, essential oils, capsicum, and camphor which are all irritant.
The evidence available does not support the use of topical rubefacients in acute or chronic musculoskeletal pain. Rubefacients should not be offered to treat osteoarthritis. Stop any prescribing.
The County Durham & Darlington or Tees DO NOT PRESCRIBE List can be accessed online at: http://medicines.necsu.nhs.uk/guidelines/durhamdarlington or
https://medicines.necsu.nhs.uk/guidelines/tees-guidelines/
The County Durham & Darlington or Tees GREY List – items to be prescribed in certain specific circumstances only can be accessed online at: http://medicines.necsu.nhs.uk/guidelines/durham-darlington or https://medicines.necsu.nhs.uk/guidelines/tees-guidelines/
Topical rubefacient preparations may contain nicotinate and salicylic acid compounds, essential oils, capsicum, and camphor which are all irritant.
The evidence available does not support the use of topical rubefacients in acute or chronic musculoskeletal pain. Rubefacients should not be offered to treat osteoarthritis. Stop any prescribing.
The County Durham & Darlington or Tees DO NOT PRESCRIBE List can be accessed online at: http://medicines.necsu.nhs.uk/guidelines/durhamdarlington or
https://medicines.necsu.nhs.uk/guidelines/tees-guidelines/
The County Durham & Darlington or Tees GREY List – items to be prescribed in certain specific circumstances only can be accessed online at: http://medicines.necsu.nhs.uk/guidelines/durham-darlington or https://medicines.necsu.nhs.uk/guidelines/tees-guidelines/
Topical rubefacient preparations may contain nicotinate and salicylic acid compounds, essential oils, capsicum, and camphor which are all irritant.
The evidence available does not support the use of topical rubefacients in acute or chronic musculoskeletal pain. Rubefacients should not be offered to treat osteoarthritis. Stop any prescribing.
The County Durham & Darlington or Tees DO NOT PRESCRIBE List can be accessed online at: http://medicines.necsu.nhs.uk/guidelines/durhamdarlington or
https://medicines.necsu.nhs.uk/guidelines/tees-guidelines/
The County Durham & Darlington or Tees GREY List – items to be prescribed in certain specific circumstances only can be accessed online at: http://medicines.necsu.nhs.uk/guidelines/durham-darlington or https://medicines.necsu.nhs.uk/guidelines/tees-guidelines/
For intra-articular injection into the knee
The County Durham & Darlington or Tees DO NOT PRESCRIBE List can be accessed online at: http://medicines.necsu.nhs.uk/guidelines/durhamdarlington or
https://medicines.necsu.nhs.uk/guidelines/tees-guidelines/
The County Durham & Darlington or Tees GREY List – items to be prescribed in certain specific circumstances only can be accessed online at: http://medicines.necsu.nhs.uk/guidelines/durham-darlington or https://medicines.necsu.nhs.uk/guidelines/tees-guidelines/