NICE NG100: Rheumatoid arthritis in adults: management
NICE NG167: COVID-19 rapid guideline: rheumatological autoimmune, inflammatory and metabolic bone disorders
The County Durham and Tees Valley APC Do Not Prescribe List and Grey List can be accessed online at: https://medicines.necsu.nhs.uk/download/tees-prescribing-grey-list/
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
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.)
The County Durham and Tees Valley APC Do Not Prescribe List and Grey List can be accessed online at: https://medicines.necsu.nhs.uk/download/tees-prescribing-grey-list/
NICE ES23: COVID-19 rapid evidence summary: acute use of non-steroidal anti-inflammatory drugs (NSAIDs) for people with or at risk of COVID-19
NICE ES25: COVID-19 rapid evidence summary: Long-term use of non-steroidal anti-inflammatory drugs (NSAIDs) for people with or at risk of COVID-19
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
BNF recommends a higher starting dose of misoprostol for prophylaxis against NSAID induced GI ulceration than that provided by combination preparations
The County Durham and Tees Valley APC Do Not Prescribe List and Grey List can be accessed online at: https://medicines.necsu.nhs.uk/download/tees-prescribing-grey-list/
Not a cost effective use of NHS resources
The County Durham and Tees Valley APC Do Not Prescribe List and Grey List can be accessed online at: https://medicines.necsu.nhs.uk/download/tees-prescribing-grey-list/
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
Any shared care guidelines listed below which have passed their review date will remain in use until an updated CDTV APC approved version is available, with only technical updates to address any emerging safety issues. The responsibility for the production and updating of SCGs lies with the originating trusts along with the CDTV APC but may be superseded by the adoption of national shared care templates.
In particular the DMARD shared care had their review date extended for a further six months in April 2022 as the national RMOC shared care guidelines are not yet available but expected very soon.
25mg & 50mg tablets;
50mg in 5ml suspension (unlicensed)
For non Cancer indications
Shared care guidelines for DMARDs can be found here:
Durham & Darlington Guidelines
10mg, 25mg, 50mg & 100mg capsules
Prescribe by brand name to ensure continuity
Shared care guidelines for DMARDs can be found here:
Durham & Darlington Guidelines
Tablets - 200mg
Shared care guidelines for DMARDs can be found here:
Durham & Darlington Guidelines
MHRA Drug Safety Update (Feb 2022): Hydroxychloroquine, chloroquine: increased risk of cardiovascular events when used with macrolide antibiotics; reminder of psychiatric reactions
Tablets - 10mg, 20mg, 100mg
Shared care guidelines for DMARDs can be found here:
Durham & Darlington Guidelines
Tablets - 2.5mg
Injection – for non cancer indications
Shared care guidelines for DMARDs can be found here:
Durham & Darlington Guidelines
Methotrexate Subcutaneous = AMBER SHARED CARE in North Yorkshire and County Durham & Darlington
Methotrexate Subcutaneous = RED drug in Tees
MHRA Drug Safety Update (Sept 2020): Methotrexate once-weekly for autoimmune diseases: new measures to reduce risk of fatal overdose due to inadvertent daily instead of weekly dosing
250mg capsules; 500mg tablets
Shared care guidelines for DMARDs can be found here:
Durham & Darlington Guidelines
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:
Durham & Darlington Guidelines
500mg e/c tablets
Shared care guidelines for DMARDs can be found here:
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
Not approved for refractory chronic non-bacterial osteomyelitis osteitis (CNO) (all ages) as per the NHSE Clinical Commissioning Policy Statement.
Biosimilars are available – note that indications can differ between different products – prescribe by brand. Consult with individual trust pharmacy department for details of preferred biosimilar brand.
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.
NICE ES26: COVID 19 rapid evidence summary: Anakinra for COVID-19 associated secondary haemophagocytic lymphohistiocytosis
Commissioner: NHS England
Approved for use in accordance with the following NICE TAs:
10mg, 20mg and 30mg tablets
MHRA Drug Safety Update (Jan 2017): Apremilast (Otezla ▼): risk of suicidal thoughts and behaviour
Approved for use in accordance with the following NICE TAs:
2mg and 4mg tablets
Approved for use in accordance with the following NICE TAs:
MHRA Drug Safety Update (Mar 2020): Baricitinib (Olumiant▼): risk of venous thromboembolism
MHRA Drug Safety Update (Aug 2020): Baricitinib (Olumiant▼): increased risk of diverticulitis, particularly in patients with risk factors
120mg and 400mg IV infusion
Approved for use in accordance with the following NICE TAs:
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
Approved for use in accordance with the following NICE TAs:
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.
Biosimilars are available – note that indications can differ between different products – prescribe by brand. Consult with individual trust pharmacy department for details of preferred biosimilar brand.
100mg and 200mg tablets
Approved for use in accordance with the following NICE TAs:
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®)
120 mg solution for injection in pre-filled syringe or pre-filled pen for subcutaneous injection (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.
NTAG June 2020: The Northern (NHS) Treatment Advisory Group recommends Remsima SC® be available as additional treatment option during the COVID-19 pandemic for both licensed and off-label uses as part individual hospital Trust management strategies to reduce hospital day case admissions, and keep immunosuppressed people out of hospital during the COVID-19 pandemic. Remsima SC® could be considered as an option where the patient would otherwise get the intravenous Remsima® formulation of Infliximab. This recommendation is subject to any off-label use of Remsima SC® being considered and approved via individual hospital trust governance processes (including clinical governance) for the use of unlicensed/off-label drugs. It was also agreed that this recommendation would be reviewed after 12 months. In June 2021 NTAG reviewed this recommendation after 12 months as agreed. NTAG agreed at this time to make no changes to the recommendation due to the ongoing COVID-19 pandemic and review the position again in a further six months time
Biosimilars are available – note that indications can differ between different products – prescribe by brand. Consult with individual trust pharmacy department for details of preferred biosimilar brand.
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)
Biosimilars are available – note that indications can differ between different products – prescribe by brand. Consult with individual trust pharmacy department for details of preferred biosimilar brand.
150mg pre-filled syringe or pen
200mg pre-filled syringe or pen
Commissioner: CCG -
Approved for use in accordance with the following NICE TAs:
150mg/ml injection
Approved for use in accordance with the following NICE TAs:
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
15 mg prolonged-release tablets
Approved for use in accordance with the following NICE TA:
45mg vial
Approved for use in accordance with the following NICE TAs:
100 mg solution for injection in pre-filled pen.
Approved for use in accordance with the following NICE TAs:
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
Not approved in accordance with the following NICE TAs:
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
NICE guidance for the management of osteoarthritis (CG177) does not recommend glucosamine or chondroitin preparations; there is limited and uncertain evidence on the effectiveness of these preparations in the management of osteoarthritis. NHS England (November 2017) supports the deprescribing of glucosamine and/or chondroitin preparations.
The County Durham and Tees Valley APC Do Not Prescribe List and Grey List can be accessed online at: https://medicines.necsu.nhs.uk/download/tees-prescribing-grey-list/
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, 4mg
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.
See Sunderland or North of Tyne APC websites for local shared care guidelines
Not recommended for use to treat chronic pain. For further information see NICE NG144
Not cost effective use of NHS resources, deemed less suitable for prescribing in BNF.
The County Durham and Tees Valley APC Do Not Prescribe List and Grey List can be accessed online at: https://medicines.necsu.nhs.uk/download/tees-prescribing-grey-list/
167 mg hard capsules
Indicated for the symptomatic treatment of myotonia in adult patients with non-dystrophic myotonic disorders. NHS England commissioned.
Approved for use in accordance with the following NICE TAs:
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:
0.75 mg/mL powder for oral solution
Approved for use in accordance with the following NICE TAs:
Commissioner: NHS England
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.
NHS England in 2017 stated that rubefacients should not be initiated in primary care for any new patients (excluding topical NSAIDs) this has been updated in June 2019 to exclude capsaicin cream when used to treat osteoarthritis and neuropathic pain in line with NICE guidance.
The BNF states “The evidence available does not support the use of topical rubefacients in acute or chronic musculoskeletal pain.”
NICE have issued the following “Do not do” recommendation: Do not offer rubefacients for treating osteoarthritis.
Capsaicin cream falls within NICE guidance:
The County Durham and Tees Valley APC Do Not Prescribe List and Grey List can be accessed online at: https://medicines.necsu.nhs.uk/download/tees-prescribing-grey-list/
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 and Tees Valley APC Do Not Prescribe List and Grey List can be accessed online at: https://medicines.necsu.nhs.uk/download/tees-prescribing-grey-list/
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 and Tees Valley APC Do Not Prescribe List and Grey List can be accessed online at: https://medicines.necsu.nhs.uk/download/tees-prescribing-grey-list/
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 and Tees Valley APC Do Not Prescribe List and Grey List can be accessed online at: https://medicines.necsu.nhs.uk/download/tees-prescribing-grey-list/
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 and Tees Valley APC Do Not Prescribe List and Grey List can be accessed online at: https://medicines.necsu.nhs.uk/download/tees-prescribing-grey-list/
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 and Tees Valley APC Do Not Prescribe List and Grey List can be accessed online at: https://medicines.necsu.nhs.uk/download/tees-prescribing-grey-list/
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 and Tees Valley APC Do Not Prescribe List and Grey List can be accessed online at: https://medicines.necsu.nhs.uk/download/tees-prescribing-grey-list/
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 and Tees Valley APC Do Not Prescribe List and Grey List can be accessed online at: https://medicines.necsu.nhs.uk/download/tees-prescribing-grey-list/
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 and Tees Valley APC Do Not Prescribe List and Grey List can be accessed online at: https://medicines.necsu.nhs.uk/download/tees-prescribing-grey-list/
For intra-articular injection into the knee
The County Durham and Tees Valley APC Do Not Prescribe List and Grey List can be accessed online at: https://medicines.necsu.nhs.uk/download/tees-prescribing-grey-list/