Musculoskeletal joint diseases

10.1.1 Non-steroidal anti-inflammatory drugs

First line: ibuprofen, naproxen

Second line: diclofenac, meloxicam, etodolac

For dysmenorrhoea: mefenamic acid

For hospital use only: piroxicam MELT

For rheumatology use only: phenylbutazone 

10.1.2.1 Systemic corticosteroids

First line: prednisolone

10.1.2.2 Local corticosteroid injections

First line: dexamethasone, methylprednisolone acetate, methyprednisolone actate with lignocaine, triamcinolone acetate

For hospital use only: hydrocortisone acetate, prednisolone acetate

10.1.3. Drugs that suppress the rheumatic disease process

For hospital initiation: methotrexate, sulfasalazine, leflunomide, hydroxychloroquine, azathioprine, ciclosporin, sodium aurothiomalate, penicillamine

• shared care guideline for leflunomide
• shared care guideline for methotrexate

For hospital use only: adalimumab, certolizumab, etanercept, infliximab, rituximab, abatacept, tocilizumab

• Biologics Pathway for Rheumatoid Arthritis in Dorset 2013

10.1.4. Acute attacks of gout

First line: indometacin, naproxen or alternative NSAID

Second line: colchicine

10.1.4 Long-term control of gout

First line: allopurinol

For specialist initiation: febuxostat

• shared care guideline for febuxostat

10.1.4 Hyperuricaemia associated with cytotoxic drugs

For hospital use only: rasburicase

10.2.1 Drugs that enhance neuromuscular transmission

For myasthenia gravis: pyridostigmine

For specialist initiation: distigmine, neostigmine

amifampridine (Firdapse®) commissioning statement

10.2.2 Skeletal muscle relaxants

First line: baclofen, diazepam

For nocturnal leg cramps where cramps cause regular disruption to sleep: quinine sulphate (not for routine use, see BNF 10.2.2)

For specialist initiation: dantrolene sodium

For specialist initiation: tizanidine

• shared care guideline for tizanidine

10.3.1 Enzymes

For hospital use only: hyaluronidase

10.3.2 Rubefacients, topical NSAIDs, capsaicin and poultices

First line: ibuprofen gel 5%

For specialist initiation: capsaicin 0.025%, 0.075% cream