There can be variation in the licensing of
different medicines containing the same drug. Forms available
from special-order manufacturers include: capsule, oral
suspension, oral solution
Solution for injection
EXCIPIENTS: May contain Glycocholic acid, lecithin
▶Konakion MM (Cheplapharm Arzneimittel GmbH)
Phytomenadione 10 mg per 1 ml Konakion MM Paediatric
2mg/0.2ml solution for injection ampoules | 5 ampoule P £4.71
DT = £4.71
Konakion MM 10mg/1ml solution for injection ampoules |
10 ampoule P £3.78 DT = £3.78
6.1 Neural tube defects
(prevention in pregnancy)
Neural tube defects (prevention in
pregnancy)
Description of condition
Neural tube defects represent a group of congenital defects,
caused by incomplete closure of the neural tube within
28 days of conception. The most common forms are
anencephaly, spina bifida and encephalocele.
The main risk factors are maternal folate deficiency,
maternal vitamin B12 deficiency, previous history of having
an infant with a neural tube defect, smoking, diabetes,
obesity, and use of antiepileptic drugs. For information on
smoking cessation see Smoking cessation p. 520.
Prevention in pregnancy
g Pregnant women or women who wish to become
pregnant should be advised to take supplementation with
folic acid p. 1084 before conception and until week 12 of
pregnancy.
A higher daily dose (see folic acid) is recommended for
women at a high risk of conceiving a child with a neural tube
defect, including women who have previously had an infant
with a neural tube defect, who are receiving antiepileptic
medication (see Epilepsy p. 321), or who have diabetes or
sickle-cell disease. h
Useful Resources
Antenatal care for uncomplicated pregnancies. National
Institute for Health and Care Excellence. Clinical guideline
62. March 2008 (Updated March 2016).
www.nice.org.uk/guidance/cg62
Fertility problems: assessment and treatment. National
Institute for Health and Care Excellence. Clinical guideline
156. June 2015.
www.nice.org.uk/guidance/cg156
Blood and nutrition
Chapter 10
Musculoskeletal system
CONTENTS
Arthritis
page 1152
Hyperuricaemia and gout
Neuromuscular disorders
Muscular dystrophy
3.1
Musculoskeletal system
Myasthenia gravis and Lambert-Eaton
3.2
myasthenic syndrome
Myotonic disorders
3.3
Arthritis
Osteoarthritis and soft-tissue
disorders
Overview
For pain relief in osteoarthritis and soft-tissue disorders,
paracetamol p. 465 should be used first and may need to be
taken regularly. A topical NSAID or topical capsaicin 0.025%
p. 505 should also be considered, particularly in knee or hand
osteoarthritis. An oral NSAID can be substituted for, or used
in addition to, paracetamol. If further pain relief is required
in osteoarthritis, then the addition of an opioid analgesic
may be considered, but with a substantial risk of adverse
effects; however, an opioid analgesic should be considered
before a NSAID in patients taking low-dose aspirin.
Intra-articular corticosteroid injections may produce
temporary benefit in osteoarthritis, especially if associated
with soft-tissue inflammation.
Non-drug measures, such as weight reduction and
exercise, should also be encouraged.
Glucosamine p. 1156 and rubefacients are not
recommended for the treatment of osteoarthritis.
Hyaluronic acid and its derivatives are available for
osteoarthritis of the knee, but are not recommended. Sodium
hyaluronate p. 1233 (Durolane ®, Euflexxa ®, Fermathron ®,
Orthovisc ®, Ostenil ®, Ostenil Plus ®, RenehaVis ®, Suplasyn ®,
Synocrom ®, Synopsis ®) or hylan G-F 20 (Synvisc ®) is injected
intra-articularly to supplement natural hyaluronic acid in
the synovial fluid. These injections may reduce pain over
1–6 months, but are associated with a short-term increase in
knee inflammation. Sodium hyaluronate (SportVis ®) is also
licensed for the relief of pain and optimisation of recovery
following ankle sprain, and for the relief of chronic pain and
disability associated with tennis elbow.
Rheumatoid arthritis
Description of condition
Rheumatoid arthritis is a chronic systemic inflammatory
disease that causes persistent symmetrical joint synovitis
(inflammation of the synovial membrane) typically of the
small joints of the hands and feet, although any synovial
joint can be affected. Synovitis presents as pain and
prolonged stiffness that tends to be worse at rest or
following periods of inactivity, swelling, tenderness, and
Nocturnal leg cramps
page 1190
3.4
Spasticity
3.5
Pain and inflammation in musculoskeletal
disorders
Soft tissue and joint disorders
Local inflammation of joints and soft tissue
5.1
Soft tissue disorders
5.2
heat in the affected joints. Other symptoms of rheumatoid
arthritis include rheumatoid nodules and non-specific
symptoms such as malaise, fatigue, fever, and weight loss.
As the disease progresses, it can cause joint deformity and
affect different organs of the body, such as the heart, lungs,
and eyes; therefore early diagnosis and treatment of
rheumatoid arthritis is essential to reduce the impact of the
disease.
Palindromic rheumatism is a rare form of inflammatory
arthritis which causes attacks of joint pain and swelling
similar to rheumatoid arthritis, but the joints return to
normal in between attacks. Patients with palindromic
rheumatism may later develop rheumatoid arthritis.
Aims of treatment
The aims of treatment are to relieve the symptoms of
rheumatoid arthritis, achieve disease remission or low
disease activity if remission cannot be achieved, and to
improve the patient’s ability to perform daily activities.
Non-drug treatment
g Patients with rheumatoid arthritis should have access
to a multidisciplinary team, and may benefit from
physiotherapy to encourage exercise, enhance flexibility of
joints and strengthen muscles. Psychological interventions
such as relaxation, stress management, and cognitive coping
skills to support patients with their perception and
management of their disease can also be offered. h
Drug treatment
g All patients with suspected persistent synovitis of
unknown cause should be referred to a specialist for advice
as soon as possible to confirm diagnosis and evaluate disease
activity.
In patients with newly diagnosed active rheumatoid
arthritis, monotherapy with a conventional disease-
modifying antirheumatic drug (DMARD), either oral
methotrexate p. 963, leflunomide p. 1157, or sulfasalazine
p. 47, should be given as first-line treatment;
hydroxychloroquine sulfate p. 1156, a weak DMARD, is an
alternative in patients with mild rheumatoid arthritis or
those with palindromic rheumatism. Treatment should be
started as soon as possible, ideally within 3 months of onset
of persistent symptoms, and the dose should be titrated to
the maximum tolerated effective dose. h
Conventional DMARDs have a slow onset of action and can
take 2–3 months to take effect. g Consider short-term
bridging treatment with a corticosteroid (by oral,
intramuscular, or intra-articular administration) when
starting treatment with a new DMARD to provide rapid
symptomatic control, while waiting for the DMARD to take
effect. Short-term corticosteroids should also be given to
rapidly decrease inflammation during flare-ups.
If symptoms of rheumatoid arthritis are inadequately
controlled despite dose escalation on DMARD monotherapy,
combination therapy with another conventional DMARD
(either oral methotrexate p. 963, leflunomide p. 1157,
sulfasalazine p. 47, or hydroxychloroquine sulfate p. 1156)
should be given.
Treatment with a tumour necrosis factor (TNF) alpha
inhibitor (either adalimumab p. 1170, certolizumab pegol
p. 1173, etanercept p. 1175, golimumab p. 1177, or
infliximab p. 1179), other biological DMARD (either
abatacept p. 1169, sarilumab p. 1160, or tocilizumab
p. 1162), or targeted synthetic DMARD (either baricitinib
p. 1166 or tofacitinib p. 1167) is recommended if there has
been an inadequate response to combination therapy with
conventional DMARDS. h See National funding/access
decisions for individual drugs for full prescribing
information.
g Rituximab p. 933 in combination with methotrexate
p. 963 is an alternative option for patients with severe active
rheumatoid arthritis who have had an inadequate response
to, or are intolerant of other DMARDs, including at least one
TNF alpha inhibitor. h See National funding/access
decisions for rituximab p. 933.
g In patients with established rheumatoid arthritis, the
long-term use of corticosteroids should only be continued if
all other treatments options (including biological and
targeted synthetic DMARDs) have been offered.
Patients with active rheumatoid arthritis should be
monitored monthly until the treatment target (either
remission or low disease activity) has been achieved, and all
patients with rheumatoid arthritis should be reviewed
annually. In patients who have maintained the treatment
target for at least 1 year without corticosteroids, cautiously
reducing drug doses to the lowest that are clinically
effective, or tapering and stopping at least one drug if the
patient is being treated with two or more DMARDs should be
considered. h
Older conventional DMARDs such as sodium
aurothiomalate (gold) p. 1159, azathioprine p. 881,
ciclosporin p. 883 and penicillamine p. 1158 are no longer
commonly used in practice due to the availability of newer,
more effective drugs.
Pain relief
g Short-term use of an oral non-steroidal anti-
inflammatory drug (NSAID) or a selective cyclo-oxygenase-2
inhibitor should be considered for additional control of pain
and stiffness associated with rheumatoid arthritis. Patients
should be offered a proton pump inhibitor to minimise
associated gastrointestinal adverse effects. In patients
already taking low-dose aspirin p. 130, paracetamol p. 465 or
a compound analgesic should be considered before giving a
NSAID. NSAIDs should be used at the lowest effective dose,
and if possible, withdrawn when a good response to
DMARDs is achieved. h
Surgery
g Surgery may be an option for some patients if drug
treatment has failed to adequately manage persistent pain
due to joint damage or other identifiable soft tissue causes, if
there is worsening of joint function, progressive deformity,
or persistent localised synovitis. h
Useful Resources
Rheumatoid arthritis in adults: management. National
Institute for Health and Care Excellence. NICE guideline 100.
July 2018.
www.nice.org.uk/guidance/ng100
Spondyloarthritis
Description of condition
Spondyloarthritis refers to a group of inflammatory
musculoskeletal conditions with shared features which affect
both axial and peripheral joints. Most people with these
conditions have either axial spondyloarthritis (which
includes ankylosing spondylitis and non-radiographic axial
spondyloarthritis) or psoriatic arthritis. Axial
spondyloarthritis primarily affects the spine, in particular
the sacroiliac joint.
Psoriatic arthritis may present in several forms, including
involvement of small joints (in the hands and feet), large
joints (particularly in the knees), or combinations of both.
Psoriatic arthritis may also involve the axial joints, finger
Musculoskeletal system
and toe joints, and inflammation of the connective tissue
between tendon/ligament and bone.
Less common subgroups are enteropathic
spondyloarthritis, which is associated with inflammatory
bowel disease (Crohn’s disease p. 41 and Ulcerative colitis
p. 43), and reactive arthritis (a form of peripheral arthritis),
which can occur following gastro-intestinal or genito-
urinary infections.
Aims of treatment
The aims of treatment are to relieve symptoms, slow the
progression of the condition, and improve quality of life.
Non-drug treatment
g Patients who have difficulties with everyday activities
should be referred to a specialist therapist (such as a
physiotherapist, occupational therapist, hand therapist,
orthotist or podiatrist). Hydrotherapy can be considered as
an adjunctive therapy to manage pain and maintain or
improve function for people with axial spondyloarthritis. h
Drug treatment
Axial spondyloarthritis
g For pain associated with axial spondyloarthritis, start
one of the Non-steroidal anti-inflammatory drugs p. 1193
(NSAIDs) at the lowest effective dose. Clinical assessment,
monitoring of risk factors, and the use of gastroprotective
treatment should be considered. If an NSAID taken at the
maximum tolerated dose for 2–4 weeks does not provide
adequate pain relief, consider switching to a different
NSAID.
A tumour necrosis factor (TNF) alpha inhibitor (or
biological DMARD) such as adalimumab p. 1170,
certolizumab pegol p. 1173, etanercept p. 1175, golimumab
p. 1177, or infliximab p. 1179 is recommended as an option
for treating severe active ankylosing spondylitis in patients
whose disease has responded inadequately to, or who are
intolerant of, NSAIDs.
Secukinumab p. 1161 is recommended as an option for
treating active ankylosing spondylitis in patients who have
responded inadequately to NSAIDs or TNF-alpha inhibitors
(see National funding/access decisions under secukinumab
p. 1161).
Adalimumab p. 1170, certolizumab pegol p. 1173 and
etanercept p. 1175 are also recommended as options for
treating severe non-radiographic axial spondyloarthritis
in patients whose disease has responded inadequately to, or
who are intolerant of, NSAIDs.
The choice of treatment should depend on patient
preference and extra-articular involvement. The response to
treatment should be assessed after 12 weeks and should only
be continued if there is clear evidence of response.
Treatment with another TNF-alpha inhibitor is
recommended in those who cannot tolerate, or whose
disease has not responded to, treatment with the first TNF-
alpha inhibitor, or in those whose disease has stopped
responding after an initial response. h
Psoriatic arthritis and other peripheral spondyloarthritides
g Monotherapy with local corticosteroid injections
should be considered for non-progressive monoarthritis
(see Corticosteroids, inflammatory disorders p. 1216).
Standard DMARDs, such as methotrexate p. 963,
leflunomide p. 1157 or sulfasalazine p. 47, can be used for
patients with peripheral polyarthritis, oligoarthritis, or
persistent or progressive monoarthritis associated with
peripheral spondyloarthritis.
Standard DMARDs, such as methotrexate p. 963 or
leflunomide p. 1157 can also be used for patients with
psoriatic arthritis.
The choice of DMARD will depend on numerous factors
such as the patient’s circumstances (such as pregnancy
planning and alcohol consumption), comorbidities (such as
Musculoskeletal system
uveitis, psoriasis and inflammatory bowel disease), and
potential side-effects.
If a standard DMARD taken at the maximum tolerated
dose for at least 3 months does not provide adequate relief
from symptoms, a switch to, or the addition of, another
standard DMARD can be considered.
An NSAID can be used as an adjunct to standard DMARDs
or biological DMARDs to manage symptoms. If NSAIDs do
not provide adequate relief from symptoms, consider
corticosteroid injections or short-term oral corticosteroid
therapy as an adjunct to standard DMARDs or biological
DMARDs to manage symptoms.
If extra-articular disease is adequately controlled by an
existing standard DMARD but peripheral spondyloarthritis is
not, consider adding another standard DMARD. h
Further options for psoriatic arthritis
g The targeted DMARD apremilast p. 1181, used alone or
in combination with standard DMARDs, is recommended for
the treatment of active and progressive psoriatic arthritis if
the patient has peripheral arthritis with 3 or more tender
joints and 3 or more swollen joints, and the psoriatic
arthritis has not responded to at least 2 standard DMARDs
given alone or in combination.
The biological DMARDs etanercept p. 1175, infliximab
p. 1179, golimumab p. 1177 and adalimumab p. 1170 (TNF-
alpha inhibitors) are recommended for the treatment of
active and progressive psoriatic arthritis if the patients has
peripheral arthritis with 3 or more tender joints and 3 or
more swollen joints, and the psoriatic arthritis has not
responded to at least 2 standard DMARDs given alone or in
combination.
Ustekinumab p. 1164, alone or in combination with
methotrexate, is recommended for treating active psoriatic
arthritis when treatment with TNF-alpha inhibitors is
contra-indicated but would otherwise be considered or the
patient has had treatment with one or more TNF-alpha
inhibitors. The response to treatment should be assessed at
24 weeks and should only be continued if there is clear
evidence of response. h
Reactive arthritis
g After treating the initial infection, do not offer long-
term (4 weeks or longer) treatment with an antibacterial
solely to manage reactive arthritis caused by a gastro-
intestinal or genito-urinary infection. h
Useful Resources
Spondyloarthritis in over 16s: diagnosis and management.
National Institute for Health and Care Excellence. Clinical
Guideline NG65. February 2017.
www.nice.org.uk/guidance/ng65
Rheumatic disease, suppressing
drugs
Overview
Certain drugs such as those affecting the immune response
can suppress the disease process in rheumatoid arthritis and
psoriatic arthritis, see Rheumatoid arthritis p. 1152 or
Spondyloarthritis p. 1153. Systemic and discoid lupus
erythematosus are sometimes treated with chloroquine p. 651
or hydroxychloroquine sulfate p. 1156.
The choice of a disease-modifying antirheumatic drug
(DMARD) should take into account co-morbidity and patient
preference. Methotrexate p. 963, sulfasalazine p. 47,
intramuscular gold, and penicillamine p. 1158 are similar in
efficacy. However, methotrexate or sulfasalazine may be
better tolerated.
Gold
Gold, given as sodium aurothiomalate p. 1159, is licensed for
active progressive rheumatoid arthritis; it must be given by
deep intramuscular injection and the area gently massaged.
A test dose must be given followed by doses at weekly
intervals until there is definite evidence of remission. In
patients who do respond, the interval between injections is
then gradually increased to 4 weeks and treatment is
continued for up to 5 years after complete remission. If
relapse occurs the dosage frequency may be immediately
increased and only once control has been obtained again
should the dosage frequency be decreased; if no response is
seen within 2 months, alternative treatment should be
sought. It is important to avoid complete relapse since
second courses of gold are not usually effective.
Penicillamine
Penicillamine has a similar action to gold. More patients are
able to continue treatment than with gold but side-effects
are common.
Patients should be warned not to expect improvement for
at least 6 to 12 weeks after treatment is initiated.
Penicillamine should be discontinued if there is no
improvement within 1 year.
Sulfasalazine
Sulfasalazine has a beneficial effect in suppressing the
inflammatory activity of rheumatoid arthritis. Sulfasalazine
may also be used by specialists, in the management of
psoriatic arthritis affecting peripheral joints [unlicensed
indication]. Haematological abnormalities occur usually in
the first 3 to 6 months of treatment and are reversible on
cessation of treatment.
Antimalarials
The antimalarial hydroxychloroquine sulfate is used to treat
rheumatoid arthritis of mild inflammatory activity;
chloroquine is also licensed for treating inflammatory
disorders but is used much less frequently and is generally
reserved for use if other drugs have failed.
Chloroquine and hydroxychloroquine sulfate are effective
for mild systemic lupus erythematosus, particularly
involving the skin and joints. These drugs should not be used
for psoriatic arthritis. Chloroquine and hydroxychloroquine
sulfate are better tolerated than gold or penicillamine.
Retinopathy rarely occurs provided that the recommended
doses are not exceeded; in the elderly it is difficult to
distinguish drug-induced retinopathy from changes of
ageing.
Mepacrine hydrochloride p. 527 is sometimes used in
discoid lupus erythematosus [unlicensed].
Drugs affecting the immune response
Methotrexate is a DMARD used in active rheumatoid
arthritis. Methotrexate is usually given by mouth once a
week, adjusted according to response. In patients who
experience mucosal or gastro-intestinal side-effects with
methotrexate, folic acid p. 1084 given every week
[unlicensed indication], on a different day from the
methotrexate, may help to reduce the frequency of such
side-effects.
Leflunomide p. 1157 acts on the immune system as a
DMARD. Its therapeutic effect starts after 4–6 weeks and
improvement may continue for a further 4–6 months.
Drugs that affect the immune response are also used in the
management of severe cases of systemic lupus erythematosus
and other connective tissue disorders. They are often given
in conjunction with corticosteroids for patients with severe
or progressive renal disease. They may be used in cases of
polymyositis that are resistant to corticosteroids. They are
used for their corticosteroid-sparing effect in patients whose
corticosteroid requirements are excessive. Azathioprine
p. 881 is usually used.
In the specialist management of psoriatic arthritis
affecting peripheral joints, leflunomide, methotrexate, or
azathioprine [unlicensed indication] may be used.
Juvenile idiopathic arthritis
Many children with juvenile idiopathic arthritis (juvenile
chronic arthritis) do not require DMARDs. Methotrexate is
effective; sulfasalazine is an alternative [unlicensed
indication] but it should be avoided in systemic-onset juvenile
idiopathic arthritis. Gold and penicillamine are no longer
used. Cytokine modulators have a role in juvenile idiopathic
arthritis.
Cytokine modulators
Cytokine modulators should be used under specialist
supervision.
Adalimumab p. 1170, certolizumab pegol p. 1173,
etanercept p. 1175, golimumab p. 1177, and infliximab
p. 1179 inhibit the activity of tumour necrosis factor alpha
(TNF-a).
Adalimumab is licensed for moderate to severe active
rheumatoid arthritis when response to other DMARDs
(including methotrexate) has been inadequate; it is also
licensed for severe, active, and progressive disease in adults
not previously treated with methotrexate. In the treatment
of rheumatoid arthritis, adalimumab should be used in
combination with methotrexate, but it can be given alone if
methotrexate is inappropriate. Adalimumab is also licensed
for the treatment of active and progressive psoriatic arthritis
and severe active ankylosing spondylitis that have not
responded adequately to other DMARDs. It is also licensed
for the treatment of severe axial spondyloarthritis without
radiographic evidence of ankylosing spondylitis but with
objective signs of inflammation, in patients who have had an
inadequate response to, or are intolerant of NSAIDs.
Adalimumab also has a role in inflammatory bowel disease
and plaque psoriasis.
Certolizumab pegol is licensed for use in patients with
moderate to severe active rheumatoid arthritis when response
to DMARDs (including methotrexate) has been inadequate.
Certolizumab pegol can be used in combination with
methotrexate, or as a monotherapy if methotrexate is not
tolerated or is contra-indicated. Certolizumab pegol is also
licensed for the treatment of severe active ankylosing
spondylitis in patients who have had an inadequate response
to, or are intolerant of NSAIDs. It is also licensed for the
treatment of severe active axial spondyloarthritis, without
radiographic evidence of ankylosing spondylitis but with
objective signs of inflammation, in patients who have had an
inadequate response to, or are intolerant of NSAIDs.
Etanercept is licensed for the treatment of moderate to
severe active rheumatoid arthritis either alone or in
combination with methotrexate when the response to other
DMARDs is inadequate and in severe, active and progressive
rheumatoid arthritis in patients not previously treated with
methotrexate. It is also licensed for the treatment of active
and progressive psoriatic arthritis inadequately responsive to
other DMARDs, and for severe ankylosing spondylitis
inadequately responsive to conventional therapy. Etanercept
also has a role in plaque psoriasis.
Golimumab is licensed in combination with methotrexate
for the treatment of moderate to severe active rheumatoid
arthritis when response to DMARD therapy (including
methotrexate) has been inadequate; it is also licensed in
combination with methotrexate for patients with severe,
Musculoskeletal system
active, and progressive rheumatoid arthritis not previously
treated with methotrexate p. 963. Golimumab p. 1177 is also
licensed for the treatment of active and progressive psoriatic
arthritis, as monotherapy or in combination with
methotrexate, when response to DMARD therapy has been
inadequate; it is also licensed for the treatment of severe
active ankylosing spondylitis when there is an inadequate
response to conventional treatment.
Infliximab p. 1179 is licensed for the treatment of active
rheumatoid arthritis in combination with methotrexate when
the response to other DMARDs, including methotrexate, is
inadequate; it is also licensed in combination with
methotrexate for patients not previously treated with
methotrexate or other DMARDs who have severe, active, and
progressive rheumatoid arthritis. Infliximab is also licensed
for the treatment of ankylosing spondylitis, in patients with
severe axial symptoms who have not responded adequately
to conventional therapy, and in combination with
methotrexate (or alone if methotrexate is not tolerated or is
contra-indicated) for the treatment of active and progressive
psoriatic arthritis which has not responded adequately to
DMARDs.
Rituximab p. 933 is licensed in combination with
methotrexate for the treatment of severe active rheumatoid
arthritis in patients whose condition has not responded
adequately to other DMARDs (including one or more tumour
necrosis factor inhibitors) or who are intolerant of them.
Rituximab has a role in malignant disease.
Abatacept p. 1169 prevents the full activation of T-
lymphocytes. It is licensed for moderate to severe active
rheumatoid arthritis in combination with methotrexate, in
patients unresponsive to other DMARDs (including
methotrexate or a tumour necrosis factor (TNF) inhibitor).
Abatacept is not recommended for use in combination with
TNF inhibitors.
Anakinra p. 1159 inhibits the activity of interleukin-1.
Anakinra (in combination with methotrexate) is licensed for
the treatment of rheumatoid arthritis which has not
responded to methotrexate alone. Anakinra is not
recommended for the treatment of rheumatoid arthritis
except when used in a controlled long-term clinical study.
Patients who are already receiving anakinra for rheumatoid
arthritis should continue treatment until they and their
specialist consider it appropriate to stop.
Baricitinib p. 1166 and tofacitinib p. 1167 are licensed
alone or in combination with methotrexate for the treatment
of moderate to severe active rheumatoid arthritis in patients
who have had an inadequate response to, or who are
intolerant to, one or more DMARDs.
Belimumab p. 890 inhibits the activity of B-lymphocyte
stimulator. Belimumab is licensed as adjunctive therapy in
patients with active, autoantibody-positive systemic lupus
erythematosus with a high degree of disease activity despite
standard therapy.
Sarilumab p. 1160 is a recombinant human monoclonal
antibody that specifically binds to interleukin-6 receptors
and blocks the activity of pro-inflammatory cytokines; it is
licensed alone or in combination with methotrexate for the
treatment of moderate to severe active rheumatoid arthritis
in patients who have had an inadequate response to, or are
intolerant to one or more DMARDs.
Secukinumab p. 1161 inhibits the activity of interleukin-
17A. Secukinumab is licensed for the treatment of active
psoriatic arthritis, in combination with methotrexate or
alone, which has not responded adequately to DMARDs; it is
also licensed for the treatment of ankylosing spondylitis, in
patients who have not responded adequately to conventional
therapy. Secukinumab also has a role in plaque psoriasis.
Tocilizumab p. 1162 antagonises the actions of
interleukin-6. Tocilizumab is licensed for use in patients
with moderate to severe active rheumatoid arthritis when
response to at least one DMARD or tumour necrosis factor
Musculoskeletal system
inhibitor has been inadequate, or in those who are intolerant
of these drugs. Tocilizumab can be used in combination with
methotrexate, or as monotherapy if methotrexate is not
tolerated or is contra-indicated.
Ustekinumab p. 1164 inhibits the activity of interleukins
12 and 23. It is licensed for the treatment of active psoriatic
arthritis (in combination with methotrexate or alone) in
patients who have had an inadequate response to one or
more DMARDs.
Other drugs used for Arthritis Aceclofenac, p. 1194.
Celecoxib, p. 1195. Cyclophosphamide, p. 945.
Dexibuprofen, p. 1196. Diclofenac potassium, p. 1197.
Diclofenac sodium, p. 1198. Etodolac, p. 1201. Etoricoxib,
p. 1201. Flurbiprofen, p. 1203. Ibuprofen, p. 1203.
Indometacin, p. 1206. Ixekizumab, p. 1325. Ketoprofen,
p. 1207. Mefenamic acid, p. 1208. Meloxicam, p. 1209.
Nabumetone, p. 1210. Naproxen, p. 1211. Piroxicam,
p. 1212. Sulindac, p. 1213. Tenoxicam, p. 1214. Tiaprofenic
acid, p. 1215
CHONDROPROTECTIVE DRUGS
PDF pages 1172, 1173, 1174, 1175, 1176, 1177, 1178
