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10: MUSCULOSKELETAL and JOINT DISEASES 10.1 Drugs used in rheumatic diseases and gout 10.1.1 NSAIDs All NSAIDs and Cox-2 inhibitors carry a cardiovascular risk. Modified release preparations should be restricted for patients with early morning stiffness or compliance problems as they encourage regular higher doses and do not afford dosage flexibility. Patients with OA may only require intermittent treatment and may benefit from regular paracetamol. ibuprofen naproxen diclofenac sodium Patients at high risk of serious gastro-intestinal adverse events: NSAID (see 10.1.1) + omeprazole caps Patients at high risk of serious gastro-intestinal adverse events intolerant of NSAIDs celecoxib etoricoxib Patients at high risk but also requiring low dose aspirin for cardiovascular protection: NSAID (see 10.1.1) + omeprazole caps 10.1.2 Systemic corticosteroids Oral: prednisolone plain Please refer to osteoporosis guidance for advice on bone protection Intravenous injection: methylprednisolone sodium succinate (Solu-Medrone®) Intramuscular depot injection: methylprednisolone acetate (Depo-Medrone®) triamcinolone acetonide (Kenalog®) Local corticosteroid injections Soft tissue injection: hydrocortisone acetate Intra-articular injection (only to be administered by appropriately trained staff): methylprednisolone acetate (Depo-Medrone®) triamcinolone acetonide (Adcortyl® Intra-articular/intradermal or Kenalog® Intra-articular/intramuscular) 10.1.3 Disease-modifying antirheumatic drugs Initiated in consultation with a specialist methotrexate 2.5mg (prescribe in small quantities – 4 weeks supply and in 2.5mg strength tablets. Practice to give patient a NPSA patient information / dosage record booklet or similar with 1st prescription) sulfasalazine e/c leflunomide specialist only initiation sodium aurothiomalate penicillamine azathioprine hydroxychloroquine certolizumab▼ adalimumab▼ etanercept▼ infliximab rituximab tocilizumab▼ 10.1.4 Drugs for treatment of gout (a) acute attacks of gout diclofenac sodium naproxen colchicine (500mcg THREE times a day, Note at doses described in the BNF, toxicity usually occurs before the therapeutic effect) etoricoxib (reserved for special cases of acute gout where the patient has not responded to courses of both diclofenac or naproxen) (b) prophylaxis of gout allopurinol 10.2 Drugs used in neuromuscular disorders 10.2.1 Drugs used in myasthenia gravis pyridostigmine bromide neostigmine 10.2.2 Skeletal muscle relaxants baclofen dantrolene sodium diazepam – short term use for muscle spasm only 10.2.3 Drugs used in acute exacerbations of multiple sclerosis methylprednisolone sodium succinate injection dexamethasone tablets 10.3.2 Rubefacients and other topical antirheumatics Diethylamine salicylate 10% cream (Algesal) Oral NSAIDs should be prescribed in preference to topical gels Piroxicam 0.5% gel Ibuprogen 5% gel