Specialist Paediatric Rheumatology Management

Prescribing Notes:

Management of paediatric rheumatology conditions may require the use of non-steroidal anti-inflammatory drugs (NSAIDs), systemic corticosteroids, disease modifying ant-rheumatic drugs (DMARDs) and biologics directed by a specialist paediatric rheumatology prescriber experienced in the management of the condition and in line with relevant local or national guidance. The position of specialist treatment in these specialist paediatric rheumatology pathways are not intended to guide on place in therapy given the diversity of conditions and limited evidence base. Systemic treatments for inflammatory rheumatic disease and musculoskeletal disorders in children are initiated by specialists. Where more than one treatment option is considered clinically appropriate prescribers will select the item of the lowest acquisition cost. Where applicable children and young people should be offered the opportunity to participate in clinical trials if eligible. 

For formulary recommendations for use of bisphosphonates see “Treatment of osteoporosis secondary to another condition in children” and Scottish Paediatric and Adolescent Rheumatology Network (SPARN) websites.

Where a new medicine is introduced and is within Scottish Medicines Consortium (SMC) remit, the advice of the SMC health technology appraisal applies to the proposed use of the medicine. Where medicines are not recommended in NHS Scotland and a specialist considers it to be the preferred treatment option, individual patient approval is required (seek advice from local board pharmacy colleagues or formulary teams). 

Some treatments for rare conditions recommended by specialists include licensed medicines being used outside the terms of the manufacturers product license, where treatment is not included on the formulary.  When a specialist considers it to be the preferred treatment option in NHS Lothian refer to Safe Use of Medicines – Policy Online for further guidance in the procedures for prescribing non formulary medicines and the policy on the use of unlicensed (and off-label) medicines procedure. 

For treatments continuing in primary care responsibility for monitoring to be agreed, refer to individual board shared care policies for more information. In NHS Lothian refer to Safe Use of Medicines – Policy Online for further guidance. 

The British Society for Rheumatology and Scottish Paediatric and Adolescent Rheumatology Network (SPARN) websites include useful supporting information. However, some of the treatment guidelines are due for update. Locally, specialists refer to the current edition of the Paediatric Rheumatology (Oxford Specialist Handbook in Paediatrics). Please consult up to date BNFc and product literature for full information. 

Prescribing Notes:

For children at high risk of gastro-intestinal adverse events:

• First choice would be to avoid a NSAID. Second choice, prescribe a NSAID + omeprazole.
• Children at ‘high risk’ of developing serious gastro-intestinal adverse events include: 
  • Children with previous peptic ulcer 
  • Children with previous GI bleed 
  • Children receiving systemic corticosteroids 
  • Children receiving anticoagulants 
  • Children requiring very high dose NSAIDs [greater than 120% average daily dose] 
• Consider whether an NSAID is required; regular dosing of paracetamol is often adequate for pain. 
• All long-term use of NSAIDs in children should be under the guidance of a specialist. 
• Relative contra-indications to NSAIDs include heart failure, hypertension, renal impairment, history of gastro-intestinal bleeding, coagulation defects; absolute contra-indications include proven hypersensitivity to aspirin or any NSAID. 
• NSAIDs may worsen asthma; they are contra-indicated if aspirin or any other NSAID has precipitated attacks of asthma, although this rarely occurs in children. 
• Naproxen is an alternative NSAID which combines good efficacy with a low incidence of side-effects.  
• Naproxen is associated with a 10% risk of blistering skin rash in blonde, blue eyed, non-tanning children. 
• Diclofenac e/c tablets are only suitable for children who are able to swallow tablets whole. Naproxen oral suspension may be a suitable alternative preparation for patients who cannot swallow tablets. For those patients in whom naproxen is not a suitable choice the rheumatology team will advise.  
• If other therapy is successful in controlling arthritis, then consider withdrawing NSAIDs especially in children receiving conventional DMARDs and drugs affecting the immune system (see DMARD and biologic pathways). 

Prescribing Notes:

• Corticosteroids should ideally only be commenced after liaison with a rheumatologist, and a steroid card given in every case. 
• Patient/parent/carer should be provided with written information and given the opportunity to discuss the benefits and risks of long-term corticosteroids before treatment is commenced. 
• Further weekly doses of intravenous methylprednisolone sodium succinate may be required for some patients on the advice of a specialist.  
• The requirement for prophylactic bone protection in children is uncertain. However, this should be considered for children receiving long-term corticosteroids. 
• Long-term steroids should be withdrawn gradually. 
• In patients receiving high doses of corticosteroids consider assessment for adrenal suppression using a short Synacthen (tetracosactide) test. 
• For patients with swallowing difficulties prednisolone oral solution or soluble tablets may be considered. Prednisolone tablets may be dispersed in water as an alternative to soluble tablets or oral solution preparations. This is an off-label use but more cost-effective option. Refer to local board policies on the use of unlicensed (and off-label) medicines for further guidance.
• The British Society for Rheumatology and Scottish Paediatric and Adolescent Rheumatology Network (SPARN) websites include useful supporting information. However, some of the treatment guidelines are due for update and/or may not have had pharmacist peer review. Locally, specialists refer to the current edition of the Paediatric Rheumatology (Oxford Specialist Handbook in Paediatrics). Please consult up to date BNFc and product literature for full information. 

Prescribing Notes:

• Note product discontinuations and (MSAN 2025) 16 for Triamcinolone acetonide. 
• Children requiring joint injections may require general anaesthesia or sedation. Factors to consider include: patients age, the number and the type of joints affected. In children> 5 years Entonox may be considered for some patients. Older children can be administered intra-articular injections with a topical local anaesthetic, e.g. Emla cream. 

Prescribing Notes:

• The medicines in this pathway are for use within specialist rheumatology services including those working within the paediatric rheumatology network.
• DMARDs are used for paediatric rheumatology conditions at the discretion of a specialist experienced in the management of the condition, the order of choices in this pathway is therefore not intended to guide treatment choice.
• For use of intravenous immunoglobulin refer to Scottish IVIG guidelines. 
• Methotrexate is the first choice in the majority of rheumatic diseases but in certain conditions other agents may be preferred first e.g. lupus. 
• Risks/benefits of DMARDS and drugs affecting the immune response should be discussed with the patient/parent/carer before commencing using a written information sheet available from the Versus Arthritis website or RHCYP. 
• DMARDs are appropriate for a shared care arrangements to facilitate the seamless transfer of individual patient care from secondary care to general practice. 
• The MHRA has received reports of prescription and dispensing errors for methotrexate that have resulted in serious and fatal adverse reactions. Methotrexate tablets should be prescribed in 2.5mg strength only. The 10mg strength should not be used since they may be confused with the 2.5mg tablets. 
• The use of oral methotrexate for non-malignant conditions such as rheumatoid arthritis has been highlighted nationally as a potential risk for fatal medication errors. New measures have been implemented to prompt healthcare professionals to record the day of the week for intake and to remind patients of the dosing schedule and the risks of overdose due to continued reports of inadvertent overdose. For further advice see MHRA Drug Safety Update September 2020. 
• Patients who have a partial response to or intolerance of oral methotrexate may be switched to subcutaneous methotrexate under the guidance of a rheumatologist. 
• Subcutaneous methotrexate should only be given by individuals trained to administer methotrexate competently. 
• Providing monitoring procedure is followed, NSAIDs may be prescribed with methotrexate. However, the need for NSAID therapy should be reviewed once methotrexate becomes effective. 
• Calcium folinate (folinic acid) 15mg orally or by injection may be an alternative for children who are unwilling to take folic acid due to gastro-intestinal intolerance or its unpalatability.
• All children must be adequately monitored refer to SPARN guidelines/BNFc/SPC for full details for the medication in question.   
• Azathioprine is sometimes used as an adjunct to infliximab. 
• Concurrent use of ciclosporin and corticosteroids is common and advantageous but be alert for any evidence of increased ciclosporin and corticosteroid adverse effects. 

Prescribing Notes:

• Management of non-bacterial osteitis is directed by a specialist paediatric rheumatology prescriber experienced in the management of the condition, use is in line with relevant local or national guidance. 
• Refer to guidance for chronic non-infective osteitis and bisphosphonate guidelines available from the Scottish Paediatric and Adolescent Rheumatology Network (SPARN).  
• For formulary recommendations for bisphosphonates see “Treatment of osteoporosis secondary to another condition in children”.