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Royal United Hospitals Bath NHS Foundation Trust
Great Western Hospitals NHS Foundation Trust
Salisbury NHS Foundation Trust
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 Formulary Chapter 6: Endocrine system - Full Chapter
Notes:

Endocrine-related Prescribing Guidance

Please see our Prescribing Guidelines page for all prescribing guidance relating to this chapter.

Endocrine-related Shared Care Agreements

Please see our Shared Care Agreements page for all shared care agreements (SCAs) relating to this chapter.

 

 Details...
06.01.02.03  Expand sub section  Other antidiabetic drugs
06.01.02.03  Expand sub section  Alpha glucosidase inhibitors
06.01.02.03  Expand sub section  DPP4 inhibitors (gliptins)
Alogliptin
(Tablets)
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First Choice
traffic lightGreen
  • 6.25mg, 12.5mg, 25mg
  • Not licensed for monotherapy and no data to support the use of alogliptin with metformin & a sulphonylurea in triple oral therapy
  • First line DPP-4 for all new patients who fulfil criteria in accordance with NICE guidance NG28 December 2015
  • Most cost-effective gliptin
  • Renal Impairment: See SPC for dose adjustments
 
Linagliptin
(DPP4 inhibitor ,Tablet)
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Formulary
traffic lightGreen
  • 5mg
  • Note: Licensed as monotherapy, dual therapy with metformin, triple therapy (SU+metformin), Insulin add on (plus or minus metformin). 
  • No dose reduction in renal impairment
 
Link  MHRA Dec 2014 - Gliptins: risk of acute pancreatitis
 
Sitagliptin
(DPP4 inhibitor ,Tablet)
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Formulary
traffic lightGreen
  • 50mg,100mg
  • licensed for use in a triple combination.
  • Renal Impairment: See SPC for dose adjustments
 
Link  MHRA Dec 2014- Gliptins: risk of acute pancreatitis
 
06.01.02.03  Expand sub section  GLP1 agonists
 note 

NICE NG28 May 2017: Type 2 diabetes in adults: management

Initiation of GLP1s:

If triple therapy with metformin and 2 other oral drugs is not effective, not tolerated or contraindicated, consider combination therapy with metformin, a sulfonylurea and a glucagon-like peptide-1 (GLP-1) mimetic for adults with type 2 diabetes who:

  • have a BMI of 35 kg/m2 or higher (adjust accordingly for people from black, Asian and other minority ethnic groups) and specific psychological or other medical problems associated with obesity or
  • have a BMI lower than 35 kg/m2 and:

  • for whom insulin therapy would have significant occupational implications or weight loss would benefit other significant obesity-related comorbidities.

Continuation of GLP1s:

Only continue GLP-1 mimetic therapy if the person with type 2 diabetes has had a beneficial metabolic response (a reduction of at least 11 mmol/mol [1.0%] in HbA1c and a weight loss of at least 3% of initial body weight in 6 months).

Use of GLP1s with insulin:

In adults with type 2 diabetes, only offer a GLP-1 mimetic in combination with insulin with specialist care advice and ongoing support from a consultant-led multidisciplinary team.

June 2019 DSU GLP-1 receptor agonists: reports of diabetic ketoacidosis when concomitant insulin was rapidly reduced or discontinued

BSW Quick Ref Guide – PresQIPP Ensuring appropriate quantities of GLP-1 mimetics are prescribed

 

 

Lixisenatide
(Once Daily Injection)
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Formulary
  •  Green BaNES and Wiltshire - can be initiated in primary care where a healthcare professional feels they have sufficient knowledge to initiate without specialist support 
  •  Amber Swindon 

  • 10micrograms/0.2ml. 3ml pre-filled pen (for titration dose only)
  • 20microgams/0.2ml. 3ml pre-filled pen (1 pack containing 2 pens is sufficient for 30 days)

 

 

 
 
Dulaglutide
(Once Weekly Injection)
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Formulary
  •  Green BaNES and Wiltshire - can be initiated in primary care where a healthcare professional feels they have sufficient knowledge to initiate without specialist support 
  •  Amber Swindon 
  • 0.75mg/0.5ml, 1.5mg/0.5ml, 3mg/0.5ml, 4.5mg/0.5ml prefilled pen.
  • Each pen delivers ONE dose. One pack contains 4 pens which is sufficient for 4 weeks
 
 
Exenatide (prolonged release)
(Bydureon)
(Once Weekly Injection)
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Formulary
  •  Green BaNES and Wiltshire - can be initiated in primary care where a healthcare professional feels they have sufficient knowledge to initiate without specialist support 
  •  Amber Swindon 
  • 2 mg prolonged-release suspension for injection in pre-filled pen.
  • Each pen delivers ONE dose. One pack contains 4 pens which is sufficient for 4 weeks. 
 
 
Liraglutide (Victoza )
(Once Daily Injection )
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Formulary
  • Amber Swindon 
  • Green BaNES and Wiltshire - can be initiated in primary care where a healthcare professional feels they have sufficient knowledge to initiate without specialist support  
  • 6mg/ml solution for injection in 3ml prefilled pens. 
  • For a 1.2mg daily dose; 2 x 6mg/ml, 3ml pens will be sufficient for 30 days.
  • For a 1.8mg daily dose; 3 x 6mg/ml, 3ml pens will be sufficient for 30 days.

  • Note variation in licensing of different brands of liraglutide:
    Victoza® is licensed for insufficiently controlled type 2 diabetes
    Saxenda® is licensed for obesity indications (see separate entry below)

 

 
 
Semaglutide
(Once Weekly Injection)
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Formulary
  •  Green BaNES and Wiltshire - can be initiated in primary care where a healthcare professional feels they have sufficient knowledge to initiate without specialist support 
  •  Amber Swindon 
  • 0.25mg/0.19ml. 1.5ml pre-filled pen (For titration dose only)
  • 0.5mg/0.37ml. 1.5ml pre-filled pen (One pen is sufficient for four weeks)
  • 1mg/0.74ml. 3ml pre-filled pen (One pen is sufficient for four weeks).

 

 
 
Exenatide (Immediate-release)
(Byetta)
(Twice Daily Injection )
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Formulary
  •  Green BaNES and Wiltshire - can be initiated in primary care where a healthcare professional feels they have sufficient knowledge to initiate without specialist support 
  •  Amber Swindon 
  • 5 micrograms/0.02ml. 1.2ml pre-filled pen
  • 10 micrograms/0.04ml. 2.4ml pre-filled pen
  • Each pack contains one pen containing 60 doses and is sufficient for 30 days  
 
 
Semaglutide
(Oral tablet)
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Formulary
traffic lightAmber
  • 3mg,7mg,14mg tablets. Unique oral GLP1 receptor agonist
  • Indicated as an adjunct to diet and exercise for adults with insufficiently controlled TD2. Should not be used in patients with T1D or for the treatment of diabetic ketoacidosis.
  • Reserved for patients who are unable to self-administer an injectable GLP1 formulation or where the patient is refusing to consider an injectable therapy due to needle phobia, despite involvement of health care professionals. 
  • Injectable GLP1s remain first line.
  • Note specific administration instructions; should be taken on an empty stomach, swallowed whole with ≤120ml of water (preferably a sip), and no food, drink or other oral medicines should be taken for up to 30 mins (see guidance below).
  • Oral semaglutide has an AMBER TLS (no shared care) "considered suitable for GP prescribing following specialist initiation or recommendation".
  • The TLS and positioning of oral vs injectable formulations will be reviewed by the BSW APC when there is established use and experience of this novel formulation.
 
Link  BSW Prescribing Guidance for Oral Semaglutide Jan 2021
 
Liraglutide (Saxenda )
(Once Daily Injection )
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Formulary
traffic lightRed
  • Liraglutide 6mg/ml solution for injection 3ml pre-filled pens (Saxenda®) 
  • Included on the BSWformulary in line with NICE as an option for managing overweight and obesity alongside a reduced-calorie diet and increased physical activity in adult patients meeting the criteria defined in NICE TA664.

  • The use of liraglutide for this indication is restricted to prescribing in secondary care by a specialist MDT tier 3 weight management service in order to be able to access the PAS discount.  

 

 
Link  NICE TA664: Liraglutide for managing overweight and obesity
 
06.01.02.03  Expand sub section  Meglitinides to top
Repaglinide
(Tablet)
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Formulary
  • Green Swindon
  • Amber Bath
  • Not on formulary at Salisbury
  •  500 microgams, 1mg, 2mg
  • Only to be prescribed in patients for whom gliclazide is not appropriate or in patients with renal failure following specialist initiation / recommendation. 

 

 
 
06.01.02.03  Expand sub section  SGL2 inhibitors
 note 

BSW Use of SGLT2s in Diabetes during COVID-19

MHRA April 2016 -SGLT2 inhibitors: updated advice on the risk of diabetic ketoacidosis

MHRA Feb 2019 - SGLT2 inhibitors: reports of Fournier’s gangrene (necrotising fasciitis of the genitalia or perineum)

MHRA March 2017 - SGLT2 inhibitors: updated advice on increased risk of lower-limb amputation (mainly toes)

MHRA March 2020 SGLT2 inhibitors: monitor ketones in blood during treatment interruption for surgical procedures or acute serious medical illness

Renal impairment: See individual SPCs for dose adjustments.

Empagliflozin
(Tablet)
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Formulary
  • 10mg and 25mg
  • Green FOR USE IN COMBINATION WITH OTHER ORAL PRODUCTS FOR THE TREATMENT OF TYPES 2 DIABETES
  • Amber IF USED IN COMBINATION WITH INSULIN IN TYPE 2 DIABETES FOLLOWING NICE GUIDANCE ONLY
 
Link  NICE TA336 March 2015: Empagliflozin in combination therapy for treating type 2 diabetes
Link  NICE TA390 May 2016: Canagliflozin, dapagliflozin and empagliflozin as monotherapies for treating type 2 diabetes
 
Ertugliflozin
(Tablet)
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Formulary
  • 5mg and 15mg
  • Green FOR USE IN COMBINATION WITH OTHER ORAL PRODUCTS FOR THE TREATMENT OF TYPE 2 DIABETES
 
Link  NICE TA572 March 2019: Ertugliflozin as monotherapy or with metformin for treating type 2 diabetes
Link  NICE TA 583 June 2019 - Ertugliflozin with metformin and a dipeptidyl peptidase-4 inhibitor for treating type 2 diabetes
 
Canagliflozin
(Tablet)
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Formulary
  • 100mg and 300mg
  • Green  FOR USE IN COMBINATION WITH OTHER ORAL PRODUCTS FOR THE TREATMENT ON TYPE 2 DIABETES
  • Amber IF USED IN COMBINATION WITH INSULIN IN TYPE 2 DIABETES FOLLOWING NICE GUIDANCE ONLY
 
Link  NICE TA315 June 2014: Canagliflozin in combination therapy for treating type 2 diabetes
Link  NICE TA390 May 2016: Canagliflozin, dapagliflozin and empagliflozin as monotherapies for treating type 2 diabetes
 
Dapagliflozin
(Tablets)
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Formulary
  • 5mg, 10mg tablets
  • Green FOR USE IN COMBINATION WITH OTHER ORAL PRODUCTS FOR THE TREATMENT IF TYPE 2 DIABETES
  • Amber IF USED IN COMBINATION WITH INSULIN IN TYPE 2 DIABETES FOLLOWING NICE GUIDANCE ONLY
  • Red IF USED IN COMBINATION WITH INSULIN IN TYPE 1 DIABETES FOLLOWING NICE GUIDANCE ONLY. NOTE: Only the 5mg strength is licensed for this indication. Prescribing should be retained by secondary care although GPs will need to prescribe ketone test strips for type 1 diabetes patients to use whilst on dapagliflozin.
  • March 2021 update: The licence for dapagliflozin now includes the treatment of symptomatic chronic heart failure with reduced ejection fraction. Dapagliflozin is currently NOT included on the BSW formulary for this indication and should not be prescribed for HF. NICE published a positive TA recommendation for this on 24th February 2021 and local guidance is being developed. The BSW APC will deal with this TA in due course to make it available.
 
Link  NICE TA288 November 2016: Dapagliflozin in combination therapy for treating type 2 diabetes
Link  NICE TA390 May 2016: Canagliflozin, dapagliflozin and empagliflozin as monotherapies for treating type 2 diabetes
Link  NICE TA418 November 2016 Dapagliflozin in triple therapy for treating type 2 diabetes
Link  NICE TA597 August 2019: Dapagliflozin with insulin for treating type 1 diabetes
 
Sotagliflozin
(Tablet)
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Formulary
  • 200mg tablet
  • NOTE: This drug is not available yet in the UK but will be included on BSWformulary for use with insulin for treating type 1 diabetes as per NICE TA622. 
  • BSW APC will determine Traffic Light Status etc once available (expected early 2021) 
 
Link  NICE TA622: Sotagliflozin with insulin for treating type 1 diabetes
 
06.01.02.03  Expand sub section  Thiazolidinediones
Pioglitazone
(Tablet)
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Formulary
traffic lightGreen
  • 15mg, 30mg, 45mg
  • Use in accordance with NICE NG28. 
 
Link  MHRA Dec 2014- Insulin combined with pioglitazone: risk of cardiac failure
Link  MHRA Dec 2014- Pioglitazone: risk of bladder cancer
 
 ....
 Non Formulary Items
Acarbose
(Tablet)

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Non Formulary
  • No new patients - no longer recommended in any national guidance.
 
Albiglutide (Eperzan)

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Non Formulary
 
Alogliptin / metformin
(Vipdomet)

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Non Formulary
 
Alogliptin / pioglitazone
(Incresync)

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Non Formulary
 
Canagliflozin / metformin IR
(Vokanamet)

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Non Formulary
 
Dapagliflozin / metformin
(Xigduo)

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Non Formulary
 
Empagliflozin + linagliptin
(Glyxambi)

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Non Formulary
 
Empagliflozin and Metformin
(Synjardy)

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Non Formulary
 
Insulin degludec and liraglutide
(Xultophy)

View adult BNF View SPC online
Non Formulary
Link  New risk materials for healthcare professionals to use when prescribing Xultophy
 
Linagliptin/ metformin
(Jentadueto)

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Non Formulary
 
Nateglinide (Starlix)

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Non Formulary
 
Pioglitazone and Metfomin
(Competact)

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Non Formulary

Prescribe as separate ingredients. See Prescribe Well Spend Less

 
Rosiglitazone (Avandia)

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Non Formulary
 
Rosiglitazone and Metformin
(Avandamet)

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Non Formulary
 
Saxagliptin (Onglyza)

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Non Formulary
 
Saxagliptin and metformin
(Komboglyze)

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Non Formulary
 
Sitagliptin and Metformin
(Janumet)

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Non Formulary
 
Vildagliptin

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Non Formulary
 
  
Key
note Notes
Section Title Section Title (top level)
Section Title Section Title (sub level)
First Choice Item First Choice item
Non Formulary Item Non Formulary section
Restricted Drug
Restricted Drug
Unlicensed Drug
Unlicensed
Track Changes
Display tracking information
click to search medicines.org.uk
Link to adult BNF
click to search medicines.org.uk
Link to SPCs
SMC
Scottish Medicines Consortium
Cytotoxic Drug
Cytotoxic Drug
CD
Controlled Drug
High Cost Medicine
High Cost Medicine
Cancer Drugs Fund
Cancer Drugs Fund
NHSE
NHS England
Homecare
Homecare
CCG
CCG
Blueteq
High Cost Drug Approval System

Traffic Light Status Information

Status Description

Traffic LightRed

RED - Hospital only to be prescribed by a specialist and supplied from secondary care ONLY throughout treatment.  

Traffic LightAmber

Amber medicines are considered suitable for GP prescribing following specialist initiation or recommendation.  

Traffic LightAmber with Shared Care

Shared Care - these medicines require specialist initiation and stabilisation. Ongoing division of responsibility for drug and disease monitoring between specialist and GP by a Shared Care Guideline (SCG). If no SCG in place status reverts to red.  

Traffic LightGreen

These medicines are appropriate for initiation in both primary and secondary care. Prescribing is appropriate within licensed or local recommendations.  

Traffic LightSelf

Suitable for patient to be directed to buy themselves  

Traffic LightGrey

Not currently used. We intend to include this TLS in future to highlight where a decision to use this medicine is under review.   

Traffic LightBlack

(In use from Oct 2020) Used where a decision has been made by the BSW APC not to routinely commission this preparation for its licensed indications. Do not prescribe.   

Traffic LightRed Specialist Centre

Not currently used. We intend to include this TLS in future to highlight where this medicine and indication is ONLY available through a Specialist Centre according to a NICE Highly Specialised Technology or NHSE Specialised Commission Circular / Policy.  

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