Injection 100 units/mL,
Penfill® cartridge for Fiasp® devices
Flextouch® prefilled disposable injection devices
Fiasp® and NovoRapid® are not interchangeable due to differences in bioavailability.

Must be commenced by a healthcare professional who is appropriately trained and experienced in the initiation of insulin.
Insulin Aspart (Fiasp®) is recommended for the treatment of diabetes mellitus in adults who are suitable for NovoRapid® and their diabetes cannot be adequately managed with alternative formulary choices and at least one of the following applies:
- where the prescriber believes a faster onset of action would be beneficial to the patient
- where a patient requires ‘tight’ control of blood sugar levels
- where a patient has rapid post meal increase in blood sugar levels

Injection 100 units/mL,

Solution for injection in vial

Solution for injection in cartridge

KwikPen® solution for injection in pre-filled pen

Junior KwikPen® solution for injection in pre-filled pen

Insulin Lispro (Lyumjev®) is recommended for the treatment of diabetes mellitus in adults who are suitable for Humalog® and their diabetes cannot be adequately managed with alternative formulary choices and at least one of the following applies:

-Where the prescriber believes a faster onset of action would be beneficial to the patient
- Where a patient requires ‘tight’ control of blood sugar levels
- Where a patient has rapid post-meal increase in blood sugar levels

First choice insulin aspart in new users

10mL vial
3mL cartridge for NovoPen®
3mL prefilled disposable FlexPen®

Biosimilars are first line

3mL cartridge AutoPen® or HumaPen®
3mL prefilled disposable Humalog®Mix25 KwikPen®

Second line biphasic short-acting analogue insulin (Humalog Mix Kwikpen)

3mL cartridge AutoPen® or HumaPen®
3mL prefilled disposable Humalog®Mix50 KwikPen®

Second line biphasic short-acting analogue insulin (Humalog Mix Kwikpen)

10mL vial
3mL cartridge for AutoPen® or HumaPen®
3mL pre-filled disposable Humulin M3® KwikPen®

First line biphasic human insulin (Humulin M3 Kwikpen)

3mL cartridge for Innovo® or NovoPen®
3mL prefilled disposable FlexPen®

First line biphasic short-acting analogue insulin (Novomix 30 Flexpen)

10mL vial
3mL cartridge for AutoPen® or HumaPen®
3mL prefilled disposable Humulin I® KwikPen®

First line isophane insulin (Humulin I Kwikpen)

10mL vial
3mL cartridge for NovoPen®

Second line isophane insulin (Insulatard penfill)

3mL cartridge 100units/mL
3mL prefilled disposable Pen 100units/mL

First choice in new users

10mL vial
3mL cartridge for OptiPen® Pro 1
3mL prefilled disposable pen SoloSTAR®

Lantus® brand is not a preferred product in the LSCMMG antihyperglycaemics guideline. Biosimilars of Insulin glargine are also available for the treatment of NEW patients and patients assessed to need a medication change. Treatment should normally be started with the least expensive drug.

Pre-filled pen 300 units/mL

First line high strength long acting insulin (Toujeo Solostar)

Type 1 - in accordance with the recommendations in NICE NG17 and in those who experience an unacceptable frequency and/or severity of nocturnal hypoglycaemia on attempting to achieve better glycaemic control during treatment with first-line long-acting insulin analogues; or as a once daily insulin therapy for patients who require assistance with administering injections.

Type 2 - in accordance with the recommendations in NICE NG28 in those who suffer from symptomatic nocturnal hypoglycaemia whilst being treated with a first-line long-acting insulin analogue.

100 units/ml 3ml cartridges
100units/ml pre-filled pens Flextouch
200units/ml pre-filled pens Flextouch

Must be commenced by a healthcare professional who is appropriately trained and experienced in the initiation of insulin
Specialists may exceptionally consider initiating insulin degludec if:
- Patient is experiencing poor glycaemic control or recurrent hypoglycaemic episodes with their existing long-acting insulin analogue or
- Patient is unable to take basal insulin at the same time each day

Second line high strength long-acting (Tresiba FlexTouch 200).
Third line long acting insulin analogue (Tresiba Flextouch 100).

For supply via secondary care only with Blueteq approval.

Classified as  Red in secondary care and
 in Primary Care

FreeStyle Libre, Dexcom

 FreeStyle Libre® 3

Only for patients with a diagnosis of diabetes.

Tablets 80mg
M/R tablets 30mg

First choice

Tablets 1mg, 2mg, 3mg, 4mg

Second line

Patients may remain on tolbutamide but not recommended in new patients

Tablets 500mg, 850mg

M/R tablets 500mg, 750mg, 1g

Only consider using modified release metformin if the patient cannot tolerate immediate release metformin.            

Treatment of type 2 diabetes mellitus, particularly in overweight patients, when dietary management and exercise alone does not result in adequate glycaemic control

Reduction in the risk or delay of the onset of type 2 diabetes mellitus in adult, overweight patients with implied Glucose Tolerance and/or increased HbA1C who are at high risk for developing overt type 2 diabetes mellitus and still progressing towards type 2 diabetes mellitus despite implementation of intensive lifestyle change for 3-6 months.

Tablets 500micrograms, 1mg, 2mg

First line to stimulate insulin release

Tablets 6.25mg, 12.5mg, 25mg
 
First line gliptin on LSCMMG pathway

Tablets 100mg
 
Second line gliptin on LSCMMG pathway

Tablets 5mg

Second line gliptin on LSCMMG pathway for patients with renal impairment.
 
  

Tablets 100mg, 300mg

First line gliflozin

Tablets 5mg, 10mg

First line gliflozin

 ICB commissioned for NICE TA775 Dapagliflozin for treating chronic kidney disease 

Tablets 10mg, 25 mg

First line gliflozin

Tablets 5mg, 15mg

Restriction - only to be used as second line

Pre-filled pen 0.75mg/0.5mL, 1.5mg/0.5mL

First line GLP-1 agonist

prolonged-release suspension for injection in pre-filled pen (BCise) 2mg

Third line GLP-1 agonist

Injection 6mg/mL pre-filled pen

Second line GLP-1 agonist, if daily administration preferred.
Prescribe by brand.

Managing overweight and obesity.
Prescribe by brand.

Solution for injection - pre-filled pen 0.25mg, 0.5mg, 1mg

First line GLP-1 agonist.

Prescribe by brand.

Tablets 3mg, 7mg, 14mg

First line GLP-1 agonist.

Alternative GLP-1 receptor agonist for patients who are unable to use subcutaneous formulations or patients who prefer oral administration. 

Managing overweight and obesity.

Prescribe by brand.

Type 2 Diabetes

Preference of agent should be decided based on the clinician’s judgement about patient characteristics. Local specialists have suggested the following: 

1. Semaglutide (or other available GLP-1 RAs) may be preferred in patients with lower BMIs e.g. < BMI 35 kg/m2 or patients who have established CVD or are at high risk of CV events and require an agent with proven CV benefit. 

2. Tirzepatide may be preferred in patients with higher BMIs e.g. > BMI 40 kg/m2 or who despite optimisation of all other therapies still require further glycaemic control.

Careful consideration MUST be given to stopping tirzepatide if ineffective or not tolerated (evidence of poor tolerance as dose escalates). Tirzepatide should be reviewed after 6 months, and the deprescribing of other agents, e.g. sulfonylureas and gliptins, should be considered where possible. 

As a minimum expectation, it is recommended that tirzepatide is only continued if the adult with type 2 diabetes has had a beneficial metabolic response (a reduction of at least 11 mmol/mol [1.0%] in HbA1c and weight loss of at least 3% of initial body weight in 6 months).

 Managing overweight and obesity

100iu/mL  pre-filled pens

Patients may remain on acarbose but not recommended in new patients.

Tablets 15mg, 30mg, 45mg

Prescribing of Ogluo devices should be reserved for patients for whom the preparation and administration of conventional glucagon kits presents a barrier to effective treatment of hypoglycaemia and a risk to patient welfare.

Tablets 4g

Consider OTC purchase

Tablets 50mg

Chronic intractable hypoglycaemia.

Tablets 20micrograms

  Liothyronine monotherapy for the management of chronic hypothyroidism – primary and secondary care.

 For the treatment of refractory / resistant depression (unlicensed use)

  Liothyronine therapy commenced in the private sector

 For the treatment of acute conditions where thyroid replacement is needed rapidly, for a limited period and/or where a drug with shorter half-life is required

  Add-on treatment for refractory hypothyroidism – existing patient (RED RAG for Pennine only for this indication)

  Add-on treatment for refractory hypothyroidism despite adequate replacement with levothyroxine – new patients (RED RAG for Pennine only for this indication)

Tablets 5mg, 20mg

CSM warning: neutropenia and agranulocytosis

Manufacturer advises of the importance of recognising bone marrow suppression induced by carbimazole and the need to stop treatment promptly.

Warn patients that if a sore throat develops, in the first 6-8 weeks of therapy they should stop treatment and seek medical advice.

Also known as Lugol's solution

Thyrotoxicosis (pre-operative).

Tablets 100micrograms

Fludrocortisone has very high mineralocorticoid activity and insignificant glucocorticoid activity. A combination of hydrocortisone and fludrocortisone are needed in primary adrenal deficiency states.

Soluble tablets 500micrograms

Tablets 500micrograms, 2mg
Liquid 2mg/5mL, 500micrograms/5mL, 10mg/5mL

Tablets 10mg, 20mg

Tablets 1mg, 5mg
e/c tablets 2.5mg

25mg tablets are classified as 

There is no evidence that e/c prednisolone reduces the risk of gastrointestinal side effects. Uncoated tablets should be prescribed first line together with a PPI if necessary.

Injection 4mg/1mL

Should only be used for patients in whom oral prednisolone is not tolerated due to cushingoid side effects.

Granules in capsules for opening 0.5mg, 1mg, 2mg

For replacement therapy of adrenal insufficiency in children and adolescents (from birth to <18 years old)

Treatment of congenital adrenal hyperplasia (CAH) in adolescents aged 12 years and over and adults.

Injection 100mg/1mL

Injection 100mg vial

Intra-articular/intramuscular injection 40mg/1mL

Bijuve® is an alternative when other HRT treatments have not been tolerated or when Femoston-Conti® is being considered OR
> Bijuve replaces HRT regimens where separate oestrogen and micronised progesterone are used (single hormone products used in combination are more expensive than Bijuve®).

Implant 50mg

For patients who cannot tolerate other formulations.

Tablets 1mg, 2mg

Oestrogen only for women without a uterus

Tablets 10micrograms, 50micrograms

Tablets 60mg

  Secondary prevention of osteoporosis (NICE TA161)

   Primary prevention of osteoporosis in postmenopausal women - not recommended by NICE TA160 updated

Oestrogel Pump 0.06% pack gel
Sandrena gel sachets 500mcg, 1mg

2nd line agent for patients with allergy/skin reactions to patches.

Tablets 5mg, 10mg

Tablets 5mg

Pessaries 200mg, 400mg

Used in specialist pre-term birth clinic and for patients with recurring miscarriage following IVF.

Capsules 100mg

Vaginal capsules 200mg

 Approved 'off label' for specialist use only as per NICE NG126: Ectopic pregnancy and miscarriage: diagnosis and initial management.

Tablets 5mg
 

In accordance with NICE NG88, ulipristal should only be used for intermittent treatment of moderate to severe symptoms of uterine fibroids before menopause and when surgical procedures (including uterine fibroid embolisation) are not suitable or have failed.

Consult LSCMMG shared guidance for advice on brand selection

Female sexual dysfunction following oophorectomy or primary ovarian failure.

Tablets 50mg

For indications other than oncology

Dutasteride is restricted for a high risk patient group, used in combination with tamsulosin in patients with moderate to severe symptoms (IPSS>12) with larger prostates (>30cc) and elevated PSA (>1.5ng/mL).

For diagnostic use

24mg solution for injection for pre filled pen

60mg solution for injection for pre filled pen

Prescribe by brand.

Injection 75units FSH/75units LH amp with solvent

Prescribe by brand.

Injection 250micrograms

Diagnostic 30-minute test.

Tablets 100micrograms, 200micrograms
Nasal spray 10micrograms/metered spray

In adults, 1st line tablets, 2nd line nasal/injection (choose most cost effective option), 3rd line desmomelts

Injection 0.12mg/mL

Tablets 7.5mg, 15mg, 30mg, 45mg, 60mg, 90mg

Autosomal dominant polycystic kidney disease (TA358) 

Treatment of hyponatremia in adults, secondary to the syndrome of inappropriate antidiuretic hormone secretion (SIADH) (No Blueteq form required).

 Treatment of SIADH in patients requiring cancer chemotherapy is NHS England commissioned  

 Caution when prescribing - There is variation in the licensing of different products containing tolvaptan. Care should be taken to prescribe the correct product and dose for the indication.

Osteoporosis after menopause.

Injection 100units/1mL

Injection 750micrograms/3mL prefilled pen

For specialist use only in accordance with NICE TA guidance (women) or NHS England commissioning policy (men).

Usually supplied to patients by a home delivery company

Burosumab is recommended, within its marketing authorisation, as an option for treating X‑linked hypophosphataemia (XLH) in adults.

Solution for injection in pre-filled pen 105mg

Tablets 70mg
Effervescent tablets 70mg

70mg tablets are once weekly.

First line for osteoporosis.

Intravenous infusion 30mg/10mL, 60mg/10mL, 90mg/10mL

First line for osteolytic lesions and bone pain

Treatment option for hypercalcaemia of malignancy

Paget's disease

Injection 3mg/3mL pre-filled syringe

Alternative monthly bisphosphonate when alendronic acid is not appropriate.

(Bondronat®) Tablets 50mg: Oral alternative bisphosphonate for patients with breast cancer

Second line for osteoporosis.

Alternative weekly preparation when alendronic acid is not appropriate.

Capsules 400mg

Tablets 800mg

Oral alternative for patients with multiple myeloma

(Aclasta®) Specialist use in osteoporosis

Second choice treatment in Paget's disease

(Zometa ®) Second line for osteolytic lesions and bone pain treatment option for hypercalcaemia of malignancy

Injection 60mg/mL pre-filled syringe

Licensed for treatment of postmenopausal osteoporosis in women at increased risk of fractures and for the treatment of bone loss associated with hormone ablation in men with prostate cancer. See NICE guideline TA204

Treatment of bone loss associated with long-term systemic glucocorticoid therapy in adult patients at increased risk of fracture

Injection 120mg vial

Injection 120mg/ml pre-filled syringe

Granules 2g/sachet

Treatment of severe osteoporosis

- in postmenopausal women;

- in adult men

at high risk of fracture, for whom treatment with other medicinal products approved for the treatment of osteoporosis is not possible due to, for example, contraindications or intolerance. In postmenopausal women, strontium ranelate reduces the risk of vertebral and hip fractures.

The decision to prescribe strontium ranelate should be based on an assessment of the individual patient's overall risks

Tablets 200mg

Specialist use only.

Capsules 250mg

Tertiary Service Only

Idiopathic hyperandrogenism and polycystic ovary syndrome

 (unlicensed)

Tablets 2.5mg

Hyperprolactinaemic disorders.

Healthcare professionals are reminded that bromocriptine should only be used for prevention or suppression of postpartum lactation where medically indicated, in cases such as intrapartum loss, neonatal death, or a mother with HIV infection. It should not be used for routine suppression of lactation, or for relieving symptoms of postpartum breast pain and engorgement. Blood pressure should be carefully monitored, especially during the first days of treatment.

Tablets 500micrograms, 1mg, 2mg

Hyperprolactinaemic disorders.

Hyperprolactinaemic disorders.

Third line.

Moderate to severe symptoms of uterine fibroids.

Tablets : Estradiol (as Estradiol hemihydrate) 1 mg, Norethisterone acetate 500 microgram, Relugolix 40 mg

Implant 3.6mg, 10.8mg

Injection 3.75mg, 11.25mg vial with vehicle filled syringe

Injection, (powder for suspension), m/r, triptorelin (as acetate),3-mg vial (with diluent, 11.25-mg vial (with diluent), 22.5mg vial (with diluent)