| Formulary Chapter 6: Endocrine system - Full Chapter
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 LSCMMG: Trans Female Gender Dysphoria Information Sheet |
| LSCMMG: Trans Male Gender Dysphoria Information Sheet |
| Details... |
| 06.01.02.03 |
Other antidiabetic drugs |
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Repaglinide
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Formulary
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Tablets 500micrograms, 1mg, 2mg
First line to stimulate insulin release
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DPP-4 inhibitors |
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GLP-1 mimetics |
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DPP4 inhibitors (gliptins) |
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Alogliptin (Vipidia®)
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Formulary
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Tablets 6.25mg, 12.5mg, 25mg
First line gliptin on LSCMMG pathway
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 MHRA: Dipeptidylpeptidase-4 inhibitors: risk of acute pancreatitis
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Sitagliptin
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Formulary
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Tablets 100mg
Second line gliptin on LSCMMG pathway
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MHRA: Dipeptidylpeptidase-4 inhibitors: risk of acute pancreatitis
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Linagliptin (Trajenta®)
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Formulary
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Tablets 5mg
Second line gliptin on LSCMMG pathway for patients with renal impairment.
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MHRA: Dipeptidylpeptidase-4 inhibitors: risk of acute pancreatitis
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Sitagliptin & Metformin
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Formulary
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Linagliptin/ metformin Jentadueto
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Formulary
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SGLT2 inhibitors |
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Canagliflozin (Invokana®)
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Formulary
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Tablets 100mg, 300mg
First line gliflozin
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MHRA Drug Safety Update Feb 2019: SGLT2 inhibitors: reports of Fournier’s gangrene (necrotising fasciitis of the genitalia or perineum)
MHRA Drug Safety Update April 2016: SGLT2 inhibitors: updated advice on the risk of diabetic ketoacidosis
MHRA Drug Safety Update March 2020: SGLT2 inhibitors: monitor ketones in blood during treatment interruption for surgical procedures or acute serious medical illness
MHRA: SGLT2 inhibitors: updated advice on increased risk of lower-limb amputation (mainly toes)
NICE TA315: Canagliflozin in combination therapy for treating type 2 diabetes
NICE TA390: Canagliflozin, dapagliflozin and empagliflozin as monotherapies for treating type 2 diabetes
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Dapagliflozin (Forxiga®)
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Formulary
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Tablets 5mg, 10mg
First line gliflozin
ICB commissioned for NICE TA775 Dapagliflozin for treating chronic kidney disease
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NICE TA775: Dapagliflozin for treating chronic kidney disease
MHRA Drug safety Update Feb 2019: SGLT2 inhibitors: reports of Fournier’s gangrene (necrotising fasciitis of the genitalia or perineum)
MHRA Drug Safety Update April 2016: SGLT2 inhibitors: updated advice on the risk of diabetic ketoacidosis
MHRA Drug Safety Update December 2021: Dapagliflozin (Forxiga): no longer authorised for treatment of type 1 diabetes mellitus
MHRA Drug Safety Update March 2020: SGLT2 inhibitors: monitor ketones in blood during treatment interruption for surgical procedures or acute serious medical illness
MHRA: SGLT2 inhibitors: updated advice on increased risk of lower-limb amputation (mainly toes)
NICE TA288: Dapagliflozin in combination therapy for treating type 2 diabetes
NICE TA390: Canagliflozin, dapagliflozin and empagliflozin as monotherapies for treating type 2 diabetes
NICE TA418: Dapagliflozin in triple therapy for treating type 2 diabetes
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Empagliflozin (Jardiance®)
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Formulary
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Tablets 10mg, 25 mg
First line gliflozin
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MHRA Drug Safety Update Feb 2019: SGLT2 inhibitors: reports of Fournier’s gangrene (necrotising fasciitis of the genitalia or perineum)
MHRA Drug Safety Update April 2016: SGLT2 inhibitors: updated advice on the risk of diabetic ketoacidosis
MHRA Drug Safety UpdateMarch 2020: SGLT2 inhibitors: monitor ketones in blood during treatment interruption for surgical procedures or acute serious medical illness
MHRA: SGLT2 inhibitors: updated advice on increased risk of lower-limb amputation (mainly toes)
NICE TA336: Empagliflozin in combination therapy for treating type 2 diabetes
NICE TA390: Canagliflozin, dapagliflozin and empagliflozin as monotherapies for treating type 2 diabetes
NICE TA942: Empagliflozin for treating chronic kidney disease
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Ertugliflozin  (Steglatro®)
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Formulary
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Tablets 5mg, 15mg
Restriction - only to be used as second line
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MHRA Drug Safety Update Feb 2019: SGLT2 inhibitors: reports of Fournier’s gangrene (necrotising fasciitis of the genitalia or perineum)
MHRA Drug Safety update June 2015: SGLT2 inhibitors (canagliflozin, dapagliflozin, empagliflozin): risk of diabetic ketoacidosis
MHRA Drug Safety Update March 2020: SGLT2 inhibitors: monitor ketones in blood during treatment interruption for surgical procedures or acute serious medical illness
MHRA: SGLT2 inhibitors: updated advice on increased risk of lower-limb amputation (mainly toes)
NICE TA572: Ertugliflozin as monotherapy or with metformin for treating type 2 diabetes
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Canagliflozin / metformin IR Vokanamet
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Formulary
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GLP1 agonists |
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Dulaglutide (Trulicity ®)
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Formulary
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Pre-filled pen 0.75mg/0.5mL, 1.5mg/0.5mL
First line GLP-1 agonist
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MHRA Drug Safety Update June 2019: GLP-1 receptor agonists: reports of diabetic ketoacidosis when concomitant insulin was rapidly reduced or discontinued
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Exenatide prolonged release (Bydureon (BCise)®)
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Formulary
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prolonged-release suspension for injection in pre-filled pen (BCise) 2mg
Third line GLP-1 agonist
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MHRA Drug Safety Update June 2019: GLP-1 receptor agonists: reports of diabetic ketoacidosis when concomitant insulin was rapidly reduced or discontinued
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Liraglutide (Victoza®)
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Formulary
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Injection 6mg/mL pre-filled pen
Second line GLP-1 agonist, if daily administration preferred.
Prescribe by brand.
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MHRA Drug Safety Update June 2019: GLP-1 receptor agonists: reports of diabetic ketoacidosis when concomitant insulin was rapidly reduced or discontinued
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Liraglutide (Saxenda)
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Formulary
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Managing overweight and obesity.
Prescribe by brand.
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MHRA: GLP-1 receptor agonists: reports of diabetic ketoacidosis when concomitant insulin was rapidly reduced or discontinued
MHRA: Ozempic▼(semaglutide) and Saxenda (liraglutide): vigilance required due to potentially harmful falsified products
NICE TA664: Liraglutide for managing overweight and obesity
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Semaglutide (Ozempic®)
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Formulary
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Solution for injection - pre-filled pen 0.25mg, 0.5mg, 1mg
First line GLP-1 agonist.
Prescribe by brand.
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MHRA: GLP-1 receptor agonists: reports of diabetic ketoacidosis when concomitant insulin was rapidly reduced or discontinued
MHRA: Ozempic▼(semaglutide) and Saxenda (liraglutide): vigilance required due to potentially harmful falsified products
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Semaglutide (Rybelsus®)
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Formulary
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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.
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MHRA: GLP-1 receptor agonists: reports of diabetic ketoacidosis when concomitant insulin was rapidly reduced or discontinued
National Patient Safety Alert
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Semaglutide (Wegovy®)
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Formulary
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Managing overweight and obesity.
Prescribe by brand.
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MHRA: GLP-1 receptor agonists: reports of diabetic ketoacidosis when concomitant insulin was rapidly reduced or discontinued
NICE TA875: Semaglutide for managing overweight and obesity
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Tirzepatide
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Formulary
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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
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LSCMMG: Mounjaro® (Tirzepatide) for Type 2 Diabetes Position Statement
LSCMMG: Tirzepatide - Managing overweight and obesity
NICE TA924: Tirzepatide for treating type 2 diabetes
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Insulin glargine/lixisenatide
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Formulary
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100iu/mL pre-filled pens
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Meglitinides |
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SGL2 inhibitors |
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Intestinal alpha glucosidase inhibitor |
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Acarbose
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Formulary
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Patients may remain on acarbose but not recommended in new patients.
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| 06.01.02.03 |
Thiazolidinediones |
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Pioglitazone
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Formulary
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Tablets 15mg, 30mg, 45mg
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MHRA: Insulin combined with pioglitazone: risk of cardiac failure
MHRA: Pioglitazone: risk of bladder cancer
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Pioglitazone & Metformin
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Formulary
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Key |
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Restricted Drug |
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Unlicensed |
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Link to adult BNF
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Link to children's BNF
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Link to SPCs
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Scottish Medicines Consortium |
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Cytotoxic Drug |
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Controlled Drug |
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High Cost Medicine |
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Cancer Drugs Fund |
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NHS England |
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Homecare |
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ICB |
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Low carbon footprint |
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Medium carbon footprint |
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High carbon footprint |
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| Status |
Description |
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Green:
Appropriate for initiation and ongoing prescribing in both primary and secondary care.
Generally, little or no routine drug monitoring is required. |
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Green (Restricted):
Appropriate for initiation and ongoing prescribing in both primary and secondary care provided:
Additional criteria specific to the medicine or device are met, or
The medicine or device is used following the failure of other therapies as defined by the relevant LSCMMG pathway.
Generally, little or no routine drug monitoring is required.
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Red medicines:
Medicine is supplied by the hospital for the duration of the treatment course.
Primary care initiation or continuation of treatment is not recommended unless exceptional circumstances such as specialist GP.
Red medicines are those where primary care prescribing is not recommended. These treatments should be initiated by specialists only and prescribing retained within secondary care. They require specialist knowledge, intensive monitoring, specific dose adjustments or further evaluation in use. If however, a primary care prescriber has particular specialist knowledge or experience of prescribing a particular drug for a particular patient it would not always be appropriate for them to expect to transfer that prescribing responsibility back to secondary care. There should be a specific reason and a specific risk agreement, protocol and service set up to support this.
Primary care prescribers may prescribe RED medicines in exceptional circumstances to patients to ensure continuity of supply while arrangements are made to obtain ongoing supplies from secondary care. |
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Amber level 0:
Suitable for prescribing in primary care following recommendation or initiation by a specialist.
Little or no specific monitoring required.
Patient may need a regular review, but this would not exceed that required for other medicines routinely prescribed in primary care.
Brief prescribing document or information sheet may be required.
Primary care prescribers must be familiar with the drug to take on prescribing responsibility or must get the required information.
When recommending or handing over care, specialists should ask primary care prescribers to take over prescribing responsibility, and should give enough information about the indication, dose, monitoring requirements, use outside product licence and any necessary dose adjustments to allow them to confidently prescribe. |
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Amber level 1 (with shared care):
Suitable for prescribing in primary care following recommendation or initiation by a specialist.
Minimal monitoring required.
Patient may need a regular review, but this would not exceed that required for other medicines routinely prescribed in primary care.
Full prior agreement about patient’s on-going care must be reached under the shared care agreement.
Primary care prescribers are advised not to take on prescribing of these medicines unless they have been adequately informed by letter of their responsibilities with regards monitoring, side effects and interactions and are happy to take on the prescribing responsibility. A copy of locally approved shared care guidelines should accompany this letter which outlines these responsibilities. Primary care prescribers should then tell secondary care of their intentions as soon as possible by letter so that arrangements can be made for the transfer of care. |
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Amber level 2 (with shared care and enhanced service):
Initiated by specialist and transferred to primary care following a successful initiation period.
Significant monitoring required on an on-going basis.
Full prior agreement about patient’s on-going care must be reached under the shared care agreement.
Suitable for enhanced service.
These medicines are considered suitable for GP prescribing following specialist initiation of therapy, as per shared care document which will be sent out with the request to prescribe, with on-going communication between the primary care prescriber and specialist. Amber Level 2 medicines require significant monitoring for which an enhanced service may be suitable. (Subject to local commissioning agreements). |
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Do not prescribe: NOT recommended for use by the NHS in Lancashire and South Cumbria.
Includes medicines that NICE has not recommended for use and terminated technology appraisals, unless there is a local need. |
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Grey medicines:
Medicines which have not yet been reviewed or are under the review process.
GPs and specialists are recommended not to prescribe these drugs.
This category includes drugs where funding has not yet been agreed.
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Refer to local guidance. |
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