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 Formulary Chapter 6: Endocrine system - Full Chapter
06.01  Expand sub section  Drugs used in diabetes
 note 

These Audit tools have been developed by the North West Sussex Medicines Management team to support clinically effective prescribing. They are intended to be used as an aid for practice staff to review patients in line with national guidance, and may be amended to suit individual practice or clinician preferences. They are published as simple Microsoft Word documents to enable easy adaptation.

The information contained in the audit tools is correct at the time of production. Using them does not remove any of the professional obligations to prescribe safely by taking individual patient factors into consideration and clinician discretion with individual patients during the review process is essential. Staff using these audits must concurrently take full account of the practice’s internal governance and quality assurance policies, and work in line with the Data Protection Act 1998.

Audits - please click the link below

Hypoglycaemic Agents

Treatment to control blood glucose must be tailored to each individual patient’s clinical needs with safety paramount. It is generally agreed, and supported by the NICE guideline on type 2 diabetes, that metformin should be used first line and a sulfonylurea second line, unless contraindicated.

The newer hypoglycaemic drugs are all usually third-line options – although effective at reducing HbA1c levels, they all lack robust clinical outcome data, particularly around their cardiovascular effects and long term safety in people with type 2 diabetes. Improvements in surrogate markers (e.g. HbA1c levels) do not automatically confer benefits on patient mortality or morbidity, and risks may become apparent only over time when these agents have more widespread use in a diverse patient population.

This audit tool supports the review of newer hypoglycaemic agent prescribing for patients with Type 2 diabetes to ensure these agents are initiated and continued in accordance with NICE and local guidelines.

06.01.01  Expand sub section  Insulins
06.01.01.01  Expand sub section  Short-acting insulins
06.01.01.01  Expand sub section  Soluble Insulin
06.01.01.01  Expand sub section  Rapid Acting Insulin Analogues to top
06.01.01.02  Expand sub section  Intermediate- and long-acting insulins
06.01.01.02  Expand sub section  Biphasic insulins
06.01.01.02  Expand sub section  Intermediate Acting Insulin
06.01.01.02  Expand sub section  Long Acting Insulin Analogues
06.01.01.03  Expand sub section  Hypodermic equipment to top
06.01.02  Expand sub section  Antidiabetic drugs
 note 

Prescribing guidelines for the management of type 2 diabetes in primary care

06.01.02.01  Expand sub section  Sulphonyureas
06.01.02.02  Expand sub section  Biguanides
06.01.02.03  Expand sub section  Other antidiabetic drugs
 note 

Liraglutide i/r, exenatide i/r and exenatide m/r can be initiated in triple therapy (with metformin and a sulfonylurea OR metformin and a thiazolidinedione) when HbA1c 7.5% / 58 mmol/mol (or higher as agreed with patient) and:

BMI ≥ 35kg/m2 (in patients of European descent – appropriate adjustment for other ethnic groups) and there are specific psychological/medical problems associated with high body weight or

BMI < 35kg/m2 and insulin therapy has significant occupational implications or weight loss would benefit other obesity-related co-morbidities

Treatment can be continued if there is a beneficial metabolic response (1% reduction in HbA1c and 3% weight loss in 6 months).

Liraglutide i/r and exenatide m/r can be initiated in dual therapy (with metformin or a sulfonylurea) when:

The patient is intolerant to metformin or sulfonylureas or treatment with metformin or a sulfonylurea is contraindicated and

The patient is intolerant to thiazolidinediones and DPP-4 inhibitors or treatment with thiazolidinediones and DPP-4 inhibitors is contraindicated.

Treatment can be continued if there is a beneficial metabolic response (1% reduction in HbA1c in 6 months).

Dipeptidylpeptidase 4 (DPP-4) inhibitors
Continue DPP-4 inhibitors only if there is a reduction ≥ 0.5 percentage points in HbA1c within 6 months of starting treatment.
Patients taking gliptins should be made aware of the symptoms of pancreatitis and to seek help if they develop.

06.01.02.03  Expand sub section  DPP-4 inhibitors to top
06.01.02.03  Expand sub section  GLP-1 mimetics
06.01.02.03  Expand sub section  SGLT2 inhibitors
06.01.02.03  Expand sub section  Other
06.01.02.05  Expand sub section  Glucagon-like peptide-1 receptor agonists - once weekly
06.01.02.07  Expand sub section  Other antidiabetic drugs to top
06.01.03  Expand sub section  Diabetic ketoacidosis
 note  In patient procedures vary, please see local hospital policy
06.01.04  Expand sub section  Treatment of hypoglycaemia
06.01.04  Expand sub section  Chronic hypoglycaemia
06.01.05  Expand sub section  Treatment of diabetic nephropathy and neuropathy
 note  See BNF Chapter 6.6.5 - Diabetic nephropathy
https://www.medicinescomplete.com/mc/bnf/current/PHP4233-diabetic-nephropathy.htm

*Guidelines for Painful Diabetic Neuropathy* agreed by CPMAP June 2017
06.01.05  Expand sub section  Diabetic nephropathy to top
06.01.05  Expand sub section  Diabetic neuropathy
06.01.06  Expand sub section  Diagnostic and monitoring agents for diabetes mellitus
06.01.06  Expand sub section  Blood glucose monitoring
06.01.06  Expand sub section  Urinalysis
06.01.06  Expand sub section  Blood Ketones Testing Strips to top
06.02  Expand sub section  Thyroid and Antithyroid drugs
06.02.01  Expand sub section  Thyroid hormones
06.02.02  Expand sub section  Antithyroid drugs
 note  Neutropenia and agranulocytosis - Doctors are reminded of the importance of recognising bone marrow suppression induced by carbimazole and the need to stop treatment promptly. Patient should be asked to report symptoms and signs suggestive of infection, especially sore throat. A white blood cell count should be performed if there is any clinical evidence of infection. Carbimazole should be stopped promptly if there is clinical or laboratory evidence of neutropenia.
06.03  Expand sub section  Corticosteroids
 note  MHRA Drug Safety Update Aug 2017 - Corticosteroids: rare risk of central serous chorioretinopathy with local as well as systemic administration

Patients on long-term corticosteroid treatment should carry a Steroid Treatment Card which gives guidance on minimising risk and provides details of prescriber, drug, dosage and duration of treatment.

Steroid treatment cards

Steroid treatment cards (see Steroid Treatment Card) should be issued where appropriate, and are available for purchase from:

3M Security Print and Systems Limited
Gorse Street,
Chadderton
Oldham
OL9 9QH
Tel: 0845 610 1112

GP practices can obtain supplies through their Local Area Team Stores.

06.03.01  Expand sub section  Replacement therapy to top
06.03.02  Expand sub section  Glucocorticoid therapy
06.03.02  Expand sub section  Disadvantages of corticosteroids
06.03.02  Expand sub section  Use of corticosteroids
06.03.02  Expand sub section  Pregnancy and breastfeeding
06.03.02  Expand sub section  Administration to top
06.03.02  Expand sub section  Withdrawal of corticosteroids
06.04  Expand sub section  Sex hormones
 note  Gender dysphoria in adults and children - pharmacological treatment in primary care. CPMAP August 2017 the panel noted the guidelines below are useful documents but the share care agreements are unclear. The panel decided that individual drugs could be considered as AMBER but individual clinicians would make their own decision as to whether to prescribe until a clear shared care agreement was in place.

MCG 04/2017 - Gender dysphoria in adults and children – pharmacological treatment in primary care

WLMH Prescribing Guidance - Gender dysphoria Male to Female 

WLMH Prescribing Guidance - Gender dysphoria Female to Male
06.04.01  Expand sub section  Female sex hormones and their modulators
06.04.01.01  Expand sub section  Oestrogens and HRT
 note 

NICE NG23 Nov 2015 Menopause: diagnosis and management

MHRA Drug Safety Update Aug 2019 Hormone replacement therapy (HRT): further information on the known increased risk of breast cancer with HRT and its persistence after stopping

06.04.01.01  Expand sub section  Hormone replacement therapy to top
06.04.01.01  Expand sub section  Ethinylestradiol
06.04.01.01  Expand sub section  Raloxifene
06.04.01.02  Expand sub section  Progestogens
 note 

Where endometriosis required drug treatment, it may respond to a progestogen adminstered on a continuous basis. Danazol and gonadorelin analogues are also available.

Although oral progestogens have been widely used for menorrhagia they are relatively ineffective compared with tranexamic acid or, particularly where dysmenorrhoea is also a factor mefenamic acid.

Oral progestogens have also been used for severe dysmenorrhoea, but where contraception is also required in younger women the best choice is a combined oral contraceptive.

Progestogens have also been advocated for the alleviation of premenstrual symptoms, but no convincing physiological basis for such treatment has been shown.

Progestogens have been used for the prevention of miscarriage in women with a history of recurrent miscarriage but there is no evidence of benefit and they are not recommended for this purpose.

06.04.02  Expand sub section  Male sex hormones and antagonists
06.04.02  Expand sub section  Anti-androgens to top
06.04.02  Expand sub section  Dutasteride and finasteride
06.04.03  Expand sub section  Anabolic steroids
 note  The protein-building properties of anabolic steroids have not proved benficial in a clinical setting. Their use as body builders or tonics is unjustified. Some athletes may abuse them.
06.05  Expand sub section  Hypothalamic and pituitary hormones and anti-oestrogens
06.05.01  Expand sub section  Hypothalamic and anterior pituitary hormones and anti-oestrogens
 note 

Fertility guidelines

06.05.01  Expand sub section  Anti-oestrogens to top
06.05.01  Expand sub section  Anterior pituitary hormones
 note  PRODIGY recommends that in most cases, the diagnosis of Addison's disease in adults should be confirmed in secondary care, as this reflects expert opinion from the Addison's Clinical Advisory Panel.
Risk of anaphylaxis requires medical supervision.
06.05.01  Expand sub section  Gonadotrophins
06.05.01  Expand sub section  Growth Hormone
06.05.01  Expand sub section  Growth hormone receptor antagonists
06.05.01  Expand sub section  Thyrotropin to top
06.05.01  Expand sub section  Hypothalmic hormones
06.05.02  Expand sub section  Posterior pituitary hormones and antagonists
06.05.02  Expand sub section  Posterior pituitary hormones
06.05.02  Expand sub section  Antidiuretic hormone antagonists
06.06  Expand sub section  Drugs affecting bone metabolism to top
06.06  Expand sub section  Osteoporosis
06.06.01  Expand sub section  Calcitonin and parathyroid hormone
06.06.02  Expand sub section  Bisphosphonates and other drugs affecting bone metabolism
06.06.02  Expand sub section  Bisphosphonates
06.06.02  Expand sub section  Denosumab to top
06.06.02  Expand sub section  Strontium renelate
06.07  Expand sub section  Other endocrine drugs
06.07.01  Expand sub section  Bromocriptine and other dopaminergic drugs
06.07.02  Expand sub section  Drugs affecting gonadotrophins
06.07.02  Expand sub section  Gonadorelin analogues to top
06.07.02  Expand sub section  Breast pain (mastalgia)
06.07.03  Expand sub section  Metyrapone
06.07.04  Expand sub section  Somatomedins
 ....
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 children's BNF
click to search medicines.org.uk
Link to SPCs
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

Traffic Light Status Information

Status Description

Black

Comment : Not to be routinely commissioned (prescribed) in any care setting (primary or secondary care). This may be due to a lack of good clinical evidence, cost effectiveness, concerns over safety or due to the availability of more suitable alternatives. As such, drugs classified as Black should be considered as non-formulary.   

Red

Initiation : Specialist only
Repeat Prescribing : Specialist
Monitoring : Specialist
Comment : Prescribing must be in line with any specific treatment criteria outlined. In exceptional circumstances a GP may be asked to prescribe the specialist must provide adequate information and support.   

Amber

Initiation : Specialist only
Repeat Prescribing : Primary care OR specialist
Monitoring : Primary care OR specialist
Comment : Monitoring according to Effective Shared Care Agreement (ESCA) for stabilised patients only. GP agreement should be requested by specialist and confirmed/declined by GP on a patient-by-patient basis.   

Blue

Initiation/Recommendation : Specialist only
Repeat Prescribing : Primary care
Monitoring : Primary care
Comment : Should be initiated or recommended by a specialist. Monitoring of either medicine or disease does not require specialist skills or equipment   

Green

Initiation : Primary care or specialist
Repeat Prescribing : Primary care
Monitoring : Primary care
Comment : Suitable for non specialist initiation   

OTC

Patients should be advised to purchase if approriate.  

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