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6. Endocrine System

Clinical Guidelines from NICE related to endocrine disease can be found here

Actrapid (Soluble insulin)
BNF | BNFC | SPC

10ml vial

Humalog (Lispro)
BNF | BNFC | SPC

10ml vial, Cartridges for Autopen classic or Humapen, KwikPen prefilled device

Humulin S (Soluble insulin)
BNF | BNFC | SPC

10ml vial, Cartridges for Autopen Classic or HumaPen

Novorapid (Aspart)
BNF | BNFC | SPC

10ml vial, Penfill cartridges, Prefilled Flexpen pen

1.6ml PumpCart cartridges for insulin pump users only.

Lantus (Glargine)
BNF | BNFC | SPC

100units/ml soln for injection

10ml vial, 3ml cartridge, pre-filled Solostar Pen (Lantus)

Insulin glargine is a biological medicine. Biological medicines must be prescribed and dispensed by brand name

 

 

Humulin I (Isophane)
BNF | BNFC | SPC

10ml vial, Cartridges for Autopen Classic or HumaPen, Humulin I KwikPen prefilled pevice

Humulin M3
BNF | BNFC | SPC

Available as cartridge, Kwikpen and vial 
   

Insulatard (Isophane)
BNF | BNFC | SPC

10ml vial, Cartridges for Insulatard penfill, Insulatard Innolet prefilled device

Insulin Degludec (Recombinant human insulin analogue—long acting) (Tresiba®)
BNF | BNFC | SPC

5 × 3-mL Penfill® cartridges (for Novo Nordisk® devices) 100 units/mL,

5 × 3-mL FlexTouch® prefilled disposable injection devices (range 1– 80 units, allowing 1-unit dosage adjustment)

Also available as 200units / ml. NOT on formulary at this strength. For initiation by Consultant only for Type 1 diabetic patients who remain at significant risk of hypoglycaemia despite intensive insulin treatment

Initiated by diabetes consultant as per department protocol

Degludec Protocol

 

Levemir (Detemir)
BNF | BNFC | SPC

Cartridges for Novopen, Prefilled FlexPen device

Toujeo (Glargine biosimilar)
BNF | BNFC | SPC

300units/ml solution for injection

1.5ml pre-filled Solostar pen

NTAG Decision Summary: Recommended as an option for use in adults who are eligible for treatment with insulin glargine as per NICE guidance (NG17, 2015).

For limited use only. Specialist initiation by diabetes consultant/diabetes specialist nurse

 

Abasaglar (Glargine biosimilar)
BNF | BNFC | SPC

100units/ml soln for injection

3ml cartridge, 3ml pre-filled Kwikpen (Abasaglar)

Insulin glargine is a biological medicine. Biological medicines must be prescribed and dispensed by brand name

Abasaglar NTAG Recommendation

 

 

Fiasp (Aspart)
BNF | BNFC | SPC

New formulation of insulin aspart, with nicotinamide added to produce a more rapid onset of action.

Specialist initiation only when agreement between consultant and diabetes specialist nurse following CGMS.

Gliclazide
BNF | BNFC | SPC

Tablets 40mg, 80mg

 

Gliclazide Modified Release
BNF | BNFC | SPC
Glimepiride
BNF | BNFC | SPC

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

Glipizide
BNF | BNFC | SPC

Tablets 5mg

Metformin
BNF | BNFC | SPC

Tablets 500mg, 850mg

MR Tablets 500mg, 750mg, 1G

Oral Solution 500mg/5ml

Acarbose
BNF | BNFC | SPC

Gastrointestinal intolerance may limit use.

Tablets 50mg

Alogliptin
BNF | BNFC | SPC

Tablets 6.25mg 12.5mg, 25mg

Canagliflozin
BNF | BNFC | SPC

Tablets 100mg, 300mg.

Approved: NICE TA315, TA390

Dapagliflozin
BNF | BNFC | SPC

Tablets 5mg, 10mg.

Approved for use in line with: NICE TA288, TA390, TA418

Dulaglutide
BNF | BNFC | SPC

1.5 mg solution for injection in a pre-filled pen  

GLP-1 first line option is Lixisenatide, second line Dulaglutide. Liraglutide and Exenatide are approved by NICE and may be considered on an individual patient basis but are considered less cost effective than the other two agents.

Preferred Once weekly preparation.

Empagliflozin
BNF | BNFC | SPC

Tablets 10mg, 25mg.

Approved: NICE TA336, TA390

Ertugliflozin
BNF | BNFC | SPC

CCG Commissioned

Approved: NICE TA572 - Ertugliflozin as monotherapy or with metformin for treating type 2 diabetes

Exenatide
BNF | BNFC | SPC

10micrograms/0.04ml solution for injection 2.4ml prefilled disposable devices

5micrograms/0.02ml solution for injection 1.2ml prefilled disposable devices

Liraglutide for Diabetes
BNF | BNFC | SPC

6mg/ml solution for injection 3ml pre-filled disposable devices

Liraglutide for Weight Management
BNF | BNFC | SPC

Liraglutide (Saxenda) is not approved as an adjunct to a reduced-calorie diet and increased physical activity for weight management in adult patients with an initial Body Mass Index (BMI) of

• ≥ 30 kg/m² (obese), or

• ≥ 27 kg/m² to < 30 kg/m² (overweight) in the presence of at least one weight-related comorbidity such as dysglycaemia (pre-diabetes or type 2 diabetes mellitus), hypertension, dyslipidaemia or obstructive sleep apnoea.

NTAG Decision Summary: Not Recommended

Lixisenatide
BNF | BNFC | SPC

Initiated by diabetes care.

50 micrograms/mL, 100 micrograms/mL

Pioglitazone
BNF | BNFC | SPC

Tablets 15mg, 30mg, 45mg

Saxagliptin
BNF | BNFC | SPC

Tablets 2.5mg, 5mg

Sitagliptin
BNF | BNFC | SPC

Tablets 25mg, 50mg 100mg

Semaglutide
BNF | BNFC | SPC

As add-on therapy in the treatment of Type 2 Diabetes. Use 3rd line - in line with NICE.

Amitriptyline
BNF | BNFC | SPC

Tablets 10mg, 25mg, 50mg

Duloxetine
BNF | BNFC | SPC

Capsules 20mg,  40mg, 

Capsules 30mg, 60mg

For neuropathic pain, depression and stress incontinence in women only.

Please refer to BNF for dosing guidance.

NICE CG173

Accu-check Aviva test strips
BNF | BNFC | SPC

Tees Recommended Meters for Blood Glucose Testing

For initiation by a secondary care specialist or diabetes specialist nurse only

People with type 1 diabetes that count carbohydrates or have an insulin pump

Accu-check Performa test strips
BNF | BNFC | SPC
Contour next
BNF | BNFC | SPC

Tees Recommended Meters for Blood Glucose Testing

People with gestational diabetes or using an insulin pump

For initiation by a secondary care specialist or diabetes specialist nurse only

Freestyle Lite
BNF | BNFC | SPC

Tees Recommended Meters for Blood Glucose Testing

People with type 1 diabetes that count carbohydrates or have an insulin pump

For initiation by a secondary care specialist or diabetes specialist nurse only

GlucoMen areo Ketone Sensors
BNF | BNFC | SPC

Tees Recommended Meters for Blood Glucose Testing

People with type 1 diabetes who monitor blood ketones

For initiation by a secondary care specialist or diabetes specialist nurse only

GlucoMen areo Sensor
BNF | BNFC | SPC

Tees Recommended Meters for Blood Glucose Testing

People with type 1 diabetes who monitor blood ketones

For initiation by a secondary care specialist or diabetes specialist nurse only

GlucoRx HCT Glucose Test Strips
BNF | BNFC | SPC

Tees Recommended Meters for Blood Glucose Testing

People with type 1 diabetes who monitor blood ketones

For initiation by a secondary care specialist or diabetes specialist nurse only

GlucoRx HCT Ketone Test Strips
BNF | BNFC | SPC

Tees Recommended Meters for Blood Glucose Testing

People with type 1 diabetes who monitor blood ketones

For initiation by a secondary care specialist or diabetes specialist nurse only

GlucoRx Nexus Strips
BNF | BNFC | SPC

Tees Recommended Meters for Blood Glucose Testing

Available for the partially sighted

For initiation by a secondary care specialist or diabetes specialist nurse only

Levothyroxine
BNF | BNFC | SPC

Tablets 25micrograms, 50micrograms, 100micrograms

Liothyronine
BNF | BNFC | SPC

Tees Do Not Prescribe/Grey List

There is no robust evidence for the use of liothyronine either alone or in combination with levothyroxine and it is not licensed for long term use.

Natural thyroid extract products are not licensed in the UK.  The variation in hormonal content may lead to increased serum levels of T3 and subsequent thyrotoxic symptoms, such as palpitations and tremor.

 

Tablets should only be initiated by endocrinology

L-T4/L-T3 combination therapy in patients with hypothyroidism should not be used routinely, as there is insufficient evidence to show that combination therapy is superior to L-T4 monotherapy

If a decision is made to embark on a trial of L-T4/L-T3 combination therapy in patient who have unambiguously not benefited from L-T4, then this should be reached following an open and balanced discussion of the uncertain benefits, likely risks of over-replacement and lack of long-term safety data. Such patients should be supervised by accredited endocrinologists with documentation of agreement after fully informed and understood discussion of the risks and potential adverse consequences.

Carbimazole
BNF | BNFC | SPC

Tablets 5mg

BNF states: 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.

Propylthiouracil
BNF | BNFC | SPC

Tablets 50mg

Fludrocortisone Acetate
BNF | BNFC | SPC

Tablets 100micrograms (can be halved)

 

Betamethasone
BNF | BNFC | SPC

Tablets Soluble 500microgram

 

Dexamethasone
BNF | BNFC | SPC

Tablets and soluble tablets available.

Injection 4mg

IV and oral have similar bioavailability

Hydrocortisone
BNF | BNFC | SPC

tablets 10mg and 20mg

Hydrocortisone Sodium Phosphate (Efcortesol)
BNF | BNFC | SPC
Hydrocortisone granules in capsules for opening (Alkindi®)
BNF | BNFC | SPC

Strengths: 0.5mg, 1mg, 2mg, 5mg. To replace the use of crushing 5 and 10mg tablets when smaller doses are required.

For adrenal insufficiency primary and secondary in paediatric patients.

Prednisolone
BNF | BNFC | SPC

Tablets 1mg, 5mg,

Tablets soluble 5mg

There are no clinical benefits from prescribing prednisolone as enteric coated tablets. The risk of gastro-intestinal side-effects are no higher with plain tablets, especially if the patient takes the tablets with food.

Progesterone Pessaries
BNF | BNFC | SPC

Cyclogest Pessaries

Red for Luteal Phase support following IVF only. Full course to be supplied by hospital

Norethisterone
BNF | BNFC | SPC

Tees Do Not Prescribe/Grey List

For the postponement of menstruation for non-medical reasons prescribing should be via private prescription as this is considered a lifestyle choice rather than the treatment of a medical condition. Some community pharmacies may supply norethisterone (in store or online) via a private PGD.

Medroxyprogesterone
BNF | BNFC | SPC

Tees Do Not Prescribe/Grey List

For the postponement of menstruation for non-medical reasons prescribing should be via private prescription as this is considered a lifestyle choice rather than the treatment of a medical condition (please note medroxyprogesterone is unlicensed for this indication).

Cyproterone
BNF | BNFC | SPC

Tablets 50mg

This drug is Amber (to be initiated in secondary care), but there is no Shared Care protocol to follow

Finasteride
BNF | BNFC | SPC

Tablets 5mg

Testosterone
BNF | BNFC | SPC

Gel 50mg/5g

Injection 100mg/ml, 250mg/ml

Testosterone undecanoate 40mg capsule
BNF | BNFC | SPC

For induction of puberty and testosterone replacement in paediatric patients with testosterone deficiency.

Choriogonadotropin Alpha
BNF | BNFC | SPC

Infertility in women

Chorionic gonadotrophin
BNF | BNFC | SPC

Infertility in women

Follitropin Alfa
BNF | BNFC | SPC

Infertility in women

Follitropin Beta
BNF | BNFC | SPC

Infertility in women

Human menopausal gonadotrophins
BNF | BNFC | SPC

Infertility in women

Lutropin alfa
BNF | BNFC | SPC

Infertility in women

Pegvisomant
BNF | BNFC | SPC

Acromegaly (Not approved)

Somatropin
BNF | BNFC | SPC

Tariff Excluded; CCG Commissioned

Approved: NICE TA64, TA188

Tetracosactide
BNF | BNFC | SPC

NTHFT - Rejected for treatment of acute gout where other treatments have failed or are contraindicated

Clomifene citrate
BNF | BNFC | SPC

Tablets 50mg

Tolvaptan (Jinarc)
BNF | BNFC | SPC

Tariff Excluded; CCG Commissioned

Consultant initiation only. Recommended by NICE as an option in treatment of autosomal dominant polycystic kidney disease within specified criteria - NICE TA358

 

Tolvaptan (Samsca)
BNF | BNFC | SPC

Tariff Excluded; NHSE Commissioned

Hyponatremia secondary to the syndrome of inappropriate antidiuretic hormone secretion (SIADH)

Etidronate
BNF | BNFC | SPC
Teriparatide
BNF | BNFC | SPC

Tariff Excluded; CCG/NHSE Commissioned

Approved: NICE TA161

NTAG Rejected: Teriparatide for the treatment of (bisphosphonate-induced) atypical fractures 2/6/15 - Rejected due to the paucity of the data,lack of evidence of robust clinical efficacy of treatment.

Denosumab
BNF | BNFC | SPC

Shared Care

Injection 60mg/ml

Consultant initiation only. Recommended by NICE (TA204) as an option in treatment of secondary or primary prevention of osteoporotic fragility fractures in post-menopuasal women only when unable to tolerate, comply with administration instructions or contraindicated to at least two bisphosphonates.

NICE TA265

Raloxifene
BNF | BNFC | SPC

Approved: NICE TA161

Not Approved: NICE TA160

Strontium ranelate
BNF | BNFC | SPC

Powder sachet 2g

Contraindicated in current or previous VTE, IHD, PAD, cerebrovascular disease, uncontrolled hypertension, temporary or prolonged immobilisation. Severe allergic reactions including DRESS have been reported. Patients must discontinue and treatment should not be restarted.

MHRA Drug Safety Update - Strontium Ranelate: Cardiovascular Risk

This drug is Amber (to be initiated in secondary care), but there is no Shared Care protocol to follow

Bisphosphonates for treating osteoporosis: NICE TA464

Alendronate plus Vitamin D (Fosavance)
BNF | BNFC | SPC

Tees Do Not Prescribe/Grey List

No convincing randomised controlled evidence of benefits over existing bisphosphonate therapy

Alendronic Acid
BNF | BNFC | SPC

Tablets 70mg

(Dispersible tablets (Binosto): Approved only for patients with defined swallowing issues in whom the only other treatment option is IV bisphosphonates)

Once a week dose

Approved: NICE TA464

 

Ibandronic acid (Bonviva)
BNF | BNFC | SPC
Pamidronate Disodium
BNF | BNFC | SPC

Hypercalcaemia of malignancy; Osteolytic lesions and bone pain in bone metastases associated with breast cancer or multiple myeloma; Paget's disease of bone

Risedronate
BNF | BNFC | SPC

Tablets 35mg

Once a week dose

Approved: NICE TA464

Sodium clodronate
BNF | BNFC | SPC

Hypercalcaemia of malignancy

Zoledronic Acid
BNF | BNFC | SPC

Paget's disease; osteoporosis

Approved: NICE TA464

Cabergoline
BNF | BNFC | SPC

Tablets 500 microgram

Specialist initiation only

Cetrorelix
BNF | BNFC | SPC

IVF

Ganirelix acetate (Fyremadel®)
BNF | BNFC | SPC

To be used in IVF Superovulation Short Protocol to inhibit premature LH surge & ovulation prior to oocyte collection procedure.

Goserelin Injection
BNF | BNFC | SPC

Endometriosis, Breast Ca, Prostate Ca

Specialist initiation only

This drug is Amber (to be initiated in secondary care), but there is no Shared Care protocol to follow.  First injection to be given by trust.

Nafarelin
BNF | BNFC | SPC

Nasal spray 200 microgram

Specialist initiation only

This drug is Amber (to be initiated in secondary care), but there is no Shared Care protocol to follow