Approved: 1 Sep 2012. Last amended: 6 Mar 2020.

6.1 Drugs used in diabetes

Type 2 Diabetes – NICE guideline

HbA1c will be measured in millimoles per mol from 31 May 2011. Use the diabetes.co.uk converter to convert from percentage to mmol/mol

6.1.1 Insulins

Long acting insulin analogue prescribing guidance: NICE TA53

Insulin pump therapy: NICE TA151

Local Guideline: Insulin Formulary

Recommended

  • Human Insulins
  • Specific Indication

  • Recombinant human insulin analogues

    As per local guidance: Insulin Formulary

  • 6.1.1.1 Hypodermic equipment

    Needles for Pre-filled and Reusable Pen Injectors

    Recommended

  • GlucoRx Finepoint

    (4, 5, 6, 8, 10, 12mm)

  • Mylife Penfine Classic

    (4, 6, 8mm)

  • Omnican Fine

    (4, 5, 6, 8, 10mm)

    32G needles for the 4mm, 5mm and 6mm are preferred as they are thinner and more comfortable, as well as more cost-effective

  • Specific Indication

  • GlucoRx Safety Pen Needles

    May be requested and issued in situations where district or community nurses are attending a patient to administer an injectable medication to patients who are unable to do so themselves. They are not intended for self- administrating patients or family member administration (as advised in WNTW Issue 213)

  • 6.1.2 Oral anti-diabetic drugs

    6.1.2.1 Sulphonylureas

    Recommended

  • Gliclazide
  • Alternative

  • Glimepiride
  • Tolbutamide
  • Specific Indication

  • Gliclazide M/R

    A once daily sulphonylurea to improve outcome for patients where concordance with therapy is a problem.

    Note: Gliclazide MR 30mg ≈ Gliclazide (standard) 80mg

  • 6.1.2.2 Biguanides

    • The dose of metformin should be built up slowly by 500mg increments per week to minimise GI side effects.
    • NICE recommends that the dose should be reviewed if eGFR less than 45 mL/minute/1.73 m2 and to avoid if eGFR less than 30 mL/minute/1.73 m2. Withdraw or interrupt treatment in those at risk of tissue hypoxia or sudden deterioration in renal function, such as those with dehydration, severe infection, shock, sepsis, acute heart failure, respiratory failure or hepatic impairment, or those who have recently had a myocardial infarction.
    • As the intravascular administration of iodinated contrast materials in radiologic studies can lead to renal failure, metformin should be discontinued prior to (or at the time of the test) and not reinstituted until 48 hours afterwards, and only after renal function has been re-evaluated and found to be normal.
    • Metformin should be discontinued 48 hours before elective surgery with general anaesthesia and should not usually be resumed earlier than 48 hours afterwards.

    Recommended

  • Metformin
  • Specific Indication

  • Metformin M/R

    Patients who cannot tolerate standard metformin due to GI side effects

  • 6.1.2.3 Other antidiabetics: Thiazolidinediones (glitazones):

    Continue thiazolidinedione (glitazone) therapy only if there is a reduction of ≥ 0.5% in HbA1c in 6 months.

    Pioglitazone risk of bladder cancer

    MHRA Advice for healthcare professionals:

    • Patients with active bladder cancer or with a history of bladder cancer, and those with uninvestigated haematuria, should not receive pioglitazone
    • Prescribers should review the safety and efficacy of pioglitazone in individuals after 3–6 months of treatment to ensure that only patients who are deriving benefit continue to be treated. Pioglitazone should be stopped in patients who do not respond adequately to treatment (eg, reduction in glycosylated haemoglobin, HbA1c)
    • Before starting pioglitazone, the following known risk factors for development of bladder cancer should be assessed in individuals: age; current or past history of smoking; exposure to some occupational or chemotherapy agents such as cyclophosphamide; or previous irradiation of the pelvic region
    • Use in elderly patients should be considered carefully before and during treatment because the risk of bladder cancer increases with age. Elderly patients should start on the lowest possible dose and be regularly monitored because of the risks of bladder cancer and heart failure associated with pioglitazone

    Recommended

  • Pioglitazone
  • Specific Indication

  • Competact®

    (pioglitazone 15mg/ metformin 850mg): Only for patients already stabilised on this combination to aid compliance

  • 6.1.2.4 Other antidiabetics: Dipeptidylpeptidase-4 inhibitors (gliptins):

    Dipeptidylpeptidase-4 inhibitors (gliptins) should only be continued if HbA1c concentration is reduced by at least 0.5% within 6 months of starting treatment.

    Recommended

  • Alogliptin
  • Specific Indication

  • Sitagliptin

    Where alogliptin not appropriate.

  • 6.1.2.5 Other antidiabetics: Sodium-glucose co-transporter 2 (SGLT2) inhibitors:

  • Canagliflozin
  • Dapagliflozin
  • Empagliflozin
  • Ertugliflozin
  • Specific Indication

  • Dapagliflozin

    With insulin for type 1 diabetes NICE TA597

  • Sotagliflozin

    With insulin for type 1 diabetes NICE TA622

  • 6.1.2.6 Other antidiabetics: Incretin Mimetics (GLP-1 agonists):

    Recommended

  • Lixisenatide

    Daily. Note: each pre-filled pen contains 14 doses (needles not included).
    As per NICE guideline NG28

  • Semaglutide

    Weekly. Note: each pre-filled pen contains 4 doses (needles included).
    As per NICE guideline NG28

  • Alternative

  • Dulaglutide

    Weekly. Note: each pre-filled pen contains a single dose (needle included).
    As per NICE guideline NG28

  • 6.1.2.7 Other antidiabetics: Others

    Specific Indication

  • Nateglinide
  • Repaglinide
  • Acarbose
  • 6.1.3 Diabetic ketoacidosis

    Refer to BNF (section 6.1.3)

    6.1.4 Treatment of hypoglycaemia

    GHNHSFT Local Guideline: Management of hypoglycaemia - intranet

    Recommended

  • GlucoTabs® tablets
  • Specific Indication

  • GlucoGel®

    Disorientated / confused patients who are able to swallow

  • Glucagon

    Acute insulin-induced hypoglycaemia. If glucagon is not effective within 10 minutes, intravenous glucose should be given.

  • Glucose 10%

    (intravenous) – acute insulin-induced hypoglycaemia. Intravenous glucose should be reserved for patients where glucagon has not been effective after 10 minutes.

  • 6.1.5 Treatment of diabetic nephropathy and neuropathy

    Refer to BNF for guidance

    6.1.6 Diagnostic and monitoring agents for diabetes mellitus

    6.1.6.1 Blood glucose monitoring: Hospital use

    Recommended

  • Nova StatStrips®
  • 6.1.6.2 Blood glucose monitoring: Patient self-monitoring

    Local Guideline: Blood Glucose Monitoring (prescribing test strips for patient self-monitoring)

  • Neon Finetest Lite® test strips
  • GlucoRx Nexus® test strips
  • Wavesense Jazz® test strips
  • 6.1.6.3 Urinalysis: Hospital use

    Recommended

  • Combur-7 Test®
  • Combur-10 Test®
  • Ketostix®
  • 6.2 Thyroid and antithyroid drugs

    The metabolism of some drugs may be altered in hyperthyroidism – seek Specialist advice

    6.2.1 Thyroid hormones

    Recommended

  • Levothyroxine
  • Alternative

  • Liothyronine

    Injection: Hypothyroid coma / rapid response desired (Seek specialist advice)

  • 6.2.2 Antithyroid drugs

    Recommended

  • Carbimazole
  • Alternative

  • Propylthiouracil
  • Specific Indication

  • Propranolol

    Relief of thyrotoxic symptoms

  • Atenolol

    Relief of thyrotoxic symptoms

  • Aqueous Iodine Oral Solution

    (Lugol’s Solution) – thyrotoxicosis (pre-operatively)

  • 6.3 Corticosteroids

    GHNHSFT Local Guideline: Perioperative Steroid Management

    Withdrawal of corticosteroids: General Guidance

    6.3.1 Replacement therapy

    Recommended

  • Fludrocortisone

    Mineralocorticoid (oral)

  • Hydrocortisone

    Glucocorticoid (oral)

    Note:

    10mg tablets - prescribe Hydventia brand

    20mg tablets - prescribe generically

  • 6.3.1.1 Glucocorticoid therapy

    Recommended

  • Prednisolone

    (oral)
    Please note: enteric coated prednisolone is not recommended. The gastric side effects of oral prednisolone are primarily due to a systemic rather than a local effect. In addition, enteric coating results in unpredictable and variable absorption.

  • Hydrocortisone

    (parenteral)

  • Alternative

  • Dexamethasone

    (oral and parenteral)

  • Methylprednisolone

    (parenteral)

  • 6.4 Sex hormones

    6.4.1 Female sex hormones

    6.4.1.1 Oestrogens and HRT: Women with uterus

    Recommended

  • Elleste-Duet® 1, 2mg
    • Oral
    • Tablets (estradiol & norethisterone)
  • Kliofem®
    • Oral
    • (continuous - estradiol and norethisterone)
  • Kliovance®
    • Oral
    • (continuous – estradiol and norethisterone)
  • Femoston®
    • Oral
    • 1/10, 2/10 tablets (estradiol and dydrogesterone)
  • Femoston-conti®
    • Oral
    • (continuous – estradiol and dydrogesterone)
  • Evorel® Conti
    • Transdermal Patch
    • (estradiol & norethisterone)
  • 6.4.1.2 Oestrogens and HRT: Women without uterus

    Recommended

  • Oral Elleste-Solo® 1, 2mg

    Tablets (estradiol)

  • Estradot®
    • Transdermal Patch
    • (estradiol 23, 37.5, 50, 75, 100mcg)
  • Oestrogel®
    • Topical
    • (estradiol)
  • 6.4.1.3 Oestrogens and HRT: Tibolone

    Recommended

  • Tibolone
  • 6.4.1.4 Oestrogens and HRT: Ethinylestradiol

    Recommended

  • Ethinylestradiol

    Note: 2mcg (unlicensed) and 10mcg tablets may be used in a graduated estradiol regime to optimise puberty)

  • 6.4.1.5 Oestrogens and HRT: Raloxifene

    Specific Indication

  • Raloxifene

    Where no effect on the endometrium and/or anti-oestrogenic effect on the breast is required (see also 6.6.1)

  • 6.4.1.6 Progestogens and progesterone receptor modulators

    Recommended

  • Medroxyprogesterone
  • Norethisterone
  • Specific Indication

  • Ulipristal
    • Progesterone receptor modulator
    • Pre-operative treatment of moderate to severe uterine fibroids. Maximum 3 months' treatment.
  • 6.4.2 Male sex hormones and antagonists

    6.4.2.1 Testosterone and esters

    Recommended

  • Testosterone implant
  • Testosterone Intramuscular injection:
    • Testosterone enantate
    • Sustanon® (100 & 250)
  • Specific Indication

  • Nebido®

    Patients who are unable to tolerate testosterone enantate or Sustanon®

  • Testosterone capsules

    Restandol®)

  • Testosterone 2% gel

    (Testavan® 20 mg/g Transdermal gel)

  • Testosterone buccal tablet

    (Striant® SR) – alternative to Tostran®

  • 6.4.2.2 Anti-androgens

    Recommended

  • Finasteride
  • Specific Indication

  • Dutasteride

    Restricted for patients who are unable to tolerate finasteride

  • 6.4.3 Anabolic steroids

  • None
  • 6.5 Hypothalamic and pituitary hormones and anti-oestrogens

    6.5.1 Hypothalamic and anterior pituitary hormones and anti-oestrogens

    6.5.1.1 Anti-oestrogens

    Fertility – NICE guidelines

    Specific Indication

  • Clomifene

    Anovulatory infertility

  • Tamoxifen

    Anovulatory infertility

  • 6.5.1.2 Anterior pituitary hormones: Corticotrophins

    Specific Indication

  • Tetracosactide 250mcg

    (i.e. short Synacthen® test) & 1mg depot – to test adrenocortical function

  • 6.5.1.3 Anterior pituitary hormones: Gonadotrophins

    Specific Indication

  • Chorionic gonadotrophin

    Female infertility, endocrine tests

  • Gonal-F®

    Female infertility

  • Menopur®

    Female infertility

  • 6.5.1.4 Anterior pituitary hormones: Growth hormone

    Specific Indication

  • Somatropin

    (synthetic Human Growth Hormone)

  • 6.5.1.5 Anterior pituitary hormones: Thyrotrophin

    Specific Indication

  • Thyrotropin alfa

    Post-thyroidectomy procedures

  • 6.5.2 Posterior pituitary hormones and antagonists

    6.5.2.1 Posterior pituitary hormones

    Recommended

  • Desmopressin

    Oral, parenteral, nasal spray 10mcg per spray

  • Specific Indication

  • Desmopressin (Noqdirna®) oral lyophilisate
    • Idiopathic nocturnal polyuria
  • Terlipressin
    • bleeding from oesophageal varices
    • hepatorenal syndrome (unlicenced use)
  • 6.5.2.2 Antidiuretic hormone antagonists

    Recommended

  • Demeclocycline

    For treatment of hyponatraemia from SIADH

  • Specific Indication

  • Tolvaptan (Samsca®)

    Consultant Endocrinologist only.

    Restricted to patients with symptomatic hyponatraemia (secondary to SIADH) who have failed to respond to fluid restriction and demeclocycline.

  • Tolvaptan (Jinarc®)

    Consultant Nephrologist only. For autosomal dominant polycystic kidney disease, as per NICE TA358

  • 6.6 Drugs affecting bone metabolism

    Gloucestershire Osteoporosis Guidelines

    Osteoporosis primary prevention: NICE TA160

    Osteoporosis secondary prevention: NICE TA161

    GHNHSFT Local Guideline: Treatment of Vitamin D Deficiency

    6.6.1 Calcitonin & parathyroid hormone

    Specific Indication

  • Teriparatide

    Postmenopausal osteoporosis (as per NICE TA161)

  • Raloxifene

    Postmenopausal osteoporosis (as per NICE TA160 and NICE TA161)

  • 6.6.1.1 Bisphosphonates & other dugs affecting bone metabolism: Bisphosphonates

    Recommended

  • Alendronic acid

    70mg once weekly

    NICE TA464

  • Alternative

  • Ibandronic acid

    150mg tablet monthly. Patients who are intolerant to alendronic acid or where compliance may be improved by monthly versus weekly dosing.

    NICE TA464

  • Risedronate sodium

    35mg once weekly. Patients who are intolerant to alendronic acid

    NICE TA464

  • Specific Indication

  • Denosumab
  • Risedronate sodium

    Paget's disease (30mg daily for 2 months)

  • Sodium Clodronate

    Osteolytic lesions, hypercalcaemia and bone pain associated with skeletal metastases in patients with breast cancer or multiple myeloma. Shared Care Guideline

  • Disodium pamidronate
    • Hypercalcaemia of malignancy
    • Osteolytic lesions & bone pain in bone metastases
    • Paget’s disease
  • Ibandronic acid

    Injection. Osteoporosis treatment for patients who are unable to take oral treatments NICE TA464

  • Zoledronic acid
    • 4mg: Hypercalcaemia of malignancy
    • 5mg: Paget's disease in patients refractory to pamidronate
    • 5mg: small number of patients who are unable to take oral osteoporosis treatments. Specialist only: NICE TA464
  • 6.7 Other endocrine drugs

    6.7.1 Bromocriptine and other dopamine-receptor stimulants

    Recommended

  • Cabergoline
  • Alternative

  • Bromocriptine
  • 6.7.2 Drugs affecting gonadotrophins

    Recommended

  • Danazol
  • 6.7.2.1 Gonadorelin analogues

    Recommended

  • Buserelin

    Nasal spray Shared Care Guideline (intranet)

  • Goserelin
    • Injection
    • 4 week preparation: Available in primary or secondary care
    • 12 week preparation: Primary care only
  • Leuprorelin
    • Injection
    • 4 week preparation: Available in primary or secondary care
    • 12 week preparation: Primary care only
  • Nafarelin

    Nasal spray

  • 6.7.3 Metyrapone and trilostane

    Specific Indication

  • Metyrapone

    Management of Cushing’s syndrome

  • BEST CARE FOR EVERYONE