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6. Endocrine System

CD&D Type 2 Diabetes Management Algorithm: CDDFT Intranet Link or Area Prescribing Committee website

CD&D Osteoporosis prescribing guidelines: Area Prescribing Committee website or CDDFT Intranet

Diabetes UK Information Prescriptions

Tees Guidelines for Self-Monitoring Blood Glucose in Patients with Diabetes Mellitus

HAST Type 2 Diabetes Guidelines (DECENT 5)

HAST Type 2 Diabetes Guidelines (DECENT 5) - Quick Reference Guide

Tees Paediatric Diabetes Referral Guidelines in Primary Care

Tees Recommended Meters for Blood Glucose Testing

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

NICE NG17: Type 1 diabetes in adults: diagnosis and management

NICE NG18: Diabetes (Type 1 and type 2) in children and young people: diagnosis and management

NICE NG19: Diabetic foot problems: prevention and management

NICE NG23: Menopause – diagnosis and management

NICE NG28: Type 2 diabetes in adults: management

NICE NG88: Heavy menstrual bleeding: assessment and management

NICE NG132: Hyperparathyroidism (primary): diagnosis, assessment and initial management

Regional Guidelines:

Guidelines for the use of feminising hormone therapy in gender dysphoria

Guidelines for the use of masculising hormone therapy in gender dysphoria

The County Durham & Darlington or Tees DO NOT PRESCRIBE List can be accessed online at: http://medicines.necsu.nhs.uk/guidelines/durhamdarlington or 
https://medicines.necsu.nhs.uk/guidelines/tees-guidelines/

The County Durham & Darlington or Tees GREY List – items to be prescribed in certain specific circumstances only can be accessed online at: http://medicines.necsu.nhs.uk/guidelines/durham-darlington or https://medicines.necsu.nhs.uk/guidelines/tees-guidelines/

CD&D Patient Decision Aids Resource available at: http://medicines.necsu.nhs.uk/guidelines/durham-darlington/

NHS England Guidance on “Conditions for which over the counter items should not routinely be prescribed” available at: https://www.england.nhs.uk/medicines/conditions-for-which-over-the-counter-items-should-not-routinely-be-prescribed/

Conditions for which over the counter items should not routinely be prescribed in primary care: exception criteria

Prescribing of medicines available to purchase over the counter for self-care

Self-Care and Medicines Available Over The Counter (OTC)

Common medicines available to purchase over the counter (OTC) for minor illnesses and self-limiting conditions

 

Novorapid (Aspart)
BNF | BNFC | SPC

100 units/ml

10ml - Vial, Penfill cartridges, Prefilled Flexpen pen

Fiasp ▼ (Aspart)
BNF | BNFC | SPC

Approved as option in type 1 diabetes patients in whom their diabetes cannot be adequately managed with alternative formulary choices and in whom a faster onset of action may be benefical or greater effect on post-prandial glucose is required.
Novorapid insulin remains 1st choice.

100 units/ml 

10ml vial, cartridge, pre-filled pen 

See Letter Sent to Healthcare Professionals (April 2018) - Risk of mix-ups between insulin Fiasp® (fast-acting insulin aspart)and Tresiba® (basal insulin degludec).

Insulin Lispro Sanofi▼100units / ml
BNF | BNFC | SPC

10ml vial
3ml cartridges (for AllStar Pro and JuniorSTAR pen)
3ml SoloStar prefilled pen

Prescriptions need to be written as Insulin Lispro Sanofi® or Humalog® to avoid prescribing/dispensing errors.

Humalog 100 units / ml (Lispro)
BNF | BNFC | SPC

Vial - 10ml

Cartridges for Autopen classic or Humapen, KwikPen prefilled device

Humalog Junior Kwikpen - New pen device available 0.5 units instead of 1 unit doses. 

Prescriptions need to be written as Insulin Lispro Sanofi® or Humalog® to avoid prescribing/dispensing errors.

Humalog 200 units / ml (Lispro)
BNF | BNFC | SPC

Vial - 10ml

Cartridges for Autopen classic or Humapen, KwikPen prefilled device

Prescriptions need to be written as Insulin Lispro Sanofi® or Humalog® to avoid prescribing/dispensing errors.

 

 

Actrapid (Soluble insulin)
BNF | BNFC | SPC

100 units/ml

Vial - 10ml 

Humulin S (Soluble insulin)
BNF | BNFC | SPC

100 units/ml

Vial - 10ml 

Cartridges for Autopen Classic or HumaPen

Insuman Rapid
BNF | BNFC | SPC

100 units/ml 

Vial - 5ml

Cartridges

Insulatard (Isophane)
BNF | BNFC | SPC

100 units/ml

Vial - 10ml

Cartridges for Insulatard penfill, Insulatard Innolet prefilled device

Humulin I (Isophane)
BNF | BNFC | SPC

100 units/ml

Vial - 10ml

Cartridges for Autopen Classic or HumaPen, Humulin I KwikPen prefilled device

Insuman Basal
BNF | BNFC | SPC

100 units/ml

Vial - 5ml

Cartridges for Autopen Classic or HumaPen,  SoloStar prefilled device

Lantus (Glargine)
BNF | BNFC | SPC

100 units/ml

Vial - 10ml

Cartridges for ClickSTAR and Autopen 24, Solostar prefilled device

Levemir (Detemir)
BNF | BNFC | SPC

100 units/ml

Cartridges for Novopen, Prefilled FlexPen 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)

Insulin degludec 100units/ml (Tresiba®)
Insulin degludec should be considered as a 3rd line treatment option (2nd line insulin
analogue) after treatment with Abasaglar or Lantus/ Levemir in adult patients with either of the
following issues:-
· Type 1 diabetes and are currently receiving a long-acting basal insulin analogue with poor blood glucose control.
· Are having recurrent hypoglycaemia despite having already tried on other analogue
· basal insulin.
· All patients who are being considered for insulin pump therapy should be offered degludec as this may offer significant cost saving if their hypoglycaemia can be addressed with degludec therapy.
· have experiencing nocturnal hypoglycaemia.
· Those patients presenting with recurrent admissions with DKA due to poor compliance and because of the flexibility and long acting nature of the drug may help by reducing the risk of DKA and recurrent hospital admission.
· have blood glucose variability.
· would medically benefit from the flexibility in dose timing on occasion*, such as those with irregular lifestyles or those requiring third-party assistance to administer their insulin
* A minimum of 8 hours between injections should be ensured

Approved for use in Type 1 diabetic paediatric patients.

Also available as 200units / ml. NOT on formulary at this strength. 

See Letter Sent to Healthcare Professionals (April 2018)Risk of mix-ups between insulin Fiasp® (fast-acting insulin aspart)and Tresiba® (basal insulin degludec)

Abasaglar (glargine biosimilar)▼
BNF | BNFC | SPC

100 units/ml

See NTAG Recommendation: The Northern (NHS) Treatment  Advisory Group recommends the use of Abasaglar®  insulin  glargine  biosimilar  as  a  first  line  option  for  use  in adults  who  are  eligible  for  treatment  with  insulin  glargine  as  per  NICE guidance (NG17, 2015)

Toujeo (glargine biosimilar)▼
BNF | BNFC | SPC

Insulin glargine (Toujeo®) 300units/ml.

See NTAG Recommendation: The Northern (NHS) Treatment  Advisory Group recommends the use of Toujeo® insulin glargine as an option for use in adults who  are eligible  for treatment with insulin glargine as per NICE guidance (NG17, 2015).

Humulin M3
BNF | BNFC | SPC

30%/70%, 100 units/ml

1 x 10ml Vial

Cartridges , KwikPen

Insuman Comb 25
BNF | BNFC | SPC

25%/75%, 100 units/ml

1 x 5ml Vial

Cartridges , SoloStar pre-filled pen

Biphasic Insulin Aspart (NovoMix 30)
BNF | BNFC | SPC
Biphasic Insulin Lispro (Humalog Mix 25 & Mix 50)
BNF | BNFC | SPC

Type 2 Diabetes Management Algorithm

Area Prescribing Committee website

Gliclazide
BNF | BNFC | SPC

Tablets - 40mg, 80mg

MR Tablets - 30mg

Glimepiride
BNF | BNFC | SPC

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

Gliclazide MR
BNF | BNFC | SPC

The use of modified release gliclazide should be avoided.

The County Durham & Darlington or Tees DO NOT PRESCRIBE List can be accessed online at: http://medicines.necsu.nhs.uk/guidelines/durhamdarlington or 
https://medicines.necsu.nhs.uk/guidelines/tees-guidelines/

The County Durham & Darlington or Tees GREY List – items to be prescribed in certain specific circumstances only can be accessed online at: http://medicines.necsu.nhs.uk/guidelines/durham-darlington or https://medicines.necsu.nhs.uk/guidelines/tees-guidelines/

Glipizide
BNF | BNFC | SPC

Tablets 5mg

Metformin
BNF | BNFC | SPC

Tablets - 500mg, 850mg

MR Tablets - 500mg, 750mg, 1G

Oral Solution - 500mg/5ml

Once daily MR tablets (Glucophage SR) are only approved for use in patients who have failed to tolerate the conventional tablets despite careful dose titration.

Metformin is also approved for use in Polycystic Ovary Syndrome

Metformin (Polycystic Ovary Syndrome)
BNF | BNFC | SPC

Tablets - 500mg, 850mg

For use in patients not receiving fertilty treatment from secondary care.

Yohimbine
BNF | BNFC | SPC

The County Durham & Darlington or Tees DO NOT PRESCRIBE List can be accessed online at: http://medicines.necsu.nhs.uk/guidelines/durhamdarlington or 
https://medicines.necsu.nhs.uk/guidelines/tees-guidelines/

The County Durham & Darlington or Tees GREY List – items to be prescribed in certain specific circumstances only can be accessed online at: http://medicines.necsu.nhs.uk/guidelines/durham-darlington or https://medicines.necsu.nhs.uk/guidelines/tees-guidelines/

First Choice

Lixisenatide ▼

Alternatives 

Dulaglutide

Liraglutide (Vicotza®)

Notes:
NICE criteria: If standard triple therapy is not effective then you can only use GLP-1 ONLY if BMI is ≥ 35kg/m2 in people of European descent (adjust for ethnic groups) and there are specific psychological or medical problems associated with high body weight, or BMI<35kg/m2 and insulin is unacceptable because of occupational implications or weight loss would benefit other co‐morbidities.

Approximately 25 – 33% of patients will fail to respond to GLP1-RA therapy, hence on commencement – please use a short acting agent with the lowest acquisition costs. Evaluate at 3 & 6 months

Only continue GLP-1 mimetic therapy if the person with type 2 diabetes has had a beneficial metabolic response (a reduction of at least 11 mmol/mol [1.0%] in HbA1c and a weight loss of at least 3% of initial body weight in 6 months)

Lixisenatide▼
BNF | BNFC | SPC

50 micrograms/mL, 10 micrograms/dose prefilled pen, 100 micrograms/mL, 20 micrograms/dose prefilled pen

MHRA Drug Safety Update (Jun 2019): GLP-1 receptor agonists: reports of diabetic ketoacidosis when concomitant insulin was rapidly reduced or discontinued

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.

MHRA Drug Safety Update (Jun 2019)GLP-1 receptor agonists: reports of diabetic ketoacidosis when concomitant insulin was rapidly reduced or discontinued

Liraglutide
BNF | BNFC | SPC

6mg/ml solution for injection in a pre-filled pen  

GLP-1 first line option is Lixisenatide, second line is Liraglutide or Dulaglutide.

Liraglutide 0.6mg OD increasing to 1.2mg OD (NOTE 1.8mg OD is NOT recommended by NICE)

MHRA Drug Safety Update (Jun 2019)GLP-1 receptor agonists: reports of diabetic ketoacidosis when concomitant insulin was rapidly reduced or discontinued

 

Semaglutide▼
BNF | BNFC | SPC

0.25 mg solution for injection in pre-filled pen

0.5 mg solution for injection in pre-filled pen

1 mg solution for injection in pre-filled pen

Pioglitazone
BNF | BNFC | SPC

Tablets - 15mg, 30mg

First Choice

Alogliptin▼

Alternatives 

Sitagliptin

Linagliptin

Alogliptin
BNF | BNFC | SPC

Tablets - 6.25mg, 12.5mg, 25mg

Sitagliptin
BNF | BNFC | SPC

25mg, 50mg & 100mg tablets

Linagliptin
BNF | BNFC | SPC

5mg tablets

Consider linagliptin for use in patients with renal impairment.

Saxagliptin
BNF | BNFC | SPC

Tablets 2.5mg, 5mg

MHRA Drug Safety Update (June 2015): SGLT2 inhibitors (canagliflozin, dapagliflozin, empagliflozin): risk of diabetic ketoacidosis - Test for raised ketones in patients with acidosis symptoms, even if plasma glucose levels are near-normal.

MHRA Drug Safety Update (June 2016): Canagliflozin (Invokana▼, Vokanamet▼): signal of increased risk of lower extremity amputations observed in trial in high cardiovascular risk patients.

MHRA Drug Safety Update (April 2016): SGLT2 inhibitors: updated advice on the risk of diabetic ketoacidosis

MHRA Drug Safety Update (March 2017): SGLT2 inhibitors: updated advice on increased risk of lower-limb amputation (mainly toes)

MHRA Drug Safety Update (Feb 2019): SGLT2 inhibitors: reports of Fournier’s gangrene (necrotising fasciitis of the genitalia or perineum)

Empagliflozin▼
BNF | BNFC | SPC

Tablets - 10mg, 25mg

Approved for use in accordance with the following NICE TAs

  • NICE TA336: Empagliflozin in combination therapy for treating type 2 diabetes
  • NICE TA390: Canagliflozin, dapagliflozin and empagliflozin as monotherapies for treating type 2 diabetes
Canagliflozin▼
BNF | BNFC | SPC

Tablets - 100mg, 300mg

Approved for use in accordance with the following NICE TAs

  • NICE TA315: Canagliflozin in combination therapy for treating type 2 diabetes
  • NICE TA390: Canagliflozin, dapagliflozin and empagliflozin as monotherapies for treating type 2 diabetes

 

 

Dapagliflozin▼
BNF | BNFC | SPC

Tablets - 5mg, 10mg

Approved for use in accordance with the following NICE TAs

  • 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

 

 

Ertugliflozin ▼
BNF | BNFC | SPC

5mg and 15mg film coated tablets

Approved for use in accordance with the following NICE TAs:

  • NICE TA572: Ertugliflozin as monotherapy or with metformin for treating type 2 diabetes
  • NICE TA583: Ertugliflozin with metformin and a dipeptidyl peptidase-4 inhibitor for treating type 2 diabetes
Glucagon
BNF | BNFC | SPC

1mg (1 unit) injection (with syringe)

Glucose Gel
BNF | BNFC | SPC

40% oral gel – 9.2g glucose/23g oral ampoule (GlucoGel®, formerly known as Hypostop®)

Diazoxide
BNF | BNFC | SPC

50mg tablet

For the management of chronic hypoglycaemia

Endocrinology or paediatrics only

Unlicensed liquid can be obtained but tablets can be crushed if unavailable

First Choice

Duloxetine


Alternatives


Amitriptyline
Gabapentin
See section 4.8.1
Tramadol

Duloxetine
BNF | BNFC | SPC

30mg & 60mg capsules

Amitriptyline
BNF | BNFC | SPC

See section 4.3

Gabapentin
BNF | BNFC | SPC

See section 4.8.1

MHRA Drug Safety Alert (Oct 2017): Gabapentin (Neurontin): risk of severe respiratory depression 

 

 

Test strips

County Durham & Darlington Choice

Tees Choice

GlucoRx Nexus test strips

Contour  test strips

Accu-Chek Performa test strips

 

Accu-Chek Performa test strips

 

 

Tee2 test strips

 

Freestyle Lite  test strips

Freestyle Lite  test strips

 

Contour Next Test Strips

Contour Next Test Strips

Accu-chek Aviva test strips

Accu-chek Aviva test strips

Dario test strips

 

CareSens Pro test strips and CareSens Keto sens strips

 

MyLife Pura test strips

 

 

GlucoRx HCT Glucose strips and Ketone strips

GlucoRx HCT Glucose strips and Ketone strips

 

Glucomen Areo Sensors amd ketone sensors

Accu-chek Aviva Expert test strips

 

Mylife Pura Test Strips
BNF | BNFC | SPC
GlucoRx Glucose Strips
BNF | BNFC | SPC
Accu-Check Performa Glucose Test Strips
BNF | BNFC | SPC
Tee2 Glucose test strips
BNF | BNFC | SPC
Contour Next Strips
BNF | BNFC | SPC
Accu-Check Aviva test strips
BNF | BNFC | SPC
Freestyle Test Strips
BNF | BNFC | SPC
Dario Blood Glucose Test Strips
BNF | BNFC | SPC
CareSens Ketosense ketone test strips
BNF | BNFC | SPC
CareSens Pro Blood Glucose Test Strips
BNF | BNFC | SPC
Gluco HCT Ketone Test Strips
BNF | BNFC | SPC
GlucoRx Glucose Test Strips
BNF | BNFC | SPC

Meters

County Durham & Darlington Choice

Tees Choice

GlucoRx Nexus Range

Type 1 and 2 diabetic patients

 

 

Contour Black Meter

Type 1 and 2 diabetic patients

Accu-Chek Performa

Type 1 and 2 diabetic patients

Accu-Chek Performa Nano Meter

Type 1 and 2 diabetic patients

Tee2 Blood Glucose meter

Type 1 and 2 diabetic patients

 

Animas-Any meter

Only prescribe when District Nurses are administering insulin to patients.

 

Omnipod Freestyle Lite Meter

Type 1 diabetic patients with a pump

Omnipod Freestyle Lite Meter

Type 1 diabetic patients with a pump or who count carbs

Medtronic Contour Next Meter

Type 1 diabetic patients with a pump

Medtronic Contour Next Meter

Type 1 diabetic patients with a pump OR Gestational diabetes

Accu-chek Aviva Expert Smart Meter

Type 1 diabetic patients with a pump or who count carbs

Accu-chek Aviva Expert Smart Meter

Type 1 diabetic patients with a pump or who count carbs

Dario Smart Glucose Meter

Type 1 diabetic patients who count carbs

 

CareSens Duo Blood Glucose and Ketone Meter

Type 1 diabetic patients

 

MyLife Pura Meter

Type 1 and 2 diabetic patients

 

GlucoRx HCT Meter

Type 1 diabetic patients who monitor ketones

GlucoRx HCT Meter

Type 1 diabetic patients who monitor ketones

 

Glucomen Areo 2K

Type 1 diabetic patients who monitor ketones

GlucoRx Nexus Range
BNF | BNFC | SPC

Type 1 and Type 2 diabetic patients

Accu-chek Performa
BNF | BNFC | SPC

Type 2 diabetic patients

Tee2 Blood Glucose Meter
BNF | BNFC | SPC

Type 2 diabetic patients

Animas-Any Meter
BNF | BNFC | SPC

Type 1 diabetic patients

Omnipod Freestyle Lite Meter
BNF | BNFC | SPC

Type 1 diabetic patients

Medtronic Contour Next Meter
BNF | BNFC | SPC

Type 1 diabetic patients

Accu-chek Aviva Expert Smart Meter
BNF | BNFC | SPC

Type 1 diabetic patients

Dario Smart Glucose Meter
BNF | BNFC | SPC

Type 1 diabetic patients

CareSens Duo Blood Glucose & Ketone Meter
BNF | BNFC | SPC

Type 1 diabetic patients

Mylife Pura Meter
BNF | BNFC | SPC

Type 2 diabetic patients

GlucoRX HCT Meter
BNF | BNFC | SPC

Type 1 diabetic patients

Freestyle Libre
BNF | BNFC | SPC

 

Recommended for use only as per NTAG advice and NHS England Guidance.

NTAG April 2019: The Northern (NHS) Treatment Advisory Group (NTAG) recommends Flash Glucose Monitoring as an option for glucose monitoring in the North East and Cumbria for patients who fulfil the NHS England (NHSE) Criteria for the device (see attached) or have frequent admissions (>2 per year) with DKA as per the previous Regional Medicines Optimisation Committee (RMOC) criteria.

The decision to start Flash Glucose Monitoring will only be made by the diabetes specialist.
It will be provided initially on 6 month trial basis only.


Initial sensor for the first 28 days (i.e. 2 sensors) and reader supply to be made by specialist
diabetes clinics (reader not available on prescription). Primary care prescribers should only
be asked to prescribe sensors by specialist, and should only agree to prescribe, if specialist
confirms patient meets criteria for initiation AND again after 6 months if specialist confirms they meet criteria for continuation at 6 months.

 

County Durham & Darlington Choice

Tees Choice

GlucoRX Fine Point 4mm needles

GlucoRX Fine Point 4mm needles

BD Viva 4mm needles

BBraun Omnican Fine

BD Autoshield needles

BD Autoshield safety pen needles should only be prescribed when District Nurses are using/administering insulin to patients.

 

Levothyroxine
BNF | BNFC | SPC

Tablets - 25micrograms, 50micrograms, 100micrograms

Drug protocol: levothyroxine injection – unlicensed (CDDFT intranet access only)

Liothyronine
BNF | BNFC | SPC

Tablets - 20micrograms

Only to be prescribed as per RMOC Guidance: Guidance - Prescribing of Liothyronine June 2019

The County Durham & Darlington or Tees DO NOT PRESCRIBE List can be accessed online at: http://medicines.necsu.nhs.uk/guidelines/durhamdarlington or 
https://medicines.necsu.nhs.uk/guidelines/tees-guidelines/

The County Durham & Darlington or Tees GREY List – items to be prescribed in certain specific circumstances only can be accessed online at: http://medicines.necsu.nhs.uk/guidelines/durham-darlington or https://medicines.necsu.nhs.uk/guidelines/tees-guidelines/

 

Liothyronine injection
BNF | BNFC | SPC

20microgram injection

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.

MHRA Drug Safety Update (Feb 2019): Carbimazole: increased risk of congenital malformations; strengthened advice on contraception

MHRA Drug Safety Update (Feb 2019): Carbimazole: risk of acute pancreatitis

Propylthiouracil
BNF | BNFC | SPC

Tablets - 50mg

Aqueous Iodine Oral
BNF | BNFC | SPC

Oral solution (Lugol’s Iodine) containing 130mg total iodine/ml (5% iodine & 10% potassium iodide)

Potassium Iodate
BNF | BNFC | SPC

85mg tabletsu - mainly used by medical physics

Propranolol
BNF | BNFC | SPC

80mg m/r capsules

Preferred formulation for relief of thyrotoxic symptoms.

Potassium Iodide 60mg tablets
BNF | BNFC | SPC

60mg tablets

For use by nuclear medicine only
Potassium perchlorate no longer available

MHRA Drug Safety Update (Aug 2017): Corticosteroids: rare risk of central serous chorioretinopathy with local as well as systemic administration

Fludrocortisone Acetate
BNF | BNFC | SPC

Tablets - 100micrograms

100mcg tablets can be halved

Hydrocortisone
BNF | BNFC | SPC

10mg & 20mg tablets
10mg in 5ml suspensionu
100mg injection (as the sodium succinate)

First Choice
Prednisolone - Plain tablets are preferred. Avoid enteric coated.
Prednisolone oral solution

Alternatives
Dexamethasone
Betamethasone
Methylprednisolone
Hydrocortisone
Triamcinolone

Prednisolone
BNF | BNFC | SPC

Tablets - 1mg, 5mg

Tablets soluble - 5mg

1mg/1ml oral solution (Prednisolone Dompé)

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.

Hydrocortisone
BNF | BNFC | SPC

Tablets - 10mg, 20mg

Injection - 100mg (as the sodium succinate)

Injection can be administered IM or IV
Injection can be supplied to patients to self administer for addisonian crisis

Betamethasone
BNF | BNFC | SPC

Tablets Soluble - 500microgram

Soluble tablets not used for replacement therapy.
Tablets mainly used as mouthwash see section 12.03.01

Dexamethasone
BNF | BNFC | SPC

500 microgram & 2mg tablets
2mg in 5ml oral solution; 5mg in 5ml oral solutionu
500 microgram soluble tablets
3.3mg/ml and 6.6mg/2ml injection* (both expressed as dexamethasone base)

IV and oral have similar bioavailability


*PLEASE NOTE*

Thereare two different strength preparations of dexamethasone injection available in the UK (3.8mg/ml and 3.3mg/ml) where traditionaly a 4mg/ml preparation was available and prescribed as such. 

MHRA Alert (Oct’ 2014): highlight injection “risks”

Triamcinolone
BNF | BNFC | SPC

intramuscular / intra-articular injection - 40mg/ml

Injection can be given IM or Intra-articular

Prednisolone 30mg tablets
BNF | BNFC | SPC
Methylprednisolone
BNF | BNFC | SPC

2mg, 4mg & 16mg tablets
40mg, 125mg, 500mg & 1g injections (as the sodium succinate)

MHRA Drug Safety Alert (Oct 2017): Methylprednisolone injectable medicine containing lactose (Solu-Medrone 40 mg): do not use in patients with cows’ milk allergy 

Solu-Medrone® - IV or IM injection
Depo-Medrone® - IM injection only
Neurology use high dose oral methylprednisolone for MS

Hydrocortisone Sodium Phosphate (Efcortesol)
BNF | BNFC | SPC

The County Durham & Darlington or Tees DO NOT PRESCRIBE List can be accessed online at: http://medicines.necsu.nhs.uk/guidelines/durhamdarlington or 
https://medicines.necsu.nhs.uk/guidelines/tees-guidelines/

The County Durham & Darlington or Tees GREY List – items to be prescribed in certain specific circumstances only can be accessed online at: http://medicines.necsu.nhs.uk/guidelines/durham-darlington or https://medicines.necsu.nhs.uk/guidelines/tees-guidelines/

Betamethasone IV
BNF | BNFC | SPC

Injection - 4mg

Hydrocortisone granules (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.

Approved for primary and secondary adrenal insufficiency in paediatric patients. 

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.

Estradiol
BNF | BNFC | SPC

1mg & 2mg tablets

Oestrogens conjugated (Premarin)
BNF | BNFC | SPC

625 microgram & 1.25mg tablets

Ethinylestradiol
BNF | BNFC | SPC

2 microgram u & 10 microgram tablets

Ethinylestradiol note: used on advice from appropriate specialists (mainly endocrinologists)

Estradiol Patches
BNF | BNFC | SPC

 

Twice weekly matrix patches releasing approximately 25, 50, 75 & 100 microgram/24 hours (e.g. Evorel®)

Twice weekly matrix patches releasing approximately 25, 37.5, 50, 75 & 100 microgram/24 hours (e.g. Estradot®)


Once weekly matrix patches releasing approx. 50 & 100 microgram estradiol/24 hours (Progynova TS®)

Estradiol 0.1% gel (Sandrena®)
BNF | BNFC | SPC

0.1% gel (Sandrena®)

Estradiol 0.06% gel (Oestrogel®)
BNF | BNFC | SPC

Estradiol 0.06% gel (Oestrogel®) 80g pump

Elleste Duet
BNF | BNFC | SPC

Packs of 16 x 1mg estradiol tablets + 12 x 1mg estradiol
& 1mg norethisterone tablets

Femoston
BNF | BNFC | SPC

Femoston® 1/10 - Packs of 14 estradiol 1mg tablets + 14 tablets containing
estradiol 1mg & dydrogesterone 10mg
Femoston® 2/10 - Packs of 14 estradiol 2mg tablets + 14 tablets containing
estradiol 2mg & dydrogesterone 10mg

Evorel (Evorel Sequi®)
BNF | BNFC | SPC

Pack containing 4 patches releasing 50 micrograms estradiol/24 hours & 4 patches releasing 50 micrograms estradiol and 170 micrograms norethisterone acetate/ 24 hours

Premique Low Dose
BNF | BNFC | SPC

Tablets - 300micrograms oestrogen & 1.5mg medroxyporgesterone

Kliovance®
BNF | BNFC | SPC

Tablets containing estradiol 1mg & norethisterone acetate 500 micrograms

Kliofem®
BNF | BNFC | SPC

Tablets containing 2mg estradiol & norethisterone acetate 1mg

Evorel Conti® patches
BNF | BNFC | SPC

Pack containing 8 patches releasing 50 micrograms estradiol/24 hours & 170 micrograms norethisterone acetate/24 hours

Tibolone
BNF | BNFC | SPC

Tibolone Tablets - 2.5mg

Short term treatment of symptoms

Raloxifene
BNF | BNFC | SPC

60mg tablets

For use on the advice of specialists in the prevention and treatment of osteoporosis where alternative treatments are inappropriate

Approved for use in accordance with the following NICE TAs:

  • NICE TA160: Raloxifene for the primary prevention of osteoporotic fragility fractures in postmenopausal women
  • NICE TA161: Raloxifene and teriparatide for the secondary prevention of osteoporotic fragility fractures in postmenopausal women
Norethisterone
BNF | BNFC | SPC

5mg tablets

CD&D Grey List: For the postponement of menstruation for non-medical reasons prescribing is not generally recommended as this is considered a lifestyle choice rather than the treatment of a medical
condition (please note medroxyprogesterone is unlicensed for this indication).

Tees Do Not Prescribe/Grey ListFor 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

2.5mg, 5mg & 10mg tablets - sometimes used as a progestogen component of HRT
100mg & 200mg tablets - for use in malignant disease see section 8.3.2.
50mg in ml injection - see sections 7.3.2.2 for use of medroxyprogesterone acetate injection in contraception.

CD&D Grey List: For the postponement of menstruation for non-medical reasons prescribing is not generally recommended as this is considered a lifestyle choice rather than the treatment of a medical
condition (please note medroxyprogesterone is unlicensed for this indication).

Tees Do Not Prescribe/Grey ListFor 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.

Progesterone Pessaries
BNF | BNFC | SPC

200mg & 400mg pessaries

NICE NG25: Preterm labour and birth

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

Levonorgestrel (Mirena)
BNF | BNFC | SPC

Mirena - Levonorgestrel 52mg in a T-shaped intra-uterine system- Used for treating idiopathic menorrhagia. Especially in women requiring (reversible) contraception. Also used for protection with endometrial hyperplasia during oestrogen replacement therapy. Lasts for up to 5 years- for use in accordance with agreed guidelines.

Ulipristal Acetate 5mg
BNF | BNFC | SPC

5mg tablets

For patients on treatment with Esmya, liver function should be monitored at least monthly, and 2-4 weeks after stopping treatment.

MHRA Drug Safety Update (Aug 2018):  Esmya (ulipristal acetate) and risk of serious liver injury: new restrictions to use and requirements for liver function monitoring before, during, and after treatment

 

 

Progesterone Injection
BNF | BNFC | SPC

If licensed product unavailable unlicensed product can be obtained

Progesterone capsules
BNF | BNFC | SPC

100mg cap

Testosterone gel
BNF | BNFC | SPC

10mg/0.5ml (2%)/ metered dose from pump (Tostran®)

For use on advice from endocrinologists

Testosterone Undecanoate
BNF | BNFC | SPC

1g in 4ml (250mg/ml) oily injection (Nebido®)

40mg capsules

Sustanon
BNF | BNFC | SPC

1ml injection (testosterone propionate 30mg, testosterone phenylpropionate 60mg, testosterone isocaproate 60mg & testosterone decanoate 100mg)

Finasteride
BNF | BNFC | SPC

Tablets - 5mg

Benign prostatic hyperplasia only
Avoid contact with crushed tablets

Cyproterone
BNF | BNFC | SPC

Tablets - 50mg

Note: For use on the advice of a urologist

Dutasteride
BNF | BNFC | SPC

Gender Dysphoria – Tertiary Centre initiation ONLY (Unlicensed Indication)

Documentation will be supplied by the tertiary centre.

Goserelin
BNF | BNFC | SPC

3.6mg injection

Leuprorelin
BNF | BNFC | SPC

11.25mg injection

Estradiol (Oestradiol)
BNF | BNFC | SPC

1mg & 2mg tablets

Estradiol
BNF | BNFC | SPC

Twice weekly matrix patches releasing approximately 50, 75 & 100 microgram/24 hours
0.1% gel (Sandrena®)
0.06% gel (Oestrogel®)

Finasteride
BNF | BNFC | SPC

5mg tablets

Cyproterone acetate
BNF | BNFC | SPC

50mg & 100mg tablets

Spironolactone
BNF | BNFC | SPC

25mg & 100mg tablets

Testosterone Undecanoate
BNF | BNFC | SPC

1g in 4ml (250mg/ml) oily injection (Nebido®)

Sustanon 250®
BNF | BNFC | SPC

1ml injection (testosterone propionate 30mg, testosterone
phenylpropionate 60mg, testosterone isocaproate 60mg & testosterone
decanoate 100mg)

Testosterone gel
BNF | BNFC | SPC

50mg/5g (1%) sachets (Testogel®)

Clomifene citrate
BNF | BNFC | SPC

Tablets - 50mg

Treatment of infertility by specialist

Tetracosactide
BNF | BNFC | SPC

250 microgram in 1ml injection,
1mg in 1ml depot injection

Chorionic Gonadotropin (IVF)
BNF | BNFC | SPC

1,500 units & 5,000 units injections

When used for fertilty treatment.

Chorionic Gondatrophin
BNF | BNFC | SPC

1,500 units & 5,000 units injections

When used for hypogonadism

RED when used for IVF.

Menotrophin
BNF | BNFC | SPC

75 units FSH & 75 units LH activity injection

IVF only

Chorionic Gondatrophin (Ovitrelle®)
BNF | BNFC | SPC

Injection

For use as dignostic test for hypgonadism as per Newcastle protocol.

RED when used for IVF

Follitropin Alfa
BNF | BNFC | SPC

IVF only

Follitropin Beta
BNF | BNFC | SPC

IVF only

Lutropin alfa
BNF | BNFC | SPC

IVF only

Tertiary Centre Only: NICE TA188, NICE TA64

Somatrophin (Recombinant Human Growth Hormone)▼
BNF | BNFC | SPC

1st line
Omnitrope® 5-mg (15-unit) vial (powder with diluent) for use with Omnitrope Pen L® device
3.3 mg (10 units)/ml, 1.5 ml (5-mg, 15-unit) cartridge & 6.7 mg (20 units)/ml, 1.5 ml (10-mg, 30-unit) cartridge - for use with Omnitrope Pen 5® & Omnitrope Pen 10® devices respectively
- least expensive formulation of somatropin. Omnitrope should be used in all de novo paediatric patients where possible.


2nd line
Norditropin SimpleXx® 1.5ml cartridges for use in Nordipen® devices - 5mg (15 units), 10mg (30 units) & 15mg (45 units)
- 2nd least expensive alternative formulation for patients who cannot 
tolerate omnitrope.
Saizen® 8mg vials (powder with diluent)
Saizen® 5.83 mg/ml solution for injection (6mg
cartridges), 8 mg/ml solution for injection (12mg and 20mg cartridges)
- for use in EasyPod® device
- to be used in patients with compliance issues


3rd line
Genotropin Miniquick® syringes -
0.2mg (0.6 units) 0.8mg (2.4 units)1.4mg (4.2 units) 
0.4mg (1.2 units) 1mg (3 units) 1.6mg (4.8 units) 0.6mg (1.8 units) 1.2mg (3.6 units) 2mg (6 units)
- to be used for patients when travelling.
Zomacton® 12 unit (4mg) injection
- Needle free presentation.
 1st line: 75% to 85% of total mg usage
 2nd line: 15% to 25% of total mg usage
 3rd line: up to 5% of total mg usage

Somatropin Genotropin® cartridges for use in Genotropin pens -
16 unit (5.3mg) & 36 unit (12mg) in 1ml
Genotropin Miniquick® syringes -
0.2mg (0.6 units) 0.8mg (2.4 units)1.4mg (4.2 units)
0.4mg (1.2 units) 1mg (3 units) 1.6mg (4.8 units) 0.6mg
(1.8 units) 1.2mg (3.6 units) 2mg (6 units)
- To be used for patients when travelling.

Gonadorelin
BNF | BNFC | SPC

100 microgram in 1ml injection (HRF®)

Protirelin
BNF | BNFC | SPC

200 microgram in 1ml injection u

Desmopressin
BNF | BNFC | SPC

Tablets - 100micrograms, 200micrograms

Nasal Spray - 10micrograms/metered spray



Argipressin
BNF | BNFC | SPC

20 units in 1ml injection (Synthetic Vasopressin)

Terlipressin
BNF | BNFC | SPC

1mg vials for preparing injection

Demeclocyline
BNF | BNFC | SPC

150mg capsules

Indication: Syndrome of inappropriate antidiuretic hormone secretion (SIADH)

Drug protocol: hyponatraemia (CDDFT intranet access only)

Tolvaptan (Jinarc)
BNF | BNFC | SPC

Tablets - 15mg, 30mg

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

Approved for use in accordance with the following NICE TAs

  • NICE TA358: Tolvaptan for treating autosomal dominant polycystic kidney disease
Tolvaptan (Samsca)
BNF | BNFC | SPC

15mg and 30mg tablets

Indication = treatment of hyponatraemia secondary to SIADH. Tolvaptan was rejected by NTAG for and therefore not available in CDD. NHS England – Not routinely commissioned

MHRA Drug Safety Update (Dec 2015): Bisphosphonates: very rare reports of osteonecrosis of the external auditory canal

Disodium Pamidronate
BNF | BNFC | SPC

30mg injection

Zolendronic Acid (Zometa)
BNF | BNFC | SPC

4mg injection
For use in hypercalcaemia of malignancy and the prevention of skeletal events in patients with metastatic breast cancer. Not approved for preventing skeletal events in patients with prostate cancer.
To avoid confusion it is recommended that this product is prescribed by brand name i.e. Zometa® 

Sodium Clodronate
BNF | BNFC | SPC

520mg tablets or 800mg tablets

Oncology only - for breast pain/breast cancer/myeloma patients only.

MHRA Drug Safety Update (Dec 2015): Bisphosphonates: very rare reports of osteonecrosis of the external auditory canal

Bisphosphonates to be prescribed as per NICE TA464

Alendronate Sodium
BNF | BNFC | SPC

10mg tablets (taken daily)
70mg tablets (taken once weekly) – preferred

Bisphosphonates to be prescribed as per NICE TA464

Fosavance
BNF | BNFC | SPC
Alendronate Effervescent Tablets
BNF | BNFC | SPC

70mg once a week tablets

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

Risedronate Sodium
BNF | BNFC | SPC

5mg tablets (taken daily)
35mg tablets (taken once weekly for osteoporosis) - preferred

30mg tablets (for Paget’s disease)

Bisphosphonates to be prescribed as per NICE TA464

Ibandronic Acid
BNF | BNFC | SPC

50mg tablets

Reduction of bone damage in patients with metastatic breast cancer. Not approved for use in the treatment of patients with other forms of cancer (e.g. prostate) or for the treatment of osteoporosis.

3mg in 3ml injection

For use where oral bisphosphonates are not appropriate (not tolerated, contra-indicated because of upper gastro-intestinal problems or insufficiently effective).

Bisphosphonates to be prescribed as per NICE TA464

Ibandronic Acid 150mg
BNF | BNFC | SPC

Bisphosphonates to be prescribed as per NICE TA464

Zoledronic Acid (Aclasta)
BNF | BNFC | SPC

5mg injection

For the treatment of Paget’s disease and post menopausal osteoporosis in patients where oral risedronate is contraindicated, inconvenient, poorly tolerated or ineffective in reducing bone turnover. Postmenopausal osteoporosis in patients where oral bisphosphonates are contraindicated, not tolerated or where they are ineffective, as reflected by declining bone density measurements. To avoid confusion it is recommended that this product is prescribed by brand name i.e. Aclasta®

Bisphosphonates to be prescribed as per NICE TA464

Raloxifene
BNF | BNFC | SPC

60mg tablets

For use on the advice of specialists in the prevention and treatment of osteoporosis where alternative treatments are inappropriate.

Approved for use in accordance with the following NICE TAs:
TA161 - Raloxifene and teriparatide for the secondary prevention of osteoporotic fragility fractures in postmenopausal women

Not approved in accordance with the following NICE TAs:

TA160 - Raloxifene for the primary prevention of osteoporotic fragility fractures in postmenopausal women

Denosumab
BNF | BNFC | SPC

60mg in 1ml solution in prefilled syringe

MHRA Drug Safety Update (Oct 2012): Denosumab - fatal cases of severe symptomatic hypocalcaemia, and risk of hypocalcaemia at any time during treatment – monitoring recommended

MHRA Drug Safety Update (Jul 2015): Denosumab (Xgeva▼, Prolia); intravenous bisphosphonates: osteonecrosis of the jaw—further measures to minimise risk

MHRA Drug Safety Update (June 2017): Denosumab (Prolia, Xgeva▼): reports of osteonecrosis of the external auditory canal

MHRA Drug Safety Update (June 2018): Denosumab (Xgeva▼) for advanced malignancies involving bone: study data show new primary malignancies reported more frequently compared to zoledronate

MHRA Drug Safety Update (June 2018): Denosumab (Xgeva▼) for giant cell tumour of bone: risk of clinically significant hypercalcaemia following discontinuation

Approved for use in accordance with the following NICE TAs:

  • NICE TA204: Denosumab for the prevention of osteoporotic fractures in postmenopausal women
  • NICE TA265: Denosumab for the prevention of skeletal-related events in adults with bone metastases from solid tumours

Not approved in accordance with the following NICE TAs:

  • NICE TA549: Denosumab for preventing skeletal-related events in multiple myeloma (terminated appraisal)

 

Calcitonin (Salmon)
BNF | BNFC | SPC

400 units in 2ml injection

Teriparatide
BNF | BNFC | SPC

250 microgram/ml prefilled pen

Limited use in accordance with NICE TA161

Maximum duration of treatment 24 months

Teriparatide for atypical fractures was rejected by NETAG and therefore not available in CDD for this indication.

Bromocriptine
BNF | BNFC | SPC

Tablets - 1mg, 2.5mg

Specialist initiation only

Cabergoline
BNF | BNFC | SPC

Tablets - 500 microgram

Specialist initiation only

First choice

Triptorelin

 

Alternatives

Leuprorelin

Goserelin

Danazol

Buserelin

Danazol
BNF | BNFC | SPC

Capsules - 100mg, 200mg

Specialist initiation only

Goserelin Injection
BNF | BNFC | SPC

3.6mg & 10.8mg injections

Triptorelin
BNF | BNFC | SPC

3.75mg injection (Gonapeptyl Depot®)
11.25mg injection (Decapeptyl SR®)

Leuprorelin
BNF | BNFC | SPC

3.75mg & 11.25mg pre filled syringes

Buserelin
BNF | BNFC | SPC

150 micrograms/dose nasal spray

Nafarelin
BNF | BNFC | SPC

Nasal spray 200 microgram

Specialist initiation only

RED when used as part of IVF.

Ganirelix
BNF | BNFC | SPC

IVF only - for use in IVF Superovulation Short Protocol to inhibit premature LH Surge & ovulation prior to oocyte collection procedure

Cetrorelix
BNF | BNFC | SPC

For IVF use only

Metyrapone
BNF | BNFC | SPC

250mg capsules

Endocrinology advice only

Mecasermin▼
BNF | BNFC | SPC

Commissioner: NHS England - Policy - E03/P/a