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/
Prescribing of medicines available to purchase over the counter for self-care
Self-Care and Medicines Available Over The Counter (OTC)
100 units/ml
10ml - Vial, Penfill cartridges, Prefilled Flexpen pen
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).
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.
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.
100 units/ml
Vial - 10ml
Cartridges for Insulatard penfill, Insulatard Innolet prefilled device
100 units/ml
Vial - 10ml
Cartridges for Autopen Classic or HumaPen, Humulin I KwikPen prefilled device
100 units/ml
Vial - 10ml
Cartridges for ClickSTAR and Autopen 24, Solostar prefilled device
100 units/ml
Cartridges for Novopen, Prefilled FlexPen device
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)
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)
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).
Type 2 Diabetes Management Algorithm
Area Prescribing Committee website
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/
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
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)
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
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
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
First Choice
Alogliptin▼
Alternatives
Sitagliptin
Linagliptin
5mg tablets
Consider linagliptin for use in patients with renal impairment.
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)
Tablets - 10mg, 25mg
Approved for use in accordance with the following NICE TAs
Tablets - 100mg, 300mg
Approved for use in accordance with the following NICE TAs
Tablets - 5mg, 10mg
Approved for use in accordance with the following NICE TAs
5mg and 15mg film coated tablets
Approved for use in accordance with the following NICE TAs:
40% oral gel – 9.2g glucose/23g oral ampoule (GlucoGel®, formerly known as Hypostop®)
First Choice
Duloxetine
Alternatives
Amitriptyline
Gabapentin
See section 4.8.1
Tramadol
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 |
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Accu-Chek Performa test strips
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Accu-Chek Performa test strips
|
|
Tee2 test strips |
|
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Freestyle Lite test strips |
Freestyle Lite test strips
|
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Contour Next Test Strips |
Contour Next Test Strips |
|
Accu-chek Aviva test strips |
Accu-chek Aviva test strips |
|
Dario test strips |
|
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CareSens Pro test strips and CareSens Keto sens strips |
|
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MyLife Pura test strips
|
|
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GlucoRx HCT Glucose strips and Ketone strips |
GlucoRx HCT Glucose strips and Ketone strips |
|
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Glucomen Areo Sensors amd ketone sensors |
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Accu-chek Aviva Expert test strips |
|
Meters
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County Durham & Darlington Choice |
Tees Choice |
|
GlucoRx Nexus Range Type 1 and 2 diabetic patients |
|
|
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Contour Black Meter Type 1 and 2 diabetic patients |
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Accu-Chek Performa Type 1 and 2 diabetic patients |
Accu-Chek Performa Nano Meter Type 1 and 2 diabetic patients |
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Tee2 Blood Glucose meter Type 1 and 2 diabetic patients |
|
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Animas-Any meter Only prescribe when District Nurses are administering insulin to patients. |
|
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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 |
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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 |
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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 |
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Dario Smart Glucose Meter Type 1 diabetic patients who count carbs |
|
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CareSens Duo Blood Glucose and Ketone Meter Type 1 diabetic patients |
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MyLife Pura Meter Type 1 and 2 diabetic patients |
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GlucoRx HCT Meter Type 1 diabetic patients who monitor ketones |
GlucoRx HCT Meter Type 1 diabetic patients who monitor ketones |
|
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Glucomen Areo 2K Type 1 diabetic patients who monitor ketones |
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 |
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BD Viva 4mm needles |
BBraun Omnican Fine |
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BD Autoshield needles BD Autoshield safety pen needles should only be prescribed when District Nurses are using/administering insulin to patients. |
|
Tablets - 25micrograms, 50micrograms, 100micrograms
Drug protocol: levothyroxine injection – unlicensed (CDDFT intranet access only)
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/
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
Oral solution (Lugol’s Iodine) containing 130mg total iodine/ml (5% iodine & 10% potassium iodide)
80mg m/r capsules
Preferred formulation for relief of thyrotoxic symptoms.
MHRA Drug Safety Update (Aug 2017): Corticosteroids: rare risk of central serous chorioretinopathy with local as well as systemic administration
First Choice
Prednisolone - Plain tablets are preferred. Avoid enteric coated.
Prednisolone oral solution
Alternatives
Dexamethasone
Betamethasone
Methylprednisolone
Hydrocortisone
Triamcinolone
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.
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
Tablets Soluble - 500microgram
Soluble tablets not used for replacement therapy.
Tablets mainly used as mouthwash see section 12.03.01
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”
intramuscular / intra-articular injection - 40mg/ml
Injection can be given IM or Intra-articular
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
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/
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.
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®)
Packs of 16 x 1mg estradiol tablets + 12 x 1mg estradiol
& 1mg norethisterone tablets
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:
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 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.
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 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.
200mg & 400mg pessaries
NICE NG25: Preterm labour and birth
RED for Luteal Phase support following IVF only. Full course to be supplied by hospital
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.
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
If licensed product unavailable unlicensed product can be obtained
10mg/0.5ml (2%)/ metered dose from pump (Tostran®)
For use on advice from endocrinologists
1g in 4ml (250mg/ml) oily injection (Nebido®)
40mg capsules
Gender Dysphoria – Tertiary Centre initiation ONLY (Unlicensed Indication)
Documentation will be supplied by the tertiary centre.
Twice weekly matrix patches releasing approximately 50, 75 & 100 microgram/24 hours
0.1% gel (Sandrena®)
0.06% gel (Oestrogel®)
1ml injection (testosterone propionate 30mg, testosterone
phenylpropionate 60mg, testosterone isocaproate 60mg & testosterone
decanoate 100mg)
1,500 units & 5,000 units injections
When used for fertilty treatment.
1,500 units & 5,000 units injections
When used for hypogonadism
RED when used for IVF.
Injection
For use as dignostic test for hypgonadism as per Newcastle protocol.
RED when used for IVF
Tertiary Centre Only: NICE TA188, NICE TA64
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.
150mg capsules
Indication: Syndrome of inappropriate antidiuretic hormone secretion (SIADH)
Drug protocol: hyponatraemia (CDDFT intranet access only)
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
MHRA Drug Safety Update (Dec 2015): Bisphosphonates: very rare reports of osteonecrosis of the external auditory canal
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®
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
10mg tablets (taken daily)
70mg tablets (taken once weekly) – preferred
Bisphosphonates to be prescribed as per NICE TA464
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
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
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
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
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
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:
Not approved in accordance with the following NICE TAs:
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.
First choice
Triptorelin
Alternatives
Leuprorelin
Goserelin
Danazol
Buserelin
3.75mg injection (Gonapeptyl Depot®)
11.25mg injection (Decapeptyl SR®)
Nasal spray 200 microgram
Specialist initiation only
RED when used as part of IVF.
IVF only - for use in IVF Superovulation Short Protocol to inhibit premature LH Surge & ovulation prior to oocyte collection procedure