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6. Endocrine System

Type 2 Diabetes Management Algorithm

CDDFT Intranet Link

Area Prescribing Committee website

Osteoporosis prescribing guidelines

Area Prescribing Committee website

CDDFT Intranet

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 CG44: Heavy Menstrual Bleeding – assessment and 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

 

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

CD&D APC “Do Not Prescribe List” and “Grey List – drugs prescribed under limited circumstances” available at: http://medicines.necsu.nhs.uk/guidelines/durham-darlington/

Humalog (Lispro)
BNF | BNFC | SPC

Vial - 10ml

Cartridges for Autopen classic or Humapen, KwickPen prefilled device

Novorapid (Aspart)
BNF | BNFC | SPC

10ml - Vial, Penfill cartridges, Prefilled Flexpen pen

Actrapid (Soluble insulin)
BNF | BNFC | SPC

Vial - 10ml 

Humulin S (Soluble insulin)
BNF | BNFC | SPC

Vial - 10ml 

Cartridges for Autopen Classic or HumaPen

Insuman Rapid
BNF | BNFC | SPC

Vial - 5ml

Cartridges

Humulin R
BNF | BNFC | SPC

500units/ml - 10ml vial u

Humulin R: For use in a very small number of insulin resistant patients that require very high doses

Insulatard (Isophane)
BNF | BNFC | SPC

Vial - 10ml

Cartridges for Insulatard penfill, Insulatard Innolet prefilled device

Humulin I (Isophane)
BNF | BNFC | SPC

Vial - 10ml

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

Insuman Basal
BNF | BNFC | SPC
Lantus (Glargine)
BNF | BNFC | SPC

Vial - 10ml

Cartridges for ClickSTAR and Autopen 24, Solostar prefilled device

Levemir (Detemir)
BNF | BNFC | SPC

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

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

Abasaglar (glargine biosimilar)▼
BNF | BNFC | SPC

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).

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.

Metformin
BNF | BNFC | SPC

Tablets - 500mg, 850mg

MR Tablets - 500mg, 750mg, 1G

500mg and 1g powder for oral solution in sachets

Oral Solution - 500mg/5ml

The sachets are preferred to the ready-made oral solution as much cheaper.

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

Yohimbine
BNF | BNFC | SPC

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

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.

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)

 

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.

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)

Empagliflozin▼
BNF | BNFC | SPC

Tablets - 10mg, 25mg

Approved by NICE as options for treating type 2 diabetes in adults for whom metformin is contraindicated or not tolerated, and when diet and exercise alone do not provide adequate glycaemic control, only if:

  • A dipeptidyl peptidase-4 (DPP-4) inhibitor would otherwise be prescribed
  • A sulfonylurea or pioglitazone is not appropriate.
Canagliflozin▼
BNF | BNFC | SPC

Tablets - 100mg

Approved by NICE as options for treating type 2 diabetes in adults for whom metformin is contraindicated or not tolerated, and when diet and exercise alone do not provide adequate glycaemic control, only if:

  • A dipeptidyl peptidase-4 (DPP-4) inhibitor would otherwise be prescribed
  • A sulfonylurea or pioglitazone is not appropriate

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

Dapagliflozin▼
BNF | BNFC | SPC

Tablets - 5mg, 10mg

Approved by NICE as options for treating type 2 diabetes in adults for whom metformin is contraindicated or not tolerated, and when diet and exercise alone do not provide adequate glycaemic control, only if:

  • A dipeptidyl peptidase-4 (DPP-4) inhibitor would otherwise be prescribed
  • A sulfonylurea or pioglitazone is not appropriate

Dapagliflozin: NICE TA288 NICE TA390 NICE TA418

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

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

Tramadol
BNF | BNFC | SPC

50mg capsules; 50mg dispersible tablets

County Durham and Darlington formulary choices for blood glucose test strips, ketone test strip and pen needles

Standard functionality only

Extra Functionality Required

 

Diabetic Pen Needles

 

Please only prescribe 4mm length for patient comfort

Diabetic Blood Glucose testing Strips

 

Type 2 or Type 1 patients

Meters with the inbuilt ability to measure ketones

 

Usually only needed for Type 1 patients

Smart meters with Carb counting

 

Only needed for Type 1 patients

Compatible with insulin pumps

 

(Currently 4 choices of insulin pump that use different type of strips)

Tee2

(£7.75 for 50 strips)

1st choice:

Care Sens Duo machine which uses :

1st choice:

Dario test strips

(£14.95 per 50)

Medtronic-Contour next one meter and uses Contour Next strips

(£15.00 per 50)

BD Viva needle

(£5.36 for 90)

For Ketones = Keto sens strips (£9.95 for 10)

For Blood Glucose  = Care Sens Pro Strips (£9.95 for 50)

GlucoRx Nexus range: Nexus, mini and voice meters (3 meters, one testing strip for all – £9.95 for 50 strips)

2nd choice:

Gluco RX which uses:

2nd choice:

Accucheck Aviva Expert- test strips

(£15.96 per 50)

Roche-Expert meter/ Accuchek aviva test strips (£15.96 per 50)

Gluco RX fine point needles 

(£5.95 for 100)

For Ketones =

Gluco HCT (9.95 for 10 – ketones)

For Blood Glucose= Gluco Rx (9.95 for 50).

Mylife Pura

(£9.50 for 50 strips)

 

Omnipod-Freestyle lite meter and freestyle strips (£15.97 per 50)

BD Autoshield Duo needles

(£30.08 for 100 pen needles)

ONLY PRESCRIBE when District Nurses are administering insulin to patients. 

Accu-Chek Performa

(£9.95 for 50 strips

Animas-Any meter and any 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
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

GlucoRx Fine Point
BNF | BNFC | SPC

4mm needles

BD Viva
BNF | BNFC | SPC

4mm needles

BD Autoshield needles
BNF | BNFC | SPC

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

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

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

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.

Fludrocortisone Acetate
BNF | BNFC | SPC

Tablets - 100micrograms

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
Prednisolone 30mg tablets

Alternatives
Dexamethasone
Betamethasone
Methylprednisolone
Hydrocortisone
Triamcinolone

Prednisolone
BNF | BNFC | SPC

Tablets - 1mg, 5mg, 25mg

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)

Betamethasone
BNF | BNFC | SPC

Tablets Soluble - 500microgram

Injection - 4mg

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)


*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

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

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

Hydrocortisone Sodium Phosphate (Efcortesol)
BNF | BNFC | SPC
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®)
Once weekly matrix patches releasing approx. 50 & 100 microgram estradiol/24 hours (Progynova TS®)
0.1% gel (Sandrena®)

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

Norethisterone
BNF | BNFC | SPC

5mg tablets

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.

Progesterone Pessaries
BNF | BNFC | SPC

200mg & 400mg pessaries

NICE NG25: Preterm labour and birth

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
BNF | BNFC | SPC

5mg tablets

Ulipristal acetate: approved for the preoperative treatment of moderate to severe uterine fibroids requiring surgery.

Treatment will be for 3 months as per the licensed indication.  It will initiated by a specialist who will supply the first month, with the additional 2 months being prescribed in primary care to patients prior to their surgery for fibroids.

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

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®)

Pegovisomant
BNF | BNFC | SPC

NHS England – Not routinely commissioned

Clomifene citrate
BNF | BNFC | SPC

Tablets - 50mg

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

Menotrophin
BNF | BNFC | SPC

75 units FSH & 75 units LH activity injection

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

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

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

Tolvaptan (1)
BNF | BNFC | SPC

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

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

Alendronate Sodium
BNF | BNFC | SPC

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

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

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

30mg tablets (for Paget’s disease)

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).

Ibandronic Acid 150mg
BNF | BNFC | SPC
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®

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.

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

For use in the treatment of postmenopausal osteoporosis. To be used in accordance with NICE TA204.

Strontium Ranelate
BNF | BNFC | SPC

2g sachets

Strontium Ranelate: only for use in patients with osteoporosis in whom there are no other treatment options – SAFETY NOTICE: see MHRA Drug Safety Update (March 2014): Strontium ranelate: cardiovascular risk for contraindications and restrictions.

NICE TA161

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

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

Mecasermin▼
BNF | BNFC | SPC

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