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 Formulary Chapter 6: Endocrine system - Full Chapter
06.01  Drugs used in diabetes
 note 
  • Good glycaemic control (HbA1c concentrations close to the normal range) has benefits in preventing microvascular complications (retinopathy, nephropathy and neuropathy) or slowing their progression. However frequency and severity of hypoglycaemia may increase. Tailor advice to the individual patient to encourage best glycaemic control without suffering frequent or severe hypoglycaemia.
  • Modification of diabetic regimen is necessary in diabetic ketoacidosis, hyperosmolar non-ketotic diabetic state, surgery, procedures involving fasting (e.g. colonoscopy and barium enema), pregnancy and myocardial infarction.
  • All women with diabetes contemplating pregnancy should be seen by the multidisciplinary team. If they are taking oral hypoglycaemics they should be switched to insulin before conception. Combined diabetic antenatal clinics are held at Leicester General Hospital and Leicester Royal Infirmary, women should attend clinic as soon as pregnancy is suspected.
  • Patients admitted with proven or suspected MI should be commenced on intravenous insulin with glucose (+/- potassium) as described in the guidelines for CCUs in the acute hospitals, with the aim of maintaining blood glucose in the normal range.
  • See also 'Drugs used in the treatment of obesity'
06.01.01  Insulins
 note 
  • Insulin is indicated for patients with Type 1 diabetes and those with Type 2 diabetes not adequately controlled by diet and oral antidiabetic agents, or during intercurrent illness.
  • Prescribe by brand name rather than generically since it is not safe to assume that similar preparations from different manufacturers will have identical effects in practice.
  • Do not abbreviate 'unit' on prescriptions as errors may occur, e.g. 10U may be mistaken for 100.
  • Insulin vials should not be shared between patients. Use one vial per patient.
  • Porcine insulins are no longer recommended formulary choices for initiation but may be prescribed for patients already established on therapy.
  • Apidra (insulin glulisine) may be used for patients using an insulin pump or those already using the Solostar device.
  • U500 insulin is an unlicensed insulin that is 5 times more concentrated than standard insulin (U100). U500 is available as Humulin R Kwik pen only. 
  • NHS Improvement have issued a safety alert for risk of death from incorect use of insulin. See here for the alert.

Devices for formulary choices

 Company  Pen for cartridges  Prefilled Pen
 Lilly  HumaPen Savvio  KwikPen
 Novo Nordisk  Novopen 4  FlexPen
 Sanofi- Aventis  ClikSTAR  SoloStar



06.01.01.01  Short-acting insulins
Insuman Rapid®
View adult BNF View SPC online
First Choice
Green
Cartridge + ClikSTAR 
Humulin S®
View adult BNF View SPC online
Second Choice
Green
Vial, Cartridge + HumaPen Savvio 
   
Actrapid®
View adult BNF View SPC online  Track Changes
Formulary
Green
Only available in 10ml vials.
IV Monograph available through 'Injectable Medicines Guide' link on front page of INsite. 
   
06.01.01.01  Rapid Acting Insulin Analogues
Humalog®
View adult BNF View SPC online
Formulary
Green
Insulin Lispro rapid acting insulin analogue.
Vial, Cartridge + HumaPen, Kwikpen 
   
Humalog® 200 units/ml KwikPen
View adult BNF View SPC online  Track Changes
Formulary
Green
Double concentrate Insulin Lispro rapid acting insulin analogue.
Only available as a KwikPen®
Primary care initiation conditional on appropriate competency. Otherwise simple amber
Should be reserved for the treatment of patients with diabetes requiring daily doses of more than 20 units of rapid-acting insulin 
   
NovoRapid®
View adult BNF View SPC online
Formulary
Green
Insulin Aspart rapid acting insulin analogue.
3ml Penfill® Cartridge + Novopen 4, FlexPen
1.6ml PumpCart® Cartridge for use in Accu-Chek Insight SC insulin pump 
   
06.01.01.01  Ultra-Rapid acting insulin analogues to top
Fiasp®
View adult BNF View SPC online  Track Changes
Formulary
Green

Fast Acting Insulin Aspart. Please note, this formulation is not directly equivalent to other short-acting insulins. Must be prescribed by brand

 

 
   
06.01.01.02  Intermediate- and long-acting insulins
06.01.01.02  Biphasic insulins
Humulin® M3
View adult BNF View SPC online
First Choice
Green
30/70 soluble / isophane
Vial, Cartridge + HumaPen Savvio, KwikPen 
Humalog® Mix25, Humalog®Mix50
View adult BNF View SPC online
Formulary
Green
Biphasic Insulin Lispro. Analogue insulin
Vial, Cartridge + HumaPen Savvio, KwikPen 
   
NovoMix® 30
View adult BNF View SPC online
Formulary
Green
Biphasic Insulin Aspart. Analogue insulin.
Cartridge + NovoPen 4, Flexpen 
   
06.01.01.02  Intermediate Acting Insulin
Insuman Basal®
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First Choice
Green
Vial, Cartridge + ClikSTAR, SoloStar 
Humulin I®
View adult BNF View SPC online
Second Choice
Green
Intermediate Human Isophane
Vial, Cartridge + HumaPen Savvio, KwikPen 
   
Insulatard®
View adult BNF View SPC online
Restricted Drug Restricted
Green
Intermediate Human Isophane
For use only when the Innolet device is required. Restricted to patients not able to manage less expensive devices 
   
06.01.01.02  Long Acting Insulin Analogues
Abasaglar®
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Formulary
Green
A Biosimilar of Insulin Glargine.
MUST BE PRESCRIBED BY BRAND NAME
Recommended in LLR for new patients and those undergoing review of therapy. 
Link  Statement on Use of Biosimilar Insulin
   
Lantus®
View adult BNF View SPC online  Track Changes
Formulary
Green
Insulin Glargine 100 unit per ml
MUST BE PRESCRIBED BY BRAND NAME
Recombinant human insulin analogue- long acting. Monophasic. Once daily dosage

Vial, Cartridge+ClikSTAR, SoloStar 
   
Levemir®
View adult BNF View SPC online
Formulary
Green
Insulin Detemir.
Recombinant human insulin analogue – long acting. Monophasic. Twice daily dosing
Cartridge + NovoPen 4, Flexpen
Innolet also available but only for patients not able to manage less expensive device 
   
Toujeo®
View adult BNF View SPC online  Track Changes
Formulary
Green

Insulin Glargine 300 units per ml.
MUST BE PRESCRIBED BY BRAND NAME
First line concentrated insulin of choice in insulin resistant patients requiring large amounts of insulin. Please take extra care in prescribing, insulin glargine 300units per ml and 100units per ml are not directly interchangeable - see SPC

 
Link  Leicestershire Evaluation: Toujeo® in Diabetes
Link  UKMI - Product Safety Assessment Report
   
Tresiba®
View adult BNF View SPC online  Track Changes
Formulary
Green

Insulin Degludec
For use in specific patient groups only in line with agreed algorithm.

  • Conditional Green traffic light status for GPs who have completed appropriate training.
  • Amber traffic light status for those without additional training.
 
Link  Leicestershire Evaluation: Insulin Degludec in Diabetes
Link  Tresiba (Insulin Degludec) 100 units per ml: patient selection criteria
Link  Tresiba (Insulin Degludec) 200 units per ml: patient selectin criteria
   
06.01.01.03  Hypodermic equipment to top
 note 
  • Disposable plastic insulin syringes are marked 'single use', but in practice many patients re-use them. Syringes should only be used once in hospital wards to prevent the possibility of cross-infection.
  • Advise patients on how to dispose of their contaminated sharps safely. B-D Safe-clip is recommended; this is a device, which clips the needle from the hub and retains the needle in a sealed unit.
  • Sharps bins are prescribable and information on disposal is available  here.
  • A variety of pen injectors are available. Human soluble and isophane insulins (and combinations of the two) are available for pen injectors, but no animal insulins are available. There is no evidence that such devices per se improve diabetic control, however many patients find them more convenient. Issue patients with spare pen or syringe and vial to use in case of breakage. Report defects in pens to Medical Devices Agency.
  • Specially adapted syringes exist, which enable visually handicapped patients to inject themselves safely. Further details are available from the Diabetes Specialist Nurses and Health Visitors.
  • The Innolet disposable pens are useful for patients who have difficulties with other pens as they are larger, easier to see and very simple to operate.  However, due to the higher cost they should only be used if patients have not been able to manage less expensive devices. 
06.01.01.03  Needles
06.01.01.03  Lancets
06.01.02  Antidiabetic drugs
 note 
  • Indicated for Type 2 diabetes when dietary measures alone are insufficient.
  • Do not use in Type 1 diabetes, ketosis, severe symptoms (including rapid weight loss), pregnancy or during intercurrent illness (e.g. surgery). Insulin should be used in these circumstances.
  • Aim to achieve the best possible control of blood glucose, both immediately and in the long-term. Targets for glycaemic control in Type 2 diabetes is HbA1c of 6.5-7.5%.
  • Co-existent hypertension, (target BP <130/80) hyperlipidaemia and obesity should be vigorously treated.
  • There is evidence that survival of Type 2 patients after acute myocardial infarction is improved if intravenous insulin with glucose +/- potassium is started on the coronary care unit and subcutaneous insulin rather than oral treatment continued afterwards.
06.01.02.01  Sulfonylureas
 note 
  • Sulfonylureas act on the pancreatic beta cells to stimulate insulin release
  • Hypoglycaemia is the main risk associated with sulphonylureas. Inform patients about recognition and management
  • Elderly patients are particularly vulnerable to hypoglycaemia and this may be fatal. Chlorpropamide and glibenclamide should not be used in this group of patients.
  • Weight gain is associated with sulfonylurea therapy, but tends to plateau after a mean gain of 4kg.
  • With the exception of tolbutamide the sulfonylureas are similarly effective in maximum doses and there is no justification for changing drugs within this class if control deteriorates unless compliance is an issue when a decreased tablet count may be helpful.
  • Tablets should be taken before meals
Gliclazide
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First Choice
Green
Mainly metabolised by the liver. 
Gliclazide MR (Diamicron® MR)
View adult BNF View SPC online
Restricted Drug Restricted
Green
May be used if hypoglycaemia is a problem as associated with less hypoglycaemia than standard release gliclazide. 
   
06.01.02.02  Biguanides to top
 note 
  • Reduces glucose production by the liver without stimulating insulin release.
  • Does not cause hypoglycaemia when used as sole agent and does not promote weight gain.
  • Lowers triglyceride and LDL-cholesterol concentrations.
  • Metformin powder is now available in 500mg and 1000mg sachets.  This is significantly less costly than metformin liquid but more expensive than tablets. Reserve for patients only where clinically justified. Contents should be dissolved in water before use.
Metformin Hydrochloride
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First Choice
Green
Drug of choice for obese/ overweight patients
Gastro intestinal adverse events can be reduced by a gradual dose titration, e.g. 500mg od for 7 days, 500mg bd for 7 days, 1000mg am 500mg pm for 7 days etc. to maximal tolerated dose.
 
Metformin Hydrochloride MR
View adult BNF View SPC online
Restricted Drug Restricted
Green
For patients who are unable to tolerate GI side effects despite dose titration. A 750mg tablet and a 1000mg are now available and are less costly than using multiples of the 500mg tablet.
 
   
06.01.02.03  Other antidiabetic drugs
 note 
  • Pioglitazone is an option as an adjunct to other hypoglycaemic drugs only where there is a contraindication or intolerance to metformin or sulphonylureas. Evidence for use in monotherapy or triple therapy is weak. It should not be used if there is any risk of heart failure and should probably be avoided in women at high risk of fracture.
  • Initiation of the DPP-4 inhibitors at UHL is restricted to specialist diabetologists. If the patient is on a sulfonylurea plus DPP-4 inhibitor, the sulfonylurea dose may require reduction to avoid hypoglycaemia.
  • GLP-1 agonists should only be initiated by specialist diabetologists or those in primary care who have received specific training. GLP-1 agonists should be prescribed as recommended by NICE and should be discontinued if the defined benefits are not seen within 6 months.
  • Prescribers should select a GLP-1 agonist  based on the individual patient's requirements.
  • Canagliflozin is available where recommended formulary choices of empagliflozin and dapagliflozin are not considered appropriate.  Use should be in line with NICE TA 315: Canagliflozin with the same traffic light status.  Patients may choose this drug in preference to formulary choices if they so wish.  Decision added August 2014. MHRA Advice: Canagliflozin (Invokana▼, Vokanamet▼): signal of increased risk of lower extremity amputations observed in trial in high cardiovascular risk patients issued June 2016
  •  Dapagliflozin, empagliflozin and canagliflozin are also supported in line with NICE TA 390  for monotherapy (July 2016) with the same formulary placings.

     

Nateglinide
View adult BNF View SPC online
Restricted Drug Restricted
Green
Prandial glucose regulator. May offer advantage to patients who require flexibility with mealtimes. Alternative is Repaglinide (although this is not recommended outside the age range 18-75 years). 
   
06.01.02.03  DPP4 inhibitors (gliptins)
Alogliptin
View adult BNF View SPC online  Track Changes
First Choice
Green

Preferred DPP-4 inhibitor as lower cost preparation. Use only as recommended in NICE guidance. Dosage adjustment required in renal impairment..

 
Linagliptin
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Formulary
Green

DPP-4 inhibitor. Use only as recommended in NICE guidance. No dosage adjustment required in renal impairment

 
Link  Leicestershire Evaluation: Linagliptin in Diabetes
   
Sitagliptin
View adult BNF View SPC online  Track Changes
Formulary
Green

DPP-4 inhibitor. For use only as recommended in NICE guidance. Dosage adjustment required in renal impairment

 
Link  Leicestershire Evaluation: Sitagliptin in Diabetes
   
06.01.02.03  SGLT2 inhibitors
 note 

MHRA Advice: SGLT2 inhibitors: reports of Fournier’s gangrene

Dapagliflozin
View adult BNF View SPC online  Track Changes
Formulary

Green Traffic Light for use in monotherapy to treat T2DM in line with NICE TA 390

Green Conditional  Conditional Green for use in line with NICE TA 288 as part of combination therapy to treat T2DM. Primary care initiation conditional on appropriate competency. Otherwise simple amber

Amber Simple Simple Amber for use in combination with insulin in type 1 diabetes in line with NICE TA 597

Date of entry of decision to Formulary: July 2013

 
Link  NICE TA 288: Dapaglifozin
Link  NICE TA 390: Canagliflozin, dapagliflozin and empagliflozin as monotherapies for treating type 2 diabetes
Link  MHRA Advice: SGLT2 inhibitors (canagliflozin, dapagliflozin, empagliflozin): risk of diabetic ketoacidosis
   
Empagliflozin
View adult BNF View SPC online  Track Changes
Formulary
Green

For use in line with NICE TA 336
Primary care initiation conditional on appropriate competency. Otherwise simple amber

Date decision added to Formulary: May 15

 
Link  MHRA Advice: SGLT2 inhibitors (canagliflozin, dapagliflozin, empagliflozin): risk of diabetic ketoacidosis
Link  NICE TA 336: Empagliflozin
   
Canagliflozin (Invokana®)
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Restricted Drug Restricted
Green
Canagliflozin should be considered when dapagliflozin and empagliflozin are not suitable or not tolerated

Green Traffic Light when used as monotherapy in line with NICE TA 390. Primary care initiation conditional on appropriate competency. Otherwise simple amber

Amber Traffic Light Simple amber when used in combination therapy in line with NICE TA 315.

Date decision added to Formulary: April 17 
Link  MHRA advice: Canagliflozin increased risk of lower extremity amputations observed in high cardiovascular risk patients
Link  NICE TA 315: Canagliflozin in combination therapy for treating type 2 diabetes
Link  NICE TA 390: Canagliflozin, dapagliflozin and empagliflozin as monotherapies for treating type 2 diabetes
   
Ertugliflozin (Steglatro®)
View adult BNF View SPC online  Track Changes
Formulary
Green

Type 2 diabetes mellitus (for 18 years and over) as monotherapy or with metformin  in line with NICE TA 572. As part of triple therapy with metformin and a dipeptidyl peptidase-4 inhibitor in line with NICE TA 583.

Green  Conditional on prescriber being competent to select appropriate patients.

Amber  Monotherapy is simple amber if the prescriber does not feel competent to initiate.

Date of entry of decision to Formulary: June 2019 

 
Link  NICE TA 572: Ertugliflozin as monotherapy or with metformin for treating type 2 diabetes
Link  NICE TA 583: Ertugliflozin with metformin and a dipeptidyl peptidase-4 inhibitor for treating type 2 diabetes
   
06.01.02.03  GLP1 agonists
Lixisenatide (Lyxumia®)
View adult BNF View SPC online  Track Changes
Restricted Drug Restricted
Green

Type 2 Diabetes

 
   
Semaglutide (Ozempic®)
View adult BNF View SPC online  Track Changes
Restricted Drug Restricted
Green

GLP-1 agonist.
Once weekly preparation available only in line with NICE NG28
Specialist diabetology initiation at UHL
Primary care initiation conditional on appropriate competency. Otherwise simple amber

 
Link  Leicestershire Evaluation: Semaglutide in Diabetes
   
Dulaglutide weekly (Trulicity®)
View adult BNF View SPC online  Track Changes
Restricted Drug Restricted
Green

GLP-1 agonist.
Once weekly preparation available only in line with NICE NG28
Specialist diabetology initiation at UHL
Primary care initiation conditional on appropriate competency. Otherwise simple amber

 
Link  Leicestershire Evaluation: Dulaglutide in Diabetes
Link  NICE NG 28: Type 2 diabetes in adults: management
   
Liraglutide
View adult BNF View SPC online  Track Changes
Restricted Drug Restricted
Green
GLP-1 agonist.

Specialist diabetology initiation at UHL
Primary care initiation conditional on appropriate competency.Otherwise simple amber
 
   
Xultophy®
View adult BNF View SPC online  Track Changes
Restricted Drug Restricted
Green
Liraglutide plus Degludec insulin
Specialist diabetology initiation at UHL
Primary care initiation conditional on appropriate competency. Otherwise simple amber  
Link  Leicestershire Evaluation: Insulin Ideglira in Diabetes
   
06.01.02.03  Thiazolidinediones to top
Pioglitazone
View adult BNF View SPC online
Restricted Drug Restricted
Green
See prescribing points. 
Link  MHRA advice: Pioglitazone and risk of bladder cancer
   
06.01.03  Diabetic ketoacidosis
06.01.04  Treatment of hypoglycaemia
 note 
  • Glucagon acts on the liver to cause glycogenolysis and will be ineffective in cirrhosis, starvation or other circumstances where the hepatic glycogen stores are depleted. If there has been no recovery within 15 minutes, intravenous glucose should be given, not a further dose of glucagon.
  • Recovery after glucagon is often accompanied by nausea and vomiting, which make it difficult to ensure food intake.
  • After the emergency treatment of hypoglycaemia all patients should be given a high fibre snack to prevent a further attack.
  • All patients who have had a serious hypoglycaemic episode should be referred to the diabetes team for education about prevention.
Glucose oral
View adult BNF View SPC online  Track Changes
First Choice
Green

Use in conscious patients who are able to swallow. Medicinal glucose in water, tablets (Dextro Energy) or liquid (Glucojuice) are suitable. If available fruit juice is also recommended as firstline treatment.

 
Glucose IV
View adult BNF View SPC online
First Choice
Green
For use in unconscious patients. Give up to 75ml glucose 20% intravenously into a large vein. Avoid extravasation as this is hypertonic and irritant to veins (larger volumes of less concentrated glucose solution may be a safer alternative). 
Glucagon (SC/IM/IV)
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First Choice
Green
Alternative to glucose in an unconscious patient, particularly where the intravenous route is not available. Sometimes issued to patients' relatives for emergency use at home.
 
Dextrogel ® (oral)
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Second Choice
Green
Use if unable to use other forms of oral glucose. Squeeze into the side of the mouth and massage the cheek. Glucose is absorbed from the buccal mucosa. Prescribable by GPs on FP10. Do not use in an unconscious patient as aspiration may occur, with serious consequences. Issued to relatives of patients with a history of serious hypoglycaemia and those who have 'hypoglycaemia unawareness'.
 
   
06.01.06  Diagnostic and monitoring agents for diabetes mellitus
06.01.06  Blood glucose monitoring
FreeStyle Libre® Flash glucose monitoring Black Triangle
 Track Changes
Formulary
Amber Simple

Freestyle Libre® is approved for use in Leicester, Leicestershire and Rutland from 1st February 2019 where a patient meets the criteria detailed in the LMSG position statement and the NHSE funding arrangements.

Patients will need to have the initiation contract completed in secondary care. The first 6 months of Freestyle Libre will be a trial period that will need to be reviewed in secondary care, and the continuation paperwork completed in secondary care before supply is continued by primary care. Continuation is dependant on on improvements as per the NHSE parameters.

 
Link  NHSE Flash Glucose Monitoring: National Arrangements for Funding of Relevant Diabetes Patients
Link  Leicestershire Guidance: Freestyle Libre Position Statement
Link  Leicestershire Guidance: Freestyle Libre Prescribing Algorithm
Link  LMSG: Freestyle Libre Paperwork
Link  Regional Medicines Optimisation Committee: Flash Glucose Monitoring System
   
06.02  Thyroid and Antithyroid drugs to top
06.02.01  Thyroid hormones
 note 
  • Levothyroxine is T4; Liothyronine is T3.
  • Monitoring of TSH required at regular but increasing intervals. Aim to maintain TSH in the lower part of the normal range, with serum-free T4 in the upper part of the normal range. A typical replacement dose is 100-150microg daily.
  • Patients with TSH deficiency require monitoring for free T4 levels (TSH levels are uninformative in this context).
  • Patients who are stable on levothyroxine replacement may be referred to The Leicestershire Thyroid Register (contact Chemical Pathology, 0116 256 3037 for further information).
  • In the elderly, patients with significant co-existing disease or where there is long-standing profound hypothyroidism, start thyroid hormones at a low dose (e.g. 25 micrograms daily) and increase gradually with caution as angina and arrhythmias can be precipitated. This is particularly important in patients with ischaemic heart disease or other cardiovascular disorder. Milder or younger patients can be started directly on levothyroxine 50-100 micrograms daily.
  • If hypo-adrenalism is also present start adrenal replacement therapy before starting thyroid replacement to avoid precipitation of adrenal crisis.
  • Thyroid replacement in patients with normal thyroid function tests and ‘hypothyroid’ symptoms is not recommended. Randomised trials show no benefit of levothyroxine replacement in these circumstances. Seek an alternative explanation for symptoms.
Levothyroxine Sodium (Levothyroxine)
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First Choice
Green
Long half life (about 7 days) so full effects may not be seen for several weeks. Do not monitor or adjust dose more frequently than every 2-3 months 
Liothyronine Sodium
View adult BNF View SPC online  Track Changes
Restricted Drug Restricted
Red

For patients who have had an inadequate response to thyroxine alone, in line with RMOC guidance, discontinuation if no improvement after 12 months.

Also used by specialists in psychiatry for treatment of depression where other therapies have failed unlicensed use)

 
Link  Leicestershire Guidance: Treatment of Hypothyroidism with Liothyronine
   
06.02.02  Antithyroid drugs
 note 
  • Carbimazole and propylthiouracil may cause agranulocytosis. Perform full blood count and differential before starting therapy (but beware that thyrotoxicosis per-se may be associated with mild neutropenia). Patients should be asked to report unexplained fever, malaise or sore throat – and stop treatment immediately should these occur pending an urgent (same day) full blood count CSM warning.
  • Most patients become euthyroid within 4-12 weeks. Once daily dosing of carbimazole is usually adequate for initiation and maintenance therapy, but a more rapid response may be obtained initially if given in divided doses.
  • Propranolol (40-80mg 3 times daily) may be used to control symptoms whilst thyroid function returns to normal but has no effect on underlying disease.
  • The three alternative therapeutic options of antithyroid drugs, radioactive iodine and thyroidectomy should be discussed with every patient.
  • The UHL Thyrotoxicosis Shared-care Scheme (endocrinology@uhl-tr.nhs.uk; 0116 258 5702 or via ‘Choose and Book’) is happy to advise on choice and dose adjustment of antithyroid drug therapy – both before and after any outpatient attendance.
  • If a course of antithyroid drugs is chosen then the usual treatment length is 18 months.
  • Caution in pregnancy. Specialist advice and monitoring is desirable.
Carbimazole
View adult BNF View SPC online
First Choice
Green
Typical starting doses: Free T4 >30 - Carbimazole 40mg once daily (2x20mg tablets) for 1 month then reduced to 20mg once daily with repeat thyroid function tests at 6 weeks. Free T4 <30 - Carbimazole 20mg once daily. 
Propylthiouracil
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Second Choice
Green
 
   
Iodine and Iodide (Aqueous Iodine Oral Solution)
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Restricted Drug Restricted
Red
Preparation for thyroidectomy. Start about 2 weeks preoperatively 
   
Propranolol IV
View adult BNF View SPC online
Restricted Drug Restricted
Red
Can be given I.V in doses of 1mg up to 5mg in thyrotoxic crisis. Hydrocortisone and aqueous iodine should also be given (seek specialist advice)
See also section 2.4 
   
06.03  Corticosteroids
 note 
  • The CSM has issued a notice that every patient prescribed a systemic corticosteroid should receive the patient information leaflet supplied by the manufacturer. Steroid treatment cards should also be issued where appropriate.
  • To minimise long-term adverse effects use the lowest effective dose for the shortest possible time.
  • Avoid abrupt withdrawal following long term therapy for 3 weeks or more. See BNF advice  
  • Steroid doses may need to be increased to cover the stress of acute illness or surgery.  This is often overlooked and can result in serious illness and even death.  BNF advice for patients undergoing surgery and recommendations from the Addison's Disease Self-Help group (ADSH) are available via the links below.  The latter are also relevant to patients with hypopituitarism and those on supraphysiological doses of steroids (e.g. >5mg/day).
  • Serious infections may be masked by corticosteroid therapy (e.g. septicaemia, tuberculosis); clinical presentation may be atypical.
  • Suppressive therapy should not be given in infection without appropriate anti-infective agents
06.03.01  Replacement therapy
Fludrocortisone Acetate
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Formulary
Amber Simple
Mineralocorticoid for replacement therapy. Required in primary adrenal insufficiency
 
   
Hydrocortisone
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Formulary
Green
Glucocorticoid for replacement therapy. Also has some mineralocorticoid activity
Usual replacement dose is 10mg in morning, 5mg at lunchtime and 5mg in evening. Further dose adjustments are usually based on response. 
   
Hydrocortisone Injection (Emergency HC Injection Kit)
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Formulary
Amber Simple
Kit for patients with Addison’s disease or high risk due to long term steroid use. Dose to be recommended by specialist, normally 50 or 100mg.  
   
06.03.02  Glucocorticoid therapy to top
Hydrocortisone sodium succinate injection
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First Choice
Green
For disease suppression 
Prednisolone
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First Choice
Green
For disease suppression.
Enteric coated tablets are not routinely stocked at UHL.
The potential advantage of soluble or enteric coated preparations to reduce the risk of gastric ulcers is speculative. They are considerably more costly.
Prednisolone soluble can be up to 200 times more costly than plain tablets depending on the setting. Plain tablets can be crushed and dispersed (unlicensed).

 
Dexamethasone
View adult BNF View SPC online
Second Choice
Green
For disease suppression. Preferred choice in cerebral oedema as it has less mineralocorticoid activity. Also used in vomiting associated with cancer chemotherapy.
 
   
Methylprednisolone sodium succinate injection
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Second Choice
Amber Simple
For disease suppression when larger doses of corticosteroid are required. 
   
06.04  Sex hormones
06.04.01  Female sex hormones and their modulators
06.04.01.01  Oestrogens and HRT
 note 
  • HRT is sometimes appropriate for alleviating menopausal symptoms such as vaginal atrophy or vasomotor instability.
  • HRT increases the risk of venous thromboembolism, stroke and after some years of use, breast cancer. Unopposed oestrogen and tibolone increase the risk of endometrial cancer. Women must be made aware of the risks and treatment should be reviewed at least annually.
  • Each decision to start HRT should be made on an individual basis. 
  • For osteoporosis alternative treatments should be considered first.
  • For the treatment of menopausal symptoms the benefits of short term HRT outweigh the risks in the majority of women, especially in those aged under 60 years.  Further information on risks associated with HRT and choice of preparation is available in the BNF.
  • In non-hysterectomised women combined HRT, whilst protecting against endometrial cancer, has an increased risk of breast cancer compared to unopposed oestrogen. Please see the MHRA Advice on the risk
  • In non-hysterectomised women the risk of endometrial cancer and breast cancer for each woman should be carefully assessed taking individual risk factors into account.
  • There is little comparative data to favour one product over the other.  Formulary choices are based on rationalisation of commonly used preparations and cost. A comparative list of formulary choices is available here
  • Progesterone pessaries (Cyclogest) and gel (Crinone) have been supported by TAS for use by the Assisted Conception Unit
Climagest®
View adult BNF View SPC online  Track Changes
Formulary
Green
Sequential combined HRT for women with an intact uterus
Now discontinued - Elleste Duet is the alternative choice  
   
Elleste-Duet®
View adult BNF View SPC online
Formulary
Green
Sequential combined HRT for women with an intact uterus 
   
Evorel®Sequi
View adult BNF View SPC online
Formulary
Green
Sequential combined HRT for women with an intact uterus
 
   
Ellest-Duet Conti®
View adult BNF View SPC online
Formulary
Green
Continuous combined HRT for women with an intact uterus
 
   
FemSeven® Conti Patch
View adult BNF View SPC online
Formulary
Green
Continuous combined HRT for women with an intact uterus. 
   
Kliofem®
View adult BNF View SPC online
Formulary
Green
Continuous combined HRT for women with an intact uterus
 
   
Premique®
View adult BNF View SPC online
Formulary
Green
Continuous combined HRT for women with an intact uterus 
   
Climaval®
View adult BNF View SPC online  Track Changes
Formulary
Green
Unopposed oestrogen only. For hysterectomised women and non-hysterectomised women following individual risk / benefit assessment.

Now discontinued - Elleste Solo is an alternative choice 
   
Elleste-Solo®
View adult BNF View SPC online
Formulary
Green
Unopposed oestrogen only. For hysterectomised women and non-hysterectomised women following individual risk / benefit assessment. 
   
Estradot®
View adult BNF View SPC online
Formulary
Green
Unopposed oestrogen only. For hysterectomised women and non-hysterectomised women following individual risk / benefit assessment. 
   
Evorel®
View adult BNF View SPC online
Formulary
Green
Unopposed oestrogen only. For hysterectomised women and non-hysterectomised women following individual risk / benefit assessment. 
   
Hormonin®
View adult BNF View SPC online
Formulary
Green
Unopposed oestrogen only. For hysterectomised women and non-hysterectomised women following individual risk / benefit assessment. 
   
Premarin®
View adult BNF View SPC online
Formulary
Green
Unopposed oestrogen only. For hysterectomised women and non-hysterectomised women following individual risk / benefit assessment. 
   
Gynest®
View adult BNF View SPC online
Formulary
Green
Cream (0.01%) 
   
Ortho-Gynest®
View adult BNF View SPC online
Formulary
Green
Pessary 500 microgram. Oestrogen only 
   
Ovestin®
View adult BNF View SPC online
Formulary
Green
Oestrogen only 
   
Vagifem®
View adult BNF View SPC online  Track Changes
Formulary
Green
 
   
Progesterone Pessary (Cyclogest®)
View adult BNF View SPC online  Track Changes
Formulary
Amber Simple

Maintenance of pregnancy following IVF as recommended by the Assisted Conception Unit, or when there is a risk of pre-term delivery.

 
   
06.04.01.01  Hormone replacement therapy
Testosterone (Tostran 2% Gel)
View adult BNF View SPC online  Track Changes
Formulary
Amber Simple

Testosterone deficiency in menopausal women. Unlicensed indication, but supported by NICE NG23

 
   
06.04.01.01  Raloxifene to top
Raloxifene
View adult BNF View SPC online  Track Changes
Formulary
Amber Simple

Off label chemoprevention to reduce incidence of breast cancer.
Use in line with NICE CG 164

 
Link  NICE CG 164: Familial breast cancer: managing breast cancer and related risks in people with a family history of breast cancer
   
06.04.01.02  Progestogens and progesterone receptor modulators
 note 
  • Progestogens have been used to treat severe dysmenorrhoea but an oral contraceptive is probably more appropriate. Evidence of efficacy in premenstrual syndrome and habitual abortion is lacking.
  • In menorrhagia luteal phase progestogens have been shown to be relatively ineffective (use tranexamic acid, or non-steroidal anti-inflammatory drugs). Prescription for 21days with a 7 day break can be effective over the short term.  
  • Progestogens are used in combination with oestrogen for hormone replacement therapy ,  in combined oral contraceptives, progestogen-only contraceptives and for emergency contraception
  • Medroxyprogesterone acetate is also used in malignant disease but this is not covered by the formulary at present.
  • A Mirena coil may be used with unopposed oestrogen to reduce the risk of endometrial cancer.
Norethisterone
View adult BNF View SPC online
Formulary Derivative of testosterone. May have androgenic side effects 
   
Medroxyprogesterone Acetate Injection (Depo-Provera®)
View adult BNF View SPC online
Formulary
Green
Long acting injection. Derivative of the natural hormone progesterone.
NB: Reduction of menstrual bleeding is an unlicensed indication. Long term (>2years) use has been linked to an increased risk of osteoporosis.
Also used for contraception.
 
   
06.04.02  Male sex hormones and antagonists
 note 
  • Androgens are used for replacement therapy in hypogonadal males but will not restore fertility or relieve impotence in men with normal testosterone levels. In the normal male they suppress both pituitary gonadotrophins and spermatogenesis.
  • Treatment should be under expert supervision.
Sustanon 250®
View adult BNF View SPC online
Formulary
Amber SCA
3-weekly injection 
   
Testosterone Enantate Injection
View adult BNF View SPC online
Formulary
Amber SCA
 
   
Testosterone Gel
View adult BNF View SPC online  Track Changes
Formulary
Amber SCA

Testogel and Tostran are stocked by UHL.

There are long term stock problems with Testogel Sachets. The company now produce an alternative formulation – Testogel Pump. The Testogel pump is a different strength see link below for comparative doses.

 
Link  Shortage of Testogel Sachets
   
Testosterone Undecanoate (Nebido®)
View adult BNF View SPC online
Formulary
Amber SCA
 
   
06.04.02  Dutasteride and finasteride
Finasteride
View adult BNF View SPC online
First Choice
Green
 
Combodart ®(Dutasteride + Tamsulosin)
View adult BNF View SPC online
Restricted Drug Restricted
Green
In line with pathway  
   
06.05  Hypothalamic and pituitary hormones and anti-oestrogens
 note  The following drugs have been supported by TAS for use by the Assisted Conception Unit: Choriogonadotropin Alfa, Follitropin Alfa, Follitropin Alfa with Lutropin Alfa,  Follitropin Beta, Human Chorionic Gonadotrophin. Human Menopausal Gonadotrophin 
06.05.01  Hypothalamic and anterior pituitary hormones and anti-oestrogens to top
Somatropin
View adult BNF View SPC online  Track Changes
Restricted Drug Restricted
Red
Supported in line with NICE guidance only  
Link  NICE TA 188: Somatropin (Children)
Link  NICE TA 64: Somatropin (Adults)
   
06.05.01  Anterior pituitary hormones
Tetracosactide (Synacthen®)
View adult BNF View SPC online  Track Changes
Formulary
Red

Analogue of corticotrophin (ACTH). Diagnostic agent for adrenocortical insufficiency
Ideally this should be given where a resuscitation trolley is available as, although rare, anaphylaxis has previously been described. There has previously been concern over the use of Synacthen in patients with asthma. Whilst these concerns appear to be largely unsubstantiated, please refer to the position statement below for more information.

 
Link  Position statement from the Society for Endocrinology on the use of Synacthen in patients with asthma
Link  Short synacthen test
   
06.05.02  Posterior pituitary hormones and antagonists
 note 
  • The main licensed roles of posterior pituitary hormones are in the treatment of cranial diabetes insipidus and in bleeding oesophageal varices.
  • Desmopressin (analogue of vasopressin) may be used in the treatment of cranial diabetes insipidus.
  • Desmopressin may be administered as a nasal spray. Please be aware that if desmopressin nasal spray is prescribed for diabetes insipidus, it is crucial that it is administered and that omission may be life-threatening.
  • Patients with oesophageal varices should be stabilised using appropriate cardiovascular support (including blood transfusion if necessary) prior to treatment.
  • A Sengstaken tube should only be inserted by someone experienced in the technique; otherwise contact a Gastroenterologist. Also consider using propranolol (e.g. 40mg three times a day) to keep heart rate below 60 beats/minute and reduce the risk of further bleeding.
  • Caution in severe vascular disease. If necessary use a glyceryl trinitrate patch to prevent anginal attacks and myocardial ischaemia.
  • Water retention may occur
06.05.02  Posterior pituitary hormones
Terlipressin (Glypressin®)
View adult BNF View SPC online
Restricted Drug Restricted
Red
First choice for bleeding oesophageal varices. Administered by intermittent injection.
Also used for hepatorenal syndrome in patients with cirrhosis
 
Argipressin
View adult BNF View SPC online
Restricted Drug Restricted
Red
Alternative choice for bleeding oesophageal varices. Administer infusion via a large vein (avoid extravasation as high risk of tissue necrosis)

Also supported for use in myomectomy - specialist use only  
Link  Leicestershire Evaluation: Argipressin (Pitressin®) in Myomectomy
   
Desmopressin acetate
View adult BNF View SPC online
Restricted Drug Restricted
Green
Amber traffic light for Diabetes Insipidus 
   
06.05.02  Antidiuretic hormone antagonists
Tolvaptan
View adult BNF View SPC online  Track Changes
Restricted Drug Restricted
Red
High Cost Medicine
Specialist renal use
Commissioned by CCGs in line with NICE TA 358 only


Date of entry of decision to formulary: January 2016 
Link  NICE TA 358: Tolvaptan for treating autosomal dominant polycystic kidney disease
   
06.06  Drugs affecting bone metabolism to top
06.06  Osteoporosis
06.06.02  Bisphosphonates and other drugs affecting bone metabolism
 note 
  • Prescribe for osteoporosis only in line with NICE criteria for primary or secondary prevention
  • All patients at risk of osteoporosis should be offered lifestyle advice i.e. smoking cessation, avoiding excess alcohol, weight-bearing and resisted exercise and adequate intake of calcium and vitamin D.
  • Biphosphonates decrease the risk of vertebral fracture. In addition alendronate and risedronate reduce non vertebral fractures.
  • HRT is no longer considered the first line option for osteoporosis in women over 50 years.
  • Bisphosphonates reduce the rate of bone turnover in Paget's disease and can produce remission for varying lengths of time. They may also help relieve associated bone pain.
  • Calcium and vitamin D (Adcal D3/ Calceos) is recommended for all elderly institutionalised women unless contra-indicated as has been shown to be effective in reducing hip fractures in this group of patients. (Section 9.6.4)
  • All patients who have been receiving corticosteroids at a dose equivalent to 7.5mg/day prednisolone (or more) for 3 months or longer should be assessed. Review dose and duration of treatment. Evidence-based guidelines recommend that men and women over 65 years or with a previous history of fragility fracture should be offered bone protection (bisphosphonates) when starting steroid therapy. In other patients, if steroid therapy is to continue for at least 3 months, then bone densitometry should be considered. A T-score of –1.5 or lower may indicate the need for intervention with a bone sparing agent. Treatment should usually be on specialist advice only.
  • Ibandronic acid is available as a 150mg monthly preparation in treatment of osteoporosis for those where compliance is a significant problem. It may also be used for bone metastases in breast cancer if initiated by an appropriate specialist. For the latter it is given by IV infusion or as an oral preparation at a dose of 50mg daily.
  • Biphosphonates may also be given by IV infusion in treatment of osteoporosis and in Paget’s disease in specific circumstances only. Patient selection criteria.  
  • There have been reports of oespophageal cancer in association with bisphosphonate use. The CSM has concluded that evidence is not strong enough to show that oral bisphosphonates increase risk of oesophageal cancer.  For full information see MHRA link below. 
  • There have also been reports of osteonecrosis of the jaw (ONJ) associated with bisphosphonate use. The risk appears to be higher for those who have had IV bisphosphonate rather than oral ones. (Please see EMEA link below for more information).
  • Raloxifene is also an option for use in line with NICE TA 161.
Alendronic Acid
View adult BNF View SPC online
First Choice
Green
70mg weekly for Osteoporosis. 
Risedronate Sodium
View adult BNF View SPC online
Second Choice
Green
Daily (5mg) or weekly (35mg) for Osteoporosis.
If intolerant or unable to comply with alendronic acid (as per NICE recommendations)
Due to lower incidence of gastric side effects should be used in preference to alendronic acid for those with a history of peptic ulceration.
Also available for treatment of Paget’s disease.
 
Link  MHRA Advice: Bisphosphonates: very rare reports of osteonecrosis of the external auditory canal
   
Alendronic Acid effervescent tablet (Binosto®)
View adult BNF View SPC online  Track Changes
Restricted Drug Restricted
Green
Osteoporosis treatment only for patients who cannot swallow alendronic acid tablets. Not for use in patients with a feeding tube
 
   
Denosumab (Prolia®)
View adult BNF View SPC online  Track Changes
Restricted Drug Restricted
Amber SCA

For the treatment of osteoporosis

 
Link  SCA: Denosumab (Prolia®) for osteoporosis
Link  MHRA Advice: Denosumab (Xgeva®▼, Prolia); intravenous bisphosphonates: osteonecrosis of the jaw-further measures to minimise risk
Link  MHRA Advice: Denosumab 60mg (Prolia▼): rare cases of atypical femoral fracture with long-term use
Link  MHRA Advice: Denosumab: minimising the risk of osteonecrosis of the jaw; monitoring for hypocalcaemia—updated recommendations
Link  NICE TA 204: Denosumab for the prevention of osteoporotic fractures in postmenopausal women
   
Denosumab (Xgeva®)
View adult BNF View SPC online  Track Changes
Restricted Drug Restricted
Amber SCA
Prescribe in line with NICE TA 265 only

Date of entry of decision to Formulary: January 2013
 
Link  NICE TA 265: Denosumab for the prevention of skeletal-related events in adults with bone metastases from solid tumours
Link  SCA: Denosumab (Xgeva)
Link  MHRA advice: Denosumab (Xgeva▼) for advanced malignancies involving bone: study data show new primary malignancies reported more frequently compared to zoledronate
Link  MHRA advice: Denosumab (Xgeva▼) for giant cell tumour of bone: risk of clinically significant hypercalcaemia following discontinuation
Link  MHRA Advice: Denosumab (Xgeva®▼, Prolia); intravenous bisphosphonates: osteonecrosis of the jaw-further measures to minimise risk
Link  MHRA Advice: Denosumab: minimising the risk of osteonecrosis of the jaw; monitoring for hypocalcaemia—updated recommendations
   
Ibandronic Acid - Oral (ibandronate)
View adult BNF View SPC online  Track Changes
Restricted Drug Restricted
Amber Simple
Prevention of skeletal events (pathological fractures, bone complications requiring radiotherapy or surgery) in patients with breast cancer as per NICE CG80 
Link  NICE CG 80: Early and locally advanced breast cancer: diagnosis and treatment
   
Teriparatide
View adult BNF View SPC online  Track Changes
Restricted Drug Restricted
Red
High Cost Medicine

For use in women in line with NICE guidance only for 24 months treatment

NHSE commisioned for use in men in line with NHSE commissioning policy 170064P only, for 24 months

 
Link  NICE TA 161: Osteoporosis
   
Zoledronic Acid (Aclasta®)
View adult BNF View SPC online  Track Changes
Restricted Drug Restricted
Red
 
Link  IV Zoledronic Acid Patient Selection Criteria.
Link  Leicestershire Evaluation: Zoledronic acid in Osteoporosis
   
Raloxifene
View adult BNF View SPC online  Track Changes
Restricted Drug Restricted
Amber Simple

For secondary prevention of osteoporotic fragility in menopausal women.
For use in line with NICE TA 161

 
Link  NICE TA 161: Raloxifene and teriparatide for the secondary prevention of osteoporotic fragility fractures in postmenopausal women
   
Ibandronic acid
(50mg tablets)
View adult BNF View SPC online  Track Changes
Restricted Drug Restricted
Amber Simple

Unlicensed indication
Use in line with NICE ES 15 for prevention of metastases in early breast cancer patients.

 
Link  NICE ES 15: Early breast cancer (preventing recurrence and improving survival): adjuvant bisphosphonates
   
06.07  Other endocrine drugs
 note 
06.07.01  Bromocriptine and other dopaminergic drugs
 note 
Bromocriptine
View adult BNF View SPC online  Track Changes
Restricted Drug Restricted
Amber Simple

Hyperprolactinaemic disorders

 
   
Cabergoline (Dostinex®)
View adult BNF View SPC online View childrens BNF  Track Changes
Restricted Drug Restricted
Amber Simple

For Hyperprolactinaemic disorders only

 
Link  SCA: Cabergoline
   
Quinagolide  (Norprolac®)
View adult BNF View SPC online  Track Changes
Formulary
Amber Simple

Hyperprolactinaemia

 
   
Cabergoline (Dostinex®)
View adult BNF View SPC online View childrens BNF  Track Changes
Restricted Drug Restricted
Red

For suppression of lactation post delivery

 
   
06.07.02  Drugs affecting gonadotrophins to top
 note 

Ganirelix and Buserelin have been supported by TAS for use by the Assisted Conception Unit. Cetrorelix is available if required

Triptorelin
View adult BNF View SPC online  Track Changes
Restricted Drug Restricted
Amber Simple

Preferred gonadotrophin choice for endometriosis and preoperative treatment of fibroids

Also supported for use for central precocious puberty

 
   
Goserelin
View adult BNF View SPC online
Restricted Drug Restricted
Amber Simple
For treatment of endometriosis and preoperative treatment of fibroids.
 
   
Leuprorelin acetate
View adult BNF View SPC online
Restricted Drug Restricted
Amber Simple
For treatment of endometriosis and preoperative treatment of fibroids.
 
   
Ganirelix acetate (Fyremadel®)
View adult BNF View SPC online  Track Changes
Formulary
Red

Prevention of premature luteinising hormone (LH) surges in women undergoing ovarian stimulation for IVF.

 
   
06.07.04  Somatomedins
 ....
 Non Formulary Items
Acarbose

View adult BNF View SPC online
Non Formulary
 
Albiglutide  (Eperzan®)

View adult BNF View SPC online View childrens BNF Track Changes
Non Formulary
Black

Not yet reviewed

 
Alogliptin + Metformin  (Viptomet®)

View adult BNF View SPC online Track Changes
Non Formulary
 
Armour Thyroid

View adult BNF View SPC online
Non Formulary
Black

This dried thyroid extract is recommended in a number of populist internet sites and magazine articles. There is no clinical trial evidence of benefit, and this product is not recommended by endocrinologists on either side of the Atlantic.                                                                   

Link  British Thyroid Association Statement: Armour are NOT supported
 
Cabergoline

View adult BNF View SPC online View childrens BNF Track Changes
Non Formulary
Black

Not approved for use in parkinsons disease. No new initiations. Patients already on therapy can remain on cabergoline

 
Follitropin alfa, lutropin alfa  (Pergoveris®)

View adult BNF View SPC online View childrens BNF Track Changes
Non Formulary
Black

Not yet reviewed

 
Hydrocortisone  (Alkindi®)

View adult BNF View SPC online Track Changes
Non Formulary
Black

Granules in capsules for opening.
For Adrenal insufficiency in infants.

Not formally reviewed in Leicestershire

 
Prednisolone EC

View adult BNF View SPC online Track Changes
Non Formulary
 
Raloxifene

View adult BNF View SPC online Track Changes
Non Formulary
Black

Not recommended by NICE for primary prevention of osteoporotic fragility in menopausal women.

Link  NICE TA160: Raloxifene for the primary prevention of osteoporotic fragility fractures in postmenopausal women
 
Romosozumab  (Evenity®)

View adult BNF View SPC online Track Changes
Non Formulary
Black

Not yet reviewed

 
Saxagliptin  (Onglyza ®)

View adult BNF View SPC online
Non Formulary Patients already on treatment may continue

Non Formulary status agreed as part of rationalisation of product choices
 
Strontium Ranelate

View adult BNF View SPC online Track Changes
Non Formulary
Black

Strontium has been withdrawn by the manufacturer 

Link  MHRA Advice: Strontium ranelate: cardiovascular risk—restricted indication and new monitoring requirements.
 
Testosterone patch  (Intrinsa®)

View adult BNF View SPC online
Non Formulary
Black
Not supported by TAS or LMSG
Link  Leicestershire Evaluation: Testosterone Patch / Implant in HSDD
 
Ulipristal acetate®  (Esmya)

View adult BNF View SPC online Track Changes
Non Formulary
Black

MHRA have suspended the licence for Esmya. Please contact patients currently taking Esmya for uterine fibroids as soon as possible and advise them to stop their treatment.

 
Vildagliptin  (Galvas®)

View adult BNF View SPC online
Non Formulary
Black
 
Vildagliptin/metformin  (Eucreas®)

View adult BNF View SPC online
Non Formulary
Black
 
  
Key
note Notes
Section Title Section Title (top level)
Section Title Section Title (sub level)
First Choice Item First Choice item
Non Formulary Item Non Formulary section
Restricted Drug
Restricted Drug
Unlicensed Drug
Unlicensed
Track Changes
Display tracking information
click to search medicines.org.uk
Link to adult BNF
click to search medicines.org.uk
Link to children's BNF
click to search medicines.org.uk
Link to SPCs
SMC
Scottish Medicines Consortium
High Cost Medicine
High Cost Medicine
Cancer Drugs Fund
Cancer Drugs Fund
NHSE
NHS England
Homecare
Homecare
CCG
CCG

Traffic Light Status Information

Status Description

Black

Drugs not recommended for use in the Leicestershire Health Community because of lack of evidence of clinical effectiveness, cost prioritization or concerns over safety. All new drugs will be black until they have been through the appropriate approval process - then they will appear as a specific entry   

Red

Drugs which should be prescribed only by hospital specialists (clinical review by specialist as appropriate and annually as a minimum).  

Amber SCA

Drugs which would initially be prescribed by a hospital specialist and then by a GP where full agreement to share the care of each specific patient has been reached under a LMSG Shared Care Agreement (SCA). Specific patient monitoring or intervention required.   

Amber Simple

Drugs suitable to be initiated and prescribed in primary care only after specialist assessment and recommendation. A shared care agreement is not required.   

Green

Drugs for which GPs would normally take full responsibility for prescribing and monitoring. Drugs included in this list have been specifically considered by LMSG.   

Grey

Drugs not yet reviewed  

Green Conditional

Drugs for which GPs are able to take full responsibility for prescribing and monitoring subject to specified conditions e.g. prescribing in line with agreed LMSG guidance or able to demonstrate suitable competence. See comments under individual entries  

netFormulary