6.3 Diabetes mellitus and hypoglycaemia

6.3.1 Diabetes mellitus

See the Endocrine System Guideline page for:

• BNSSG Blood Glucose Management in Type 1 Diabetes Guideline
• BNSSG Blood Glucose Management in Type 2 Diabetes Guideline

Also see:

• NICE NG28 - Type 2 diabetes in adults: management
• NICE NG17 - Type 1 diabetes in adults: diagnosis and management
• DVLA Advice for drivers with diabetes controlled by insulin, or other medications which carry a risk of inducing hypoglycaemia
• Trend Diabetes - End of Life Guidance for diabetes care
• Trend Diabetes - Type 1 diabetes: What to do when you are ill
• Trend Diabetes - Type 2 diabetes: What to do when you are ill
• Diabetes and Frailty Guidelines

Biguanides

Recommended:

Metformin (TLS Green)

Metformin modified-release (TLS Blue)

• Reserved for patients who have experienced side effects to immediate release metformin preparation
• Also formulary for Polycystic Ovary Syndrome (Unlicensed)
• Metformin must not be used in severe cardiac failure

Dipeptidyl Peptidase-4 Inhibitors (Gliptins)

Recommended: (TLS Green)

Sitagliptin

Alternatives: (TLS Blue)

Alogliptin

Saxagliptin 

Linagliptin

Qtern^® (Saxagliptin / Dapagliflozin) 

• Combination for existing patients only

Glucagon-like Peptide-1 Receptor Agonists

As per NICE Guidance 28 Type 2 diabetes in adults: management for continued prescribing patients should have achieved a reduction in HbA1c of 11mmol/ml and 3% weight loss within 6 months

There is an ongoing national shortage of glucagon like peptide-1 receptor agonists (GLP-1 RAs) used in the management of Type 2 Diabetes (T2DM). This situation is not expected to resolve until late 2024. Supplies of some GLP-1 RA preparations may be intermittent or exhausted within this time. An updated MSN has been issued (click here to view) advising that there are now products available which can be used for new initiations and conversions for people with type 2 diabetes unable to obtain their original GLP-1 RA medication. Please refer to the Guidance from the Primary Care Diabetes Society (PCDS) and Association of British Clinical Diabetologists (ABCD) for information about management of patients who may be affected by this supply issue.

Weekly GLP-1

Dulaglutide (TLS Green)

• Includes all strengths 0.75mg, 1.5mg, 3mg. 4.5mg pre-filled pens
• Existing patients only.  No new patients should be started on dulaglutide until current supply issues resolved. 
• If a person cannot obtain their medication for more than two weeks, consider prescribing Rybelsus® tablets or Mounjaro® injections as per MSN. Please see Primary Care Diabetes Society (PCDS) and Association of British Clinical Diabetologists (ABCD) for further guidance. 

Semaglutide (injectable) (TLS Green)

• Existing patients only. No new patients should be started on semaglutide injection until current supply issues resolved.
• If a person cannot obtain their medication for more than two weeks, consider prescribing Rybelsus® tablets or Mounjaro® injections as per MSN. Please see Primary Care Diabetes Society (PCDS) and Association of British Clinical Diabetologists (ABCD) for further guidance. 

Daily GLP-1

Semaglutide (oral) (TLS Blue)

• GPs or appropriate prescribers in Primary Care may initiate oral semaglutide during the current period of supply issues with injectable GLP-1 RA's in the following patient cohorts - 
  • People with type 2 diabetes in whom new initiation of GLP-1 RA therapy would be clinically appropriate or, 
  • Patients who require a switch from Byetta®or Victoza® 
  • Patients who are unable to obtain supply of Ozempic®or Trulicity® for 2 weeks or more
  • Please see Primary Care Diabetes Society (PCDS) and Association of British Clinical Diabetologists (ABCD) for further guidance.
• Patients should be switched to injectable semaglutide once stock of the injectable product is available. 
• Switching to this option requires additional patient counselling regarding the special administration requirements of oral Semaglutide.
• When injectable semaglutide becomes available, oral semaglutide is to be reserved for patients who are unable to self-administer an injectable GLP1 formulation or where the patient is refusing to consider an injectable therapy due to needle phobia, despite involvement of health care professionals
• The current injectable semaglutide will remain first line semaglutide of choice on the BNSSG formulary. Oral tablets have not shown cardiovascular benefit as opposed to the injectable therapy.
• For use of Semaglutide (Wegovy^®) as an adjunct for weight management please see 1.8 Obesity

Lixisenatide (TLS Blue)

• Existing patients only

Exenatide (TLS Blue)

• See NICE Guidance 28 Type 2 diabetes in adults: management
• Existing patients only. No new patients should be started on exenatide until current supply issues resolved.
• Byetta® is due to be discontinued March 2024, patients should be identified and if still clinically appropriate should be prescribed either Rybelsus® tablets or Mounjaro® S/C injections.
• Bydureon® - If a person cannot obtain their medication for more than two weeks, consider prescribing Rybelsus® tablets or Mounjaro® injections.

Liraglutide (Victoza^®) (TLS Blue)

• For Type 2 diabetes, see NICE Guidance 28 Type 2 diabetes in adults: management
• Victoza® is out of stock until end of 2024, people with T2DM should be identified and if still clinically appropriate should be prescribed either Rybelsus® tablets or Mounjaro® injections as per MSN. Please see Primary Care Diabetes Society (PCDS) and Association of British Clinical Diabetologists (ABCD) for further guidance.
• Existing patients only. No new patients should be started on liraglutide injection until current supply issues resolved.
• For use of Liraglutide (Saxenda^®) as an adjunct for weight management please see 1.8 Obesity

Glucose-dependent Insulinotropic Polypeptide and Glucagon-like Peptide-1 Receptor Agonists

Tirzepatide (TLS Green)

• NICE TA924 Tirzepatide for treating type 2 diabetes
• Tirzepatide Prescribing Guideline

Sodium Glucose Co-transporter 2 Inhibitors

As per NICE Guidance 28 Type 2 diabetes in adults: management offer SGLT2i with proven CV benefit to people with established CVD or chronic HF. At the current time (December 2022) funding has not been approved for patients at high risk of developing CVD pending further review. In these patients or those not at high risk of developing CV disease, SGLT2 inhibitors should only be initiated as per NICE technology appraisals (NICE TA390, NICE TA315, NICE TA572, NICE TA288, NICE TA418 and NICE TA336

For use in Heart Failure, please see Chapter 2.5

See 'Endocrine System Guidelines' page for the 'Advice on the use of SGLT-2 inhibitors in Type 2 Diabetes, Heart Failure and Chronic Kidney Disease'

See MHRA Drug Safety Update re: SGLT2i and risk of diabetic ketoacidosis

See MHRA Drug Safety Update re SGLT2i and increased risk of lower limb amputation mainly toes

Dapagliflozin (TLS Green)

• For type 2 diabetes mellitus
• NICE TA775 Dapagliflozin for treating chronic kidney disease

Canagliflozin (TLS Green)

• For type 2 diabetes mellitus

Empagliflozin (TLS Green)

• For type 2 diabetes mellitus
• NICE TA942 Empagliflozin for treating chronic kidney disease

Ertugliflozin (TLS Green)

• For type 2 diabetes mellitus

Qtern^® (Saxagliptin / Dapagliflozin) (TLS Blue)

• Combination for existing patients only

Sulphonylureas

Recommended:

Gliclazide (TLS Green)

• Not including gliclazide modified-release preparation

Alternative:

Tolbutamide (TLS Blue)

• Tolbutamide is shorter acting than gliclazide and is therefore preferable in patients at particular risk of hypoglycaemia
• For existing patients only

Glimepiride (TLS Blue)

• For existing patients only

Thiazolidinediones

Recommended:

Pioglitazone (TLS Green)

• As per NICE Guideline NG 28 Type 2 diabetes in adults: management
• Also, see BNF for MHRA safety advice on combination with insulin and increased risk of cardiac failure and increased risk of bladder cancer

Aldosterone Antagonists

Finerenone (TLS Amber Specialist Recommended)

• NICE TA877 Finerenone for treating chronic kidney disease in type 2 diabetes

Insulins - refer to BNF for details

BNSSG Insulin Formulary

Please note, patients with type 1 diabetes as a paediatric patient may have been started on products in line with the paediatric formulary, available here

The Patient Safety First Standards for insulin prescriptions include that:

• Insulin must be prescribed by brand
• The date of prescription is clearly written
• The prescriber's signature and contact details are included
• Both the word ‘insulin' and the brand name are written in full
• The word ‘units' is written in full with no abbreviations
• The form of dosage, i.e. cartridge, pen or vial, is clearly written

For compatibility of pen devices with cartridges please see individual product SPCs

Please note - Insuman products have been discontinued with supplies expected to end between February and June 2023. It is recommended no new patients are initiated on Insuman.

6.3.2 Diabetes mellitus, diagnostic and monitoring

The pathways and guidelines below are available on the Endocrine System guideline page:

• BNSSG Clinical Pathway for use of diabetes technologies in all patients with type 1 diabetes
• BNSSG Clinical Pathway for use of diabetes technologies in all patients with type 2 diabetes
• Blood monitoring in Type 1 Diabetics and Type 2 Diabetics
• BNSSG Pen Needles Guidance

Update June 2024: Please note FreeStyle Libre 2 and Dexcom One CGM sensors are being gradually phased out and replaced by their respective upgraded and new versions FreeStyle Libre 2+ and Dexcom One+

6.3.3 Hypoglycaemia

See Trend Diabetes Hypoglycaemia

Glucogel^®

• Glucogel^® should be reserved for conscious patients unable to swallow fluids and is designed to be rubbed onto the patient's gums

Alternative: (TLS Blue)

Glucagon - acute insulin-induced hypoglycaemia

• If glucagon is not effective within 10 minutes, intravenous glucose should be given.

Specific indication:

Glucose (parenteral) (TLS Blue) according to local guidelines

Acarbose tablets (TLS Amber Specialist Recommended)

• For use in post bariatric hypoglycaemia (dumping syndrome) or patients with reactive hypoglycaemia
• LFTs are required 3-6 months after initiation and this will be conducted and reviewed by the weight management team

Contact Us

Got a question or comment about the Joint Formulary? 

Please use the email address below to contact us and we will endeavour to respond within 2 working days.