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BNSSG Adult Joint Formulary

6.3 Diabetes mellitus and hypoglycaemia

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Last edited: 25-06-2024

6.3.1 Diabetes mellitus

First line drugs

Second line drugs

Specialist drugs

Secondary care drugs

See the Endocrine System Guideline page for:

Also see:

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

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.

Type 2 Diabetes
First choice insulin regimen			Products available, including device
NPH Basal Insulin	First Line
		Insulatard^®	5 × 3mL cartridges 5 × 3mL Innolet^® pre-filled pen (Innolet device to be discontinued - expected supply end date May 2024)
		Humulin^® I	5 × 3mL cartridges 5 × 3mL KwikPen^® pre-filled pen
Second choice insulin regimens			Products available, including device
Mix insulin (for patients with HbA1c > 9% or those with very high postprandial readings. Choice is dependent on proportion of short acting insulin required	First line	Humulin^® M3 (TLS Green)	5 x 3mL cartridges 5 x 3mL KwikPen^® pre-filled pen
	Alternatives
	Note: analogue mixes should NOT be used in T2DM unless started with specialist advice	Novomix^® 30 (Specialist Recommended)	5 × 3mL cartridges 5 × 3mL FlexPen^® pre-filled pen
		Humalog^® Mix 25 (Specialist Recommended)	5 × 3mL cartridges 5 × 3mL KwikPen^® pre-filled pen
		Humalog^® Mix 50 (Specialist Recommended)	5 × 3mL cartridges 5 × 3mL KwikPen^® pre-filled pen
Analogue basal insulin (for patients who have experienced hypoglycaemia on NPH insulin or at very high risk of hypoglycaemia. This is not a standard choice and use should be minimised)	First line	Semglee^® Biosimilar for Lantus^® Biosimilars must be prescribed by brand. Pen devices are not interchangeable and patients should be counselled on use of new device.	5 x 3mL pre-filled pen
	Alternatives	Lantus^®	5 x 3mL cartridges 5 x 3mL Solostar^® pre-filled pen
		Abasaglar^® See NICE advice ESNM64 Diabetes mellitus type 1 and type 2: insulin glargine biosimilar (Abasaglar^®)	5 x 3mL cartridges 5 x 3mL KwikPen^® pre-filled pen 5 x 3mL Tempo Pen^® pre-filled pen
		Levemir^®	5 x 3mL cartridges 5 x 3mL FlexPen^® pre-filled pen 5 x 3mL Innolet^® pre-filled pen (Innolet device to be discontinued - expected supply end date May 2024)
		Toujeo^® (Specialist Recommended) First line ultra long acting analogue insulin N.B. High strength insulin 300 units per mL See NICE advice ESNM65:Type 2 diabetes mellitus in adults: high-strength insulin glargine 300 units/mL (Toujeo^®)	3 x 1.5mL Solostar^® pre-filled pen, delivers 1 unit of insulin per click OR 3 x 1.5mL Doublestar^® pre-filled pen, delivers 2 units of insulin per click Doublestar^® pre-filled pen only for patients requiring >80 units per dose
		Tresiba (Specialist Recommended) For existing patients or as a second line ultra long acting analogue insulin for patients where Toujeo is unsuitable i.e.: housebound requiring community nurse support with insulin administration patients requiring extended dosing window See Risk Minimisation Material: Tresiba® (insulin degludec) - Safety information for healthcare professionals regarding two product strengths	5 x 3mL cartridges 5 x 3mL FlexTouch^® pre-filled pen

Third choice insulin regimen			Products available, including device
Basal bolus (only for patients with capacity to manage 4 injections/day and have ability to carbohydrate count	Maintain current basal insulin (NPH is first line for all patients)	NPH Basal	as above

		Analogue Basal	as above
	Add in HUMAN short acting insulin
		Humulin^® S (TLS Green)	5 x 3mL cartridges

Type 1 diabetes

Analogue Basal Insulin

Products available, including device

Choice based upon patient preference and glucose control

First line (NICE recommendation)

BD Levemir^®

5 x 3mL cartridges

5 x 3mL FlexPen^® pre-filled pen

5 x 3mL Innolet^® pre-filled pen (Innolet device to be discontinued - expected supply end date May 2024)

Alternative choices for patients who do not want 5 injections/day

or in line with NICE clinical guideline 17

Semglee^®

Biosimilar for Lantus^®

Biosimilars must be prescribed by brand. Pen devices are not interchangeable and patients should be counselled on use of new device.

5 x 3mL pre-filled pen

Lantus^®

5 x 3mL cartridges

5 x 3mL Solostar^® pre-filled pen

Abasaglar^®

See NICE advice ESNM64 Diabetes mellitus type 1 and type 2: insulin glargine biosimilar (Abasaglar^®)

5 x 3mL cartridges

5 x 3mL KwikPen^® pre-filled pen

5 x 3mL Tempo Pen^® pre-filled pen

Toujeo Solostar^® U300 (Specialist Recommended)

First line ultra long acting analogue insulin

N.B. High strength insulin 300 units per mL

See NICE advice ESNM65:Type 2 diabetes mellitus in adults: high-strength insulin glargine 300 units/mL (Toujeo^®)

3 x 1.5mL Solostar^® pre-filled pen

Specialist initiation ONLY

For patients with Type 1 diabetes who have failed on insulin glargine and who are not suitable or failed on insulin pump therapy

Or have recurrent severe hypoglycaemia, who have trialled available long acting analogues but are unable to achieve target HbA1c and/or nocturnal hypoglycaemia remains a problem before starting insulin pump therapy

For existing patients or as a second line ultra long acting analogue insulin for patients where Toujeo is unsuitable i.e.:

housebound requiring community nurse support with insulin administration
patients requiring extended dosing window

Tresiba^® U100 (Specialist Recommended)

See Risk Minimisation Material: Tresiba® (insulin degludec) - Safety information for healthcare professionals regarding two product strengths

or Tresiba^® U200 (Specialist Recommended)

See Risk Minimisation Material: Tresiba® (insulin degludec) - Safety information for healthcare professionals regarding two product strengths

5 x 3mL cartridges

5 x 3mL FlexTouch^® pre-filled pen

Analogue Rapid Acting Insulin

Products available, including device

Choice based upon patient preference and glucose control

Equal choice

Apidra^®

5 x 3mL cartridges

5 x 3mL Solostar^® pre-filled pen

Admelog^®

Biosimilar for Humalog^®

Biosimilars must be prescribed by brand. Pen devices are not interchangeable and patients should be counselled on use of new device.

5 x 3mL cartridges

10mL vial

3ml Solostar^® pre-filled pen

Humalog^®

5 x 3mL cartridges

5 x 3mL KwikPen^® 100units/mL pre-filled pen

Humalog^® (KwikPen^® 200 units/mL)

Patients on basal bolus insulin regimen requiring large insulin doses

5 x 3mL KwikPen^® 200 units/mL pre-filled pen

Trurapi^®

Biosimilar for Novorapid

Biosimilars must be prescribed by brand. Pen devices are not interchangeable and patients should be counselled on use of new device.

5 x 3mL cartridges

5 x 3mL SoloStar^® pre-filled pen

1 x 10mL vial

Novorapid^®

5 x 3mL cartridges

5 x 3mL FlexPen^® pre-filled pen

5 x 3mL FlexTouch^® pre-filled pen

Actrapid^®

1 x 10mL vial

Specialist Populations
		Products available, including device

Pregnancy Gestational diabetes/ T2DM	Levemir^®	5 x 3mL cartridges 5 x 3mL FlexPen^® pre-filled pen 5 x 3mL Innolet^® pre-filled pen (Innolet device to be discontinued - expected supply end date May 2024)
Type 1 diabetics on basal bolus regime or with insulin pumps with postprandial hyperglycaemia not controlled by first line options OR Pregnancy where there is a particular problem with postprandial hyperglycaemia not controlled by first line options	Fiasp^® (Specialist Recommended)	5 x 3mL FlexTouch^® pre-filled pen 5 x 3mL cartridges 1 x 10mL vial
Type 1 diabetics on basal bolus regime or with insulin pumps with postprandial hyperglycaemia not controlled by first line options	Lyumjev^® (Specialist Recommended)	5 x 3mL Kwikpen^® pre-filled pen 5 x 3mL Junior Kwikpen^® pre-filled pen- please note this device delivers 0.5 unit doses. It is not licensed for children. 1 x 10mL vial
Severe insulin resistance to be prescribed by secondary care ONLY	Humulin^® R U500	2 x 3mL Flexpen^® pre-filled pen 1 x 20mL vial - imported unlicensed from US

6.3.2 Diabetes mellitus, diagnostic and monitoring

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

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.

BNSSG.formulary@nhs.net

6.3 Diabetes mellitus and hypoglycaemia

6.3.1 Diabetes mellitus

Biguanides

Metformin (TLS Green)

Metformin modified-release (TLS Blue)

Dipeptidyl Peptidase-4 Inhibitors (Gliptins)

Sitagliptin

Alogliptin

Saxagliptin

Linagliptin

Qtern® (Saxagliptin / Dapagliflozin)

Glucagon-like Peptide-1 Receptor Agonists

Weekly GLP-1

Dulaglutide (TLS Green)

Semaglutide (injectable) (TLS Green)

Daily GLP-1

Semaglutide (oral) (TLS Blue)

Lixisenatide (TLS Blue)

Exenatide (TLS Blue)

Liraglutide (Victoza®) (TLS Blue)

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

Tirzepatide (TLS Green)

Sodium Glucose Co-transporter 2 Inhibitors

Dapagliflozin (TLS Green)

Canagliflozin (TLS Green)

Empagliflozin (TLS Green)

Ertugliflozin (TLS Green)

Qtern® (Saxagliptin / Dapagliflozin) (TLS Blue)

Sulphonylureas

Gliclazide (TLS Green)

Tolbutamide (TLS Blue)

Glimepiride (TLS Blue)

Thiazolidinediones

Pioglitazone (TLS Green)

Aldosterone Antagonists

Finerenone (TLS Amber Specialist Recommended)

Insulins - refer to BNF for details

BNSSG Insulin Formulary

Type 2 Diabetes

Type 1 diabetes

Specialist Populations

6.3.2 Diabetes mellitus, diagnostic and monitoring

6.3.3 Hypoglycaemia

Glucogel®

Glucagon - acute insulin-induced hypoglycaemia

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

Acarbose tablets (TLS Amber Specialist Recommended)

Contact Us

Qtern^® (Saxagliptin / Dapagliflozin)

Liraglutide (Victoza^®) (TLS Blue)

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

Glucogel^®