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BNSSG Adult Joint Formulary

6.3 Diabetes mellitus and hypoglycaemia

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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)

Semaglutide (injectable) (TLS Green)

 

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 - 
  • 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)

 

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)

 

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:

 

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

 

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