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Nottinghamshire Area Prescribing Committee
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 Formulary Chapter 6: Endocrine system - Full Chapter
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06.01  Drugs used in diabetes
06.01.01  Insulins
06.01.01.01  Short-acting insulins
Insulin (Actrapid®)
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Formulary
Green
10mL vial  
Link  NUH: Guideline for the Management of Acute Hyperkalaemia in Adults
Link  SFH: Hyperkalaemia Guideline
   
Insulin (Humulin® S)
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Formulary
Green
10mL vial
3mL cartridge (for most Autopen® Classic or HumaPen®) 
   
Insulin (Insuman® Rapid)
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Formulary
Green
3mL cartridge for ClikSTAR
3ml disposable pen (Optiset®) discontinued Dec 2011 - only cartridges available 
   
Insulin 500 units in 1mL (Humulin R®)
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Restricted Drug Restricted
Red
Kwikpen 3ml (High Strength) disposable pen - unlicenced
  • 20 ml vial discontinued. Transfer patients to Kwikpen.
  • For use by diabetic specialists only. 
  • Link  Humulin R PIL (from USA, for vials)
    Link  Humulin R SPC (from USA)
    Link  NUH: How to prescribe and administer Humulin R - Information and link to posters
    Link  SFH: Calculator for number of pens needed
    Link  SFH: Humulin R information page
    Link  SFH: Only prescribe unlicensed medicines on white hospital prescriptions, not green FP10HPs.
       
    Insulin Aspart  (NovoRapid®)
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    Formulary
    Amber 2
    10mL vial
    3mL cartridge
    3mL prefilled pen
    1.6ml cartridge (Pumpcart for insulin pump)
  • More expensive than standard insulins, but may be used where the faster onset is necessary in line with Nottinghamshire Diabetes Guidelines 
  •    
    Insulin aspart (Fiasp®)
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    Formulary
    Amber 2

    10mL vial
    3mL cartridge
    3mL prefilled pan

    • Different formulation to Novorapid®.
    • Colour of pens, vials and cartridges is changing from yellow to red and yellow- more info
     
       
    Insulin Glulisine (Apidra®)
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    Formulary
    Amber 2
    10mL vial
    3mL cartridge for ClikSTAR (OptiPen phased out Dec 2011)
    3ml pre-filled pen SoloSTAR (Optiset phased out Dec 2011)
  • Nottinghamshire diabetes guidelines 
  • Link  Link to reviews
       
    Insulin Lispro 100 units/ml (Humalog Junior Kwikpen®)
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    Formulary
    Amber 2

    3mL prefilled pen (Junior KwikPen)

    • Delivers insulin in half unit increments (to a maximum of 30 units)
     
       
    Insulin Lispro 100 units/ml (Humalog®)
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    Formulary
    Amber 2
    10mL vial
    3mL cartridge
    3mL prefilled pan (KwikPen)
  • More expensive than standard insulins, but may be used where the faster onset is necessary in line with diabetes guidelines 
  •    
    Insulin porcine  (Hypurin® Porcine Neutral)
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    Restricted Drug Restricted
    Green
    10mL vial
    3ml cartidge (for Autopen® Classic)
  • Existing patients only 
  •    
    06.01.01.02  Intermediate- and long-acting insulins
    Isophane Insulin (Humulin® I)
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    Formulary
    Green
    10mL vial, 3mL cartridge, 3mL prefilled pen (KwikPen) 
       
    Isophane Insulin (Insulatard®)
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    Formulary
    Green

    10mL vial, 3mL cartridge, InnoLet.

    NB: please note that the Innolet presentation should not be used in paediatric patients - using cartridges is recommended

     
       
    Isophane Insulin (Insuman® Basal)
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    Formulary
    Green
    5ml vial, 3mL cartridge for ClikSTAR, 3ml disposable pen - Solostar®  
       
    Insulin Glargine biosimilar
    (Semglee®)
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    Formulary
    Amber 2

    3mL prefilled pen

    • First line insulin glargine product for new patients being initiated on insulin glargine or those requiring a medication change.
    • Amber 2 - On recommendation from specialist clinic only.
    • Semglee®, Abasaglar® and Lantus® should not be used interchangeably. Ensure all prescriptions and communications specify brand.
     
       
    Insulin Glargine (Lantus®)
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    Formulary
    Amber 2

    10mL vial, 3mL cartridge for ClikSTAR, 3mL disposable prefilled pen - Solostar®

    • The first line insulin glargine product for new patients is Semglee® (available as prefilled pen only).
    • Restricted for patients as per NICE guidance
    • Amber 2 - On recommendation from specialist clinic only
    • Semglee®, Abasaglar® and Lantus® should not be used interchangeably. Ensure all prescriptions and communications specify brand.
     
    Link  Link to reviews
       
    Insulin Glargine biosimilar
    (Abasaglar®)
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    Formulary
    Amber 2

    3mL prefilled pen, 3mL refill cartridge.

    • Reserved for existing patients only.
    • Amber 2 - On recommendation from specialist clinic only
    • Semglee®, Abasaglar® and Lantus® should not be used interchangeably. Ensure all prescriptions and communications specify brand.
     
    Link  Biosimilars- Notts APC guide
    Link  Link to reviews
    Link  NHSE publication. What is a Biosimilar medicine
    Link  NICE KTT15: Biosimilar medicines
    Link  UKMi Briefing - October 2015
       
    Insulin Detemir (Levemir®)
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    Formulary
    Amber 2

    3mL cartridge, 3mL prefilled pen.

    • Restricted for patients as per NICE guidance
    • Amber 2 - On recommendation from specialist clinic only
     
    Link  Link to reviews
       
    Insulin degludec (Tresiba®)
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    Formulary
    Amber 2

    Note that there are two strengths of insulin degludec! See link to MHRA warning below. Caution should be exercised when prescribing and dispensing.

    100 units / ml cartridges, 100 units / ml FlexTouch® prefilled pens.

    • Restricted Item Initiation only for patients with:
      • type 1 diabetes currently treated with insulin glargine with recurrent admissions for ketoacidosis treatment due to insulin omission OR with recurrent, particularly nocturnal, severe hypoglycaemia.
      • type 2 diabetes currently treated with insulin glargine where existing basal insulin is running out OR with poor compliance OR requiring flexibility of administration OR with recurrent, particularly nocturnal, severe hypoglycaemia.

    200 units / ml FlexTouch® prefilled pens.

    • Restricted Item Initiation only for patients requiring high doses of insulin that cannot be delivered using the lower strength 
     
    Link  MHRA safety alert on availability of 2 strengths
    Link  Link to reviews
       
    Insulin Glargine 300 units/ml (Toujeo®)
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    Restricted Drug Restricted
    Amber 2
    • 300 units per ml (high strength)
    • Prescribe by brand name.
    • Available in two devices:
      • Solostar® disposable pen (1 unit increments and max dose 80units)
      • Doublestar® disposable pen (2 unit increments and max dose 160units)
    • Only for use in patients that would otherwise require insulin 500units/ml
      OR  As 2nd line basal insulin after insulin glargine 100units/ml in patients with poorly controlled diabetes and at least one of the following:
        - requiring twice daily basal insulin (as once daily is insufficiently long acting)
        - lipohypertrophy
        - experiencing nocturnal hypoglycaemia
        - requiring carer administration once a day, where delays in administration are impacting on diabetes control
     
    Link  Link to reviews
       
    Isophane Insulin (Hypurin® Bovine Isophane)
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    Formulary
    Green
    10mL vial
  • Existing patients only
  • Discontinued 2017 - possible availability until 2018 
  •    
    Isophane Insulin (Hypurin® Porcine Isophane)
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    Formulary
    Green
    10mL vial, 3ml cartridge
  • Existing patients only 
  •    
    Insulin Zinc suspension (Hypurin®Bovine Lente)
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    Formulary
    Green
    10mL vial, 3ml cartridges.
  • Existing patients only.
  • Discontinued 2017 - possible availability until 2019 
  •    
    06.01.01.02  Biphasic insulins to top
    Biphasic Isophane Insulin (Humulin® M3)
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    First Choice
    Green
  • 10mL vial, 3mL cartridge, 3mL prefilled pen 
  • Biphasic Insulin Aspart (NovoMix® 30)
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    Formulary
    Amber 2
  • 10mL vial, 3mL cartridge, 3mL prefilled pen 
  •    
    Biphasic Insulin Lispro (Humalog® Mix)
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    Formulary
    Amber 2
  • Available as Mix25 and Mix50.
  • 3mL cartridge, 3mL prefilled pen (KwikPen), Vial (Mix25 only) 
  •    
    Biphasic Isophane Insulin (Insuman® Comb)
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    Formulary
    Green
  • Available as Comb 15, Comb 25, and Comb 50
     
  •    
    06.01.01.03  Hypodermic equipment
     note 
    • In secondary care, for supply and advice on pens and needles please contact the diabetes specialist nurse. A small supply of NovoFine needles are available from pharmacy.
    • The needles included in the formulary below are those that are considered cost-effective for use in primary care . This is defined as <£4 per 100 needles.
    BD Viva
    (Needles for insulin pens)
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    Formulary
    Green
    • Available in the following sizes:
      -4mm/32G, 5mm/31G, 6mm/31G, 8mm/31G
     
       
    GlucoRx Carepoint
    (Needles for insulin pens)
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    Formulary
    Green
    • Available in the following sizes:
      -4mm/31G, 4mm/32G Ultra, 5mm/31G, 6mm/31G, 8mm/31G, 10mm/29G, 12mm/29G
     
       
    Injection Device (Autopen 24 (1 and 2 unit)®)
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    Formulary
    Green
     
       
    Injection Device (Autopen Classic (1 and 2 unit)®)
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    Formulary
    Green
     
       
    Injection Device (ClikStar®)
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    Formulary
    Green
     
       
    Injection Device (HumaPen Luxura HD®)
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    Formulary
    Green
     
       
    Injection Device (HumaPen Savvio®)
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    Formulary
    Green
     
       
    Injection Device (NovoPen 5)
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    Formulary
    Green
     
       
    Injection Device (NovoPen Echo®)
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    Formulary
    Green
     
       
    Omnican fine
    (Needles for insulin pens)
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    Formulary
    Green
    • Available in the following sizes:
      -4mm/32G, 5mm/32G, 6mm/32G
     
       
    Tricare
    (Needles for insulin pens)
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    Formulary
    Green
  • Available in the following sizes:
    -4mm/32G, 5mm/31G, 6mm/31G, 8mm/31G 
  •    
    06.01.02  Antidiabetic drugs
    06.01.02.01  Sulphonyureas
    Gliclazide
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    First Choice
    Green
    Tablet
  • Tablets disperse in water if needed. See here for general advice on dispersing tablets. Liquid can be made specially if required.  
  • Gliclazide MR
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    Formulary
    Amber 3
    MR tablet
  • Amber 3 - GP's can initiate as per guideline. Available for patients where there are concerns over compliance to standard release regimens as per primary care guidelines 
  • Link  Nottinghamshire APC Type 2 Diabetes Guideline
       
    06.01.02.02  Biguanides
    Metformin
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    First Choice
    Green

    Tablet (£4pm), Tablet MR (£9pm)(for patients with proven GI intolerance), liquid 500mg/5ml (£27pm (1g bd)).

    • Tablets can be crushed (they are VERY hard) and dispersed in water. Uncrushed they take ~1 hour to dissolve). See here for general advice on dispersing tablets. Do NOT crush modified release tablets.
    • Oral powder discontinued April 2014.
    • Sukkarto SR is preferred modified release brand in primary care. See Preferred Prescribing List.
    • Grey Metformin MR classified as grey for polycystic ovary syndrome
     
    06.01.02.03  Other antidiabetic drugs to top
    06.01.02.03  Alpha glucosidase inhibitors
    Acarbose (Glucobay®)
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    Formulary
    Amber 2
    Tablet
  • Useful in the occasional overweight patient but limited by gastrointestinal intolerance
  • Amber 2 - as per Nottinghamshire APC diabetes guidance
     
  •    
    06.01.02.03  DPP4 inhibitors (gliptins)
    Alogliptin (Vipidia®)
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    Formulary
    Amber 3

    Tablets

     
    Link  Link to reviews
       
    Sitagliptin (Januvia®)
    (DPP4 inhibitor)
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    Formulary
    Amber 3

    Tablet

     
    Link  Click here for independent reviews
    Link  Risk of acute pancreatitis:MHRA update Sept 12
       
    Linagliptin (Trajenta®)
    (DPP4 inhibitor)
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    Formulary
    Amber 3

    Tablets

     
    Link  Click here for independent reviews
       
    Alogliptin / metformin (Vipdomet®)
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    Formulary
    Green

    Alogliptin 12.5mg / metformin 1000mg tablets

    • For patients on a stable combination of alogliptin and metformin only. Offers cost saving vs prescribing both medications separately.
     
    Link  Link to reviews
       
    Sitagliptin and Metformin (Janumet®)
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    Formulary
    Green

    Tablet

    • For patients on a stable combination of sitagliptin and metformin only. Offers cost saving vs prescribing both medications separately.
     
       
    Linagliptin/ metformin (Jentadueto®)
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    Formulary
    Green

    Tablet

    • For patients on a stable combination of linagliptin and metformin only. Offers cost saving vs prescribing both medications separately.
     
    Link  Link to reviews
       
    06.01.02.03  GLP1 agonists
    Exenatide (Byetta®)
    (GLP1 agonist)
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    Formulary
    Amber 2

    Injection

     
    Link  Link to table of independent reviews
    Link  MRHA warning on risk of acute pancreatitis and renal failure (2009)
    Link  Pancreatic problems with GLP-1 medicines - MHRA statement 2013
       
    Exenatide prolonged release (Bydureon®)
    (GLP1 agonist)
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    Formulary
    Amber 2

    Vial, Pen

     
    Link  Link to reviews
    Link  NICE TAG 248- MR exenatide
    Link  Pancreatic problems with GLP-1 medicines - MHRA statement 2013
       
    Liraglutide (Victoza®)
    (GLP1 agonist)
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    Formulary
    Amber 2

    Injection as 6mg/ml prefilled pen

    • Amber 2 - Specialist initiation for the treatment of diabetes in line with Nottinghamshire APC diabetes treatment guidelines.
    • Prescribe by brand (Victoza®) to avoid patients inadvertently receiving a different product licensed for obesity
    • Restricted to dose of 1.2mg only (1.8mg dose is non-formulary and classified grey, Nov 18 APC)
    • Use for the treatment of obesity is non-formulary and classified grey (no formal assessment).
     
    Link  Click here for independent reviews
       
    Lixisenatide (Lyxumia®)
    (GLP1 agonist)
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    Formulary
    Amber 2

    Subcutaneous injection

     
    Link  Independent review
       
    Semaglutide (Ozempic®)
    (GLP1 agonist)
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    Formulary
    Amber 2

    Subcutaneous injection as a 4-dose pre-filled pen.

     
       
    Dulaglutide (Trulicity®)
    (GLP1 agonist)
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    Formulary
    Amber 2
    • Note: Ready made. No requirement to reconstitute powder.
     
    Link  Link to reviews
    Link  NICE: Evidence Summary (ESNM59)
       
    06.01.02.03  Meglitinides
    06.01.02.03  SGL2 inhibitors to top
    Canagliflozin (Invokana®)
    (SGLT2 inhibitor)
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    Formulary
    Amber 3

    Tablets

    • Amber 3 - as per Nottinghamshire APC diabetes treatment guideline.
      Notes on licensing:
    • Licensed for initiation in adults aged over 18years.
    • Maximum dose is 100mg daily in patients with GFR <60ml/min and should not be used if GFR is <45ml/min.
    • Due to its mechanism of action, patients taking canagliflozin will test positive for glucose in their urine and are at increased risk of urinary tract infection.
     
    Link  Link to reviews
    Link  MHRA Drug Safety Updates (Mar 2017, Feb 2019)
    Link  NICE TA315: Canagliflozin for type 2 diabetes
    Link  NICE TA390: Canagliflozin, dapagliflozin and empagliflozin as monotherapies for treating type 2 diabetes
    Link  NUH Lite Bite: SGLT-2 inhibitors should be omitted in patients undergoing major surgery or who are acutely seriously unwell (Dec 18)
       
    Dapagliflozin (Forxiga®)
    (SGLT-2 inhibitor)
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    Formulary

    Tablets

    • Grey- for Type 1 diabetes. Non-formulary (no formal assessment).
    • 10mg tablets not licensed for use in type 1 diabetes.
    • Dosing restriction to 5mg daily and patient education requirements regarding the risk of DKA apply.
    •  Amber 3- for Type 2 diabetes as per Nottinghamshire APC diabetes treatment guideline.
      Notes on licensing:
    • Licensed for initiation in adults between 18 and 75 years only.
    • Forxiga should not be initiated in patients with a GFR < 60 mL/min and should be discontinued if GFR persistently below 45 mL/min. Forxiga has not been studied in severe renal impairment (GFR < 30 mL/min) or end-stage renal disease (ESRD).
    • Due to its mechanism of action, patients taking dapagliflozin will test positive for glucose in their urine and are at increased risk of urinary tract infection.
     
    Link  Link to reviews
    Link  MHRA Drug Safety Updates (Mar 2017, Feb 2019)
    Link  NICE TA288: Dapagliflozin in combination therapy for treating T2D
    Link  NICE TA390: Canagliflozin, dapagliflozin and empagliflozin as monotherapies for treating T2D
    Link  NICE TA418: Dapagliflozin in triple therapy for treating type 2 diabetes
    Link  NICE TA597: Dapagliflozin with insulin for treating T1D
    Link  NUH Lite Bite: SGLT-2 inhibitors should be omitted in patients undergoing major surgery or who are acutely seriously unwell (Dec 18)
       
    Empagliflozin (Jardiance®)
    (SGLT-2 inhibitor)
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    Formulary
    Amber 3

    Tablets

    • Amber 3 - as per Nottinghamshire APC diabetes treatment guideline.
    • Licensed for initiation in adults aged 18years to 85years.
    • Maximum dose is 10mg daily in patients with GFR <60ml/min and should not be used if GFR is <45ml/min.
    • Due to its mechanism of action, patients taking empagliflozin will test positive for glucose in their urine and are at increased risk of urinary tract infection.
     
    Link  Link to reviews
    Link  MHRA Drug Safety Updates (Mar 2017, Feb 2019)
    Link  NICE TA336: Empagliflozin for type 2 diabetes
    Link  NICE TA390: Canagliflozin, dapagliflozin and empagliflozin as monotherapies for treating T2D
    Link  NUH Lite Bite: SGLT-2 inhibitors should be omitted in patients undergoing major surgery or who are acutely seriously unwell (Dec 18)
       
    Ertugliflozin (Steglatro®)
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    Formulary
    Amber 3

    Tablets

    Notes on licensing:

    • Licensed for initiation in patients > 18 years. Limited experience in patients > 75 years.
    • Renal impairment (eGFR or CrCl, SPC): 60-89ml/min – no dose adjustment;
      <60ml/min – do not initiate ertugliflozin; <45ml/min- discontinue if eGFR or CrCl is persistently below 45ml/min.
    • Due to its mechanism of action, patients taking ertugliflozin will test positive for glucose in their urine and are at increased risk of urinary tract infection.
     
    Link  Link to reviews
    Link  MHRA Drug Safety Updates (Mar 2017, Feb 2019)
    Link  NICE TA572: Ertugliflozin as monotherapy or with metformin for treating T2D
    Link  NICE TA583: Ertugliflozin with metformin and a DPP4i for treating T2D
    Link  NUH Lite Bite: SGLT-2 inhibitors should be omitted in patients undergoing major surgery or who are acutely seriously unwell (Dec 18)
       
    06.01.02.03  Thiazolidinediones
    Pioglitazone (Actos®)
    (Thiazolidinedione)
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    Formulary
    Green
    Tablet
  • Use according to NICE guidance No. 28
  • Consider use in patients who are intolerant/contra-indicated to sulphonyurea and metformin combination.
  • Review treatment 6 months after initiation.
  • Green - see Nottinghamshire APC diabetes guidance.
  • Combined tablet with metformin (Competact®) is non-formulary.
     
  • Link  Click here for independent reviews
    Link  Risk of bladder cancer: MHRA safety update
    Link  Risk of cardiac failure when combined with insulin (MHRA safety update Jan 2011)
       
    06.01.03  Diabetic ketoacidosis
    06.01.04  Treatment of hypoglycaemia
    Glucagon (GlucaGen® HypoKit)
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    Formulary
    Green
    Injection
  • Used in the treatment of hypogylcaemia
  • Also used for the treatment of drug induced severe hypotension, heart failure or cardiogenic shock
  • for use as an antidote see section 18 
  • Link  SFH: Protocol for paediatric glucagon stimulation test
       
    GlucoGel®
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    Formulary
    Green
    Gel
  • Formerly known as Hypostop® 
  •    
    06.01.04  Chronic hypoglycaemia
    Diazoxide
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    Formulary
    Red
    Tablet, injection, 50mg/ml suspension (Unlicensed medicine - named patient use only)
     
    Link  Link to reviews
       
    06.01.05  Treatment of diabetic nephropathy and neuropathy to top
    06.01.05  Diabetic nephropathy
    06.01.05  Diabetic neuropathy
    06.01.06  Diagnostic and monitoring agents for diabetes mellitus
    06.01.06  Blood glucose monitoring
    Blood Glucose Meters
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    Formulary
    Green
  • Criteria for formulary inclusion has been developed by multidisciplinary and multi-organisational consultation for assessing meters and test strips to support the use of the most cost effective products. See link below.
  • There may be variations in which meters individual organisations choose based on the criteria. Please check with your CCG medicines management team for the preferred choice of meter and test strip. 
  • Link  Self Monitoring Blood Glucose (SMBG) meter formulary selection and evaluation criteria
       
    FreeStyle Libre®
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    Restricted Drug Restricted
    Amber 2
    • Initiation by Consultant Endocrinologist ONLY.
    • The meter and ONE sensor will be given on initiation with prescribing passed to primary care after this point.
    • Must be reviewed at 6 months by the initiating consultant and continuation criteria met for prescribing to continue long term
    • As per the prescribing inclusion criteria
     
    Link  Freestyle Libre prescribing criteria
    Link  MHRA: Warning - Barrier methods to prevent skin reaction to sensor adhesive may affect device performance.
    Link  PrescQIPP guidance statement
       
    Test Strips (glucose)
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    Formulary
    Green

    Test strips stocked at NUH:

    • FreeStyle Precision Pro Blood Glucose
    • Medisense Optium Plus®
    • Medisense G2 control solutions
    • One Touch Ultra®
      Test strips stocked at SFH pharmacy:
    • Accu-Check Inform II®
    • Accu-Check Active® - For use at Byron house only
     
    Link  Locally agreed blood glucose testing meters Greater Nottingham
    Link  Locally agreed blood glucose testing meters Mid Nottinghamshire
       
    06.01.06  Urinalysis to top
    Combination test strips
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    Formulary
    Green
    Combination urinanalysis test strips available at NUH:
  • Combur7®
  • Combur9®
  • Medi-Test Combi 5S®
  • Multistix SG®
  • Multistix 8SG®
  • Multistix 10SG®
  • KetoDiastix®
    Combination urinanalysis test strips available at SFH:
  • Multistix SG®
  • Multistix 8SG®
  • Multistix GP® 
  •    
    Glucose test strips
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    Formulary
    Green
    NUH only: Reagent strips, for detection of glucose in urine, available at
  • Medi-Test® Glucose
  • Diabur-Test 5000® 
  •    
    Ketones test strips
    View adult BNF View SPC online View childrens BNF
    Formulary
    Green

    Reagent strips, for detection of ketones in urine, available at NUH:

    • Ketostix®

    Reagent strips, for detection of ketones in urine, available at SFH:

    • Ketostix®
    • Ketur Test®

    Reagent strips, for detection of ketones in blood, available at SFH:

    • Freestyle Optium H® β-ketone

    Reagent strips, for detection of ketones in blood, available at NUH:

    • FreeStyle Precision Pro ß-Ketone Test Strips
     
       
    Protein test strips (Albustix®)
    View adult BNF View SPC online View childrens BNF
    Restricted Drug Restricted
    Green
    SFH only:
    Reagent strips, for detection of protein in urine
     
       
    06.01.06  Oral glucose tolerance test
    Polycal®
    View adult BNF View SPC online View childrens BNF
    Formulary
    Green
  • Powder and liquid available.
  • Available for Glucose Tolerance Test. To be given as 113ml Polycal® liquid diluted with water to a total volume of 200-300ml (see BNF).
  • Cannot be prescribed on FP10 for Glucose Tolerance Test as not listed in ACBS criteria. Rapilose OGTT® is an alternative that may be prescribed.  
  •    
    Rapilose® OGTT
    View adult BNF View SPC online View childrens BNF
    Formulary
    Green
  • Option for Oral Glucose Tolerance Test that may be prescribed on FP10 
  •    
    06.02  Thyroid and Antithyroid drugs
    06.02.01  Thyroid hormones
    Levothyroxine
    (Thyroxine)
    View adult BNF View SPC online View childrens BNF
    Formulary
    Green

    Tablets, Oral solution

    • Tablets disperse in water if needed (not licensed). See here for general advice on dispersing tablets.
    • Oral solution is available, but very expensive (approx £150+ per month). Click here for more info.
    • IV thyroxine no longer available. See below entry for IV liothyronine.
     
    Link  UKMI suggested drug monitoring schedule
       
    Liothyronine (IV)
    (Triiodothyronine)
    View adult BNF View SPC online View childrens BNF
    Restricted Drug Restricted

    Injection (for tablets see non-formulary section below)

    • Expensive (£376 per 20microgram dose). For hypothyroid crisis on request of consultant endocrinologist. Levothyroxine has very long half life (~7 days) so temporary IV replacement if NBM is not needed. 
    • SFH only: To be used request of consultant endocrinologist, and only on ICCU.
    • NUH only: For use for temporary replacement of levothyroxine, when scheduled to have nuclear medicine scan of the thyroid gland and it is not possible to come off oral levothyroxine.
     
       
    06.02.02  Antithyroid drugs
    Carbimazole
    View adult BNF View SPC online View childrens BNF
    First Choice
    Green
    Tablet
  • NB: CSM warning re neutropenia and agranulocytosis
  • Tablets disperse in water if needed. See here for general advice on dispersing tablets.
    Liquid (unlicensed special) is expensive and not stocked at SFH,
     
  • Propylthiouracil
    View adult BNF View SPC online View childrens BNF
    Second Choice
    Green
    Tablet
  • NB: CSM warning re neutropenia and agranulocytosis
  • If needed tablets can be dispersed in water. More Info
  • Propylthiouracil should be reserved for patients who are intolerant of carbimazole or for those who experience sensitivity reactions to carbimazole (sensitivity is not necessarily displayed to both drugs), and for whom other treatments are inappropriate (BNF 2011)  
  • Link  Click here for SPC
    Link  UKMI suggested drug monitoring schedule
       
    Iodine and Iodide
    (Aqueous iodine oral solution)
    View adult BNF View SPC online View childrens BNF
    Restricted Drug Restricted
    Red
    Oral Solution (Unlicensed)- Secondary Care only
  • Also known as Lugol's iodine
  • Used as a diagnostic agent in oesophageal cancer at NUH 
  •    
    Potassium Iodide
    View adult BNF View SPC online View childrens BNF
    Formulary
    Red
    Capsules
    NUH only. Used to protect thyroid in patients treated with metaiodobenzylguanidine (MIBG) for neuroblastoma in childhood and phaeocromocytoma in adults. 
       
    06.03  Corticosteroids to top
    06.03.01  Replacement therapy
    Fludrocortisone
    View adult BNF View SPC online View childrens BNF
    Formulary
    Amber 2

    Tablet

    • Tablets disperse in water if needed. See here for general advice on dispersing tablets.
    • Flush well if giving via enteral tube.
    • Florinef® brand discontinued April 2016, but still available generically (£30 for 30 tablets).
    • For postural hypotension and mineralocorticoid replacement.
     
    Link  Link to reviews
    Link  NICE Evidence Summary - postural hypotension
    Link  Price Comparison: Hypertensives
       
    06.03.02  Glucocorticoid therapy
    Betamethasone (Betnesol®)
    (tablets)
    View adult BNF View SPC online View childrens BNF
    Formulary
    Amber 2

    Soluble tablets:

    • For use as a mouthwash (unlicensed indication)
     
       
    Dexamethasone
    (tablets/injection)
    View adult BNF View SPC online View childrens BNF
    Formulary
    Amber 2

    Tablet, soluble tablets, Injection, Oral solution (expensive - See here)

    Injection:

    • Caution: Different concentrations of dexamethasone injection exist
    • NUH now using Wockhardt 3.3mg/mL 1ml amps - note New 03/10/17: see memo below.
    • S/C use is unlicensed but common practice within palliative care.

    Oral:

    • Normal tablets routinely stocked which disperse easily in water.
    • Soluble tablets are available but are more expensive.
    • Dosing recommendations are usually in terms dexamethasone base (which the tablets are)
    • Classified GREEN for croup as per CKS guidance. Prednisolone is also an option and is stocked more widely.
     
    Link  NUH: Dexamethasone injection change to 3.3mg/mL memo (Oct 2017)
    Link  Dexamethasone price comparison (tabs vs sol tabs vs liquid)
    Link  See unexpectedly expensive medicines list
    Link  SFH: Advice on IV/ SC doses - 3.3mg vs 3.8mg
    Link  SFH: Dexamethasone in palliative care guide notes
    Link  SFH: Dexamethasone suppression test
    Link  SFH: Palliative care advice on equivalent s/c to oral doses
    Link  Withdrawal of steroids advice (See BNF ’Treatment cessation’ section)
       
    Hydrocortisone sodium phosphate
    View adult BNF View SPC online View childrens BNF
    Formulary
    Amber 2

    Injection (ready made liquid)

    • Usually use sodium succinate salt (Solu-Cortef®), but sodium phosphate salt is available for outpatients who may need to self administer (e.g. addisonian crisis).
    • Already in solution and doesn't require reconstitution like the sodium succinate salt requires.
    • Supply problem appears resolved - March 2019 – See memo
     
    Link  Addison’s Disease Self Help Group: What to do in an emergency
    Link  Patient guide to self administration -video
    Link  Patient guide to self injection in Addisonian crisis (Efcortesol® brand)
       
    Hydrocortisone sodium succinate (Solu-Cortef®)
    View adult BNF View SPC online View childrens BNF
    Formulary
    Green

    Injection (powder for reconstitution)

    • Self administration guidance is available here and for a video click here.
    • Surgery IV dose advice now within BNF drug monograph
     
    Link  Patient guide to self injection in Addisonian crisis
       
    Methylprednisolone
    View adult BNF View SPC online View childrens BNF
    Formulary
    Amber 2

    Tablets
    IV injection - formally known as Solu-Medrone® (40mg, 125mg, 500mg, 1g, 2g)

    • For Hikma brand injection, dilution instructions are misleading, follow the blue IV guide (UCL) or Medusa
    • For IM Depot injection - Depo-Medrone® (40mg) see BNF section 10.1.2
     
    Link  MHRA Drug Safety Update (October 2017)
    Link  Cochrane: Oral versus Intravenous Steroids for Treatment of Relapses in Multiple Sclerosis
    Link  NICE: Multiple Sclerosis; management in primary and secondary care.
       
    Prednisolone
    (Replacement)
    View adult BNF View SPC online View childrens BNF
    Formulary
    Green
    • Available as tablets, EC tablets, liquid, soluble tablets
    • EC tablets are 1.5x the price of plain tablets without any substantial evidence that they confer any GI benefits and in some cases have worsened disease control. See [memo] and [UKMI Q&A] for further information.
    • 25mg tablets are 4x (GP) more expensive per mg than 5mg tablets. [see memo]
    • Liquid 10mg/ml -- available for swallowing difficulties where the treatment course will exceed 300mg. Each bottle (containing 300mg) costs £50.
    • Soluble tablets are 25x(!) more expensive than normal tablets (which can be dispersed (unlicensed)). [see memo]. See unexpectedly expensive medicines list. The taste may be unpalatable but can be masked with juice or jam.
    • NUH & SFH: standard prednisolone 5mg tablets are preferred to soluble prednisolone in paediatric and adult specialities within NUH, excluding treatment of oral lichen planus or severe GvHD mucositis.
    • Potential for adverse reactions to drug withdrawal - See SFH info
     
    Link  SFH: reducing steroid dose chart
    Link  UKMI Q&A: Hydrocortisone IV to prednisolone conversion
    Link  UKMI: Prednisolone - use 5mg not 25mg Tablets
    Link  UKMI: Prednisolone - Use plain, Not EC Tablets
    Link  UKMI: Prednisolone - Use plain, Not Soluble Tablets
    Link  Withdrawal of steroids advice (See BNF ’Treatment cessation’ section)
       
    Hydrocortisone
    (tablets)
    View adult BNF View SPC online View childrens BNF
    Formulary
    Amber 2

    Tablet

    • Tablets disperse in water if needed. See here for general advice on dispersing tablets.
     
    Link  MHRA (Dec18): Hydrocortisone muco-adhesive buccal tablets: should not be used off-label for adrenal insufficiency in children due to serious risks
    Link  See unexpectedly expensive medicines list
       
    Hydrocortisone (Alkindi® granules in capsules)
    View adult BNF View SPC online View SMC online View childrens BNF
    Restricted Drug Restricted
    Amber 2
    • Available as 500microgram, 1mg and 2mg capsules.
    • 5mg capsules are Grey. For doses multiple of 5 mg see the entry above on hydrocortisone 10mg tablets. 
    • Restricted for cortisol replacement therapy of infants and young children with adrenal insufficiency where the hydrocortisone 10mg tablets cannot be used, either whole or halved, to administer the required dose. 
     
    Link  NUH Guideline for the Recognition and Management of children and young people with Adrenal Insufficiency/Crisis
       
    06.03.02  Disadvantages of corticosteroids
    06.03.02  Use of corticosteroids
    06.03.02  Pregnancy and breastfeeding to top
    06.03.02  Administration
    06.03.02  Withdrawal of corticosteroids
    06.04  Sex hormones
    06.04.01  Female sex hormones and their modulators
    06.04.01.01  Oestrogens and HRT to top
     note 

    Oestrogen for the treatment of patients with gender dysphoria is classified as Amber 2 (Specialist initiation) in line with NHS England guidance (pg 30-31) Dosing and monitoring information is contained in the Royal College of Psychiatrists guidelines (see page 39 onwards)

    There are several national shortages presently. Prescribers are advised to review the advice from the British Menopause Society and if unsure consult their medicines management pharmacist to discuss an alternative product. (Aug 2019)

    Oestrogen only HRT tablet (Elleste-Solo, Premarin)
    View adult BNF View SPC online View childrens BNF
    Formulary
    Green

    Elleste-Solo®- Estradiol tablet 1mg and 2mg (First choice oral estradiol only product)
    Premarin®- Conjugated oestrogens tablet

     
       
    Oestrogen only HRT patch (Estradot, Evorel, Elleste-Solo)
    View adult BNF View SPC online View childrens BNF
    Formulary
    Green
    • Evorel® (cheaper, stocked at SFH)
    • Estradot®
    • Elleste-Solo® MX
     
       
    Oestrogel ® (Estradiol gel)
    View adult BNF View SPC online View childrens BNF
    Formulary
    Green
    Oestrogel®
     
       
    Combined continuous HRT tablet (Kliofem, Kliovance, Femoston Conti, Premique low dose)
    View adult BNF View SPC online View childrens BNF
    Formulary
    Green

    Kliofem® tablet
    Kliovance® tablet (lower strength than Kliofem®)
    Femoston®-conti tablets
    Premique® tablet discontinued December 2016, now only Premique ® low dose tablet available

    • No bleed products
     
       
    Combined continuous HRT patch (Evorel® Conti)
    View adult BNF View SPC online View childrens BNF
    Formulary
    Green
    Evorel® Conti patches
  • No bleed products
     
  • Link  SPS: Shortage of Evorel patches and suggested alternatives
       
    Combined cyclical HRT tablet (Elleste-Duet®, Femoston)
    View adult BNF View SPC online View childrens BNF
    Formulary
    Green
    Elleste-Duet®- tablet 1mg and 2mg
    Femoston® 1/10 and 2/10 tablet
    Prempak-C® discontinued January 2017 
       
    Combined cyclical HRT patch (Evorel® Sequi)
    View adult BNF View SPC online View childrens BNF
    Formulary
    Green
  • Evorel® Sequi patches 
  • Link  SPS: Shortage of Evorel patches and suggested alternatives
       
    Tibolone (Livial®)
    View adult BNF View SPC online View childrens BNF
    Formulary
    Green
    Tablet 
    Link  MHRA information on breast cancer risks Feb 2009
       
    06.04.01.01  Ethinylestradiol
    Ethinylestradiol
    View adult BNF View SPC online View childrens BNF
    Formulary
    Amber 2
    Tablet 10mcg
    Tablet 2mcg for paediatric use - named patient use 
    Link  See unexpectedly expensive medicines list
       
    06.04.01.01  Raloxifene
    Raloxifene Hydrochloride (Evista®)
    View adult BNF View SPC online View childrens BNF
    Formulary
    Amber 2
    Tablet
    Amber 2 - Treatment and prevention of osteoporosis 
    Link  NICE quick reference guide on osteoporosis
    Link  NICE: Raloxifene and teriparatide for the secondary prevention of osteoporotic fragility fractures in postmenopausal women (TA161)
    Link  NICE: Raloxifene for the primary prevention of osteoporotic fragility fractures in postmenopausal women (TA160)
    Link  Nottinghamshire osteoporosis treatment guidelines Jan 2011
       
    06.04.01.02  Progestogens
    Medroxyprogesterone Acetate (Provera®)
    View adult BNF View SPC online View childrens BNF
    Formulary Tablet 
       
    Norethisterone
    View adult BNF View SPC online View childrens BNF
    Formulary Tablet 
       
    Progesterone (Cyclogest®)
    View adult BNF View SPC online View childrens BNF
    Formulary Pessary
    BNF: less suitable for prescribing for premenstrual syndrome and post-natal depression 
       
    Progesterone (Gestone®)
    View adult BNF View SPC online View childrens BNF
    Restricted Drug Restricted
    Red
    Injection-NUH only
  • June 2016 – Current supply problem  
  •    
    06.04.02  Male sex hormones and antagonists
     note 

    Testosterone for the treatment of patients with gender dysphoria is classified as Amber 2 (Specialist initiation) in line with NHS England guidance (pg 30-31). Dosing and monitoring information is contained in the Royal College of Psychiatrists guidelines (see page 39 onwards)

    Testosterone implant
    View adult BNF View SPC online View childrens BNF
    Restricted Drug Restricted
    Red
    Implant 100mg and 200mg (unlicensed)
  • Restricted: Specialist use only
  • No longer available on UK market. Unlicensed import should be available. 
  •    
    Testosterone gel  (Tostran®)
    View adult BNF View SPC online View childrens BNF
    Restricted Drug Restricted

    Gel

    • Amber 2 - Specialist recommendation only for the treatment of male hypogonadism in adults - see APC guidance below
    • Red  Available at NUH only: Specialist recommendation only for the treatment of male hypogonadism in children and adolescence
    • Red Available at NUH only: Constitutional delay in growth and puberty (CDGP) in children and adolescence only
     
    Link  Testosterone monitoring guidance (Notts APC)
       
    Testosterone injection (Sustanon 250®)
    View adult BNF View SPC online View childrens BNF
    Restricted Drug Restricted

    Injection

    • Sustanon 100 was discontinued in 2009
    • Amber 2 - Specialist recommendation only for the treatment of male hypogonadism in adults - see APC guidance below
    • Red  Available at NUH only: Specialist recommendation only for the treatment of male hypogonadism in children and adolescence
    • Red Available at NUH only: Constitutional delay in growth and puberty (CDGP) in children and adolescence only
     
    Link  Testosterone monitoring guidance (NottsAPC)
       
    Testosterone oral (Restandol Testocaps®)
    View adult BNF View SPC online View childrens BNF
    Restricted Drug Restricted
    Red

    Capsules

    Available at NUH only:

    • Constitutional delay in growth and puberty (CDGP) in children and adolescence only
    • Male hypogonadism in children and adolescence only
     
       
    Testosterone undecanoate (Nebido®)
    View adult BNF View SPC online View childrens BNF
    Restricted Drug Restricted
    Amber 2

    Injection- Deep Intramuscular

    • Amber 2-on specialist recommendation only for the treatment of male hypogonadism- see APC guidance below
     
    Link  Testosterone monitoring guidance (NottsAPC)
       
    06.04.02  Anti-androgens to top
    Finasteride
    View adult BNF View SPC online View childrens BNF
    Restricted Drug Restricted
    Amber 3
    Tablet
  • For use in Benign prostatic hyperplasia only (Amber 3) in line with guideline.
  • If needed tablets can be dispersed in water, but this should be done in a closed system- put the tablet in an oral syringe and suck up some water to dissolve it. More Info on crushing tablets
  • Dutasteride
    View adult BNF View SPC online View childrens BNF
    Second Choice
    Amber 2

    Capsule

    • Avoid contact with capsule contents.
    • Use finasteride first line which is supported by the MTOPS and PCPT trials.
    • Patients can be switched from dutasteride to finasteride in primary care if:
      - finasteride hasn't been tried before.
      - the patient has been on dutasteride for more than 3 months.
    • Amber 2 - Benign prostatic hyperplasia.
     
    Link  Link to reviews
       
    Cyproterone Acetate
    (Male hypersexuality)
    View adult BNF View SPC online View childrens BNF
    Formulary
    Amber 2
    Tablet
  • Monitor LFTs
  • If needed tablets can be dispersed in water, but this should be done in a closed system- put the tablet in an oral syringe and suck up some water to dissolve it. More info on crushing tablets.
  • Amber 2 - Severe hypersexuality and sexual deviation in males 
  •    
    06.04.03  Anabolic steroids
    06.05  Hypothalamic and pituitary hormones and anti-oestrogens
    06.05.01  Hypothalamic and anterior pituitary hormones and anti-oestrogens
    06.05.01  Anti-oestrogens
    Clomifene Citrate
    View adult BNF View SPC online View childrens BNF
    Formulary
    Red
    Tablet
    Red - Treatment of infertility  
       
    06.05.01  Anterior pituitary hormones to top
    Choriogonadotropin Alfa (Ovitrelle®)
    View adult BNF View SPC online View childrens BNF
    Restricted Drug Restricted
    Red
    Injection- secondary care only as per approved guidelines
  • Also known as Human chorionic gonadotropin
  • Red - Treatment of infertility 
  •    
    Chorionic Gonadotrophin (Pregnyl®)
    View adult BNF View SPC online View childrens BNF
    Restricted Drug Restricted
    Red
    Injection- secondary care only as per approved guidelines
  • Also known as Human Chorionic Gonadotrophin; HCG
  • Red - Treatment of Infertility
     
  •    
    Follitropin Alfa  (Gonal-F®)
    View adult BNF View SPC online View childrens BNF
    Restricted Drug Restricted
    Red
    Injection - ampoule and prefilled pen
  • Secondary care only as per approved guidelines
  • Also known as recombinant human follicle stimulating hormone)
  • Red - Treatment of infertility
    Ensure all prescriptions and communications specify brand 
  • Link  Link to reviews
       
    Follitropin Alfa biosimilar (Bemfola®)
    View adult BNF View SPC online View childrens BNF
    Restricted Drug Restricted
    Red
    Injection - pre-filled pen
  • NUH only as per approved guidelines
  • Also known as recombinant human follicle stimulating hormone
  • Red - Treatment of infertility
    Biosimilar - Ensure all prescriptions and communications specify brand.
     
  • Link  Link to reviews
    Link  NICE KTT15: Biosimilar medicines
       
    Human Menopausal Gonadotrophins (Menopur®)
    View adult BNF View SPC online View childrens BNF
    Restricted Drug Restricted
    Red
    Injection
  • Secondary care use only as per approved guidelines
  • Red - Treatment of infertility 
  •    
    Somatropin
    (Growth hormone)
    View adult BNF View SPC online View childrens BNF
    Restricted Drug Restricted
    High Cost Medicine
    Homecare

    Injection

    • Several brands available, prescribe by brand to avoid inadvertent switching as devices vary. First line products in Nottinghamshire are Omnitrope® (Sandoz), Humatrope® (Lilly), Genotropin® (Pharmacia), Norditropin Simplexx®(Novo Nordisk) and Zomacton® (Ferring). - Other brands may be used for existing patients, and those unable to tolerate or operate a first line brand device. Second line products include Saizen® (Merck Serono) and Nutropin Aq® (Ipsen)
    • For use in children only.
      Classified Red for the treatment of adults.
    • Available through homecare for NUH patients. Please contact pharmacy medicines homecare team for further information.
     
    Link  Link to reviews
    Link  NICE KTT15: Biosimilar medicines
    Link  NICE TA188: Somatropin for growth failure in children
    Link  NICE TA64: Growth hormone deficiency (adults)
    Link  Shared Care Protocol (Notts APC): GP information
    Link  Shared Care Protocol (Notts APC): Overarching document
       
    Tetracosactide (Synacthen®)
    View adult BNF View SPC online View childrens BNF
    Formulary
    Red
    • Used to be called Tetracosactrin.
    • Available in two types; 250mcg (IM/IV) for short synacthen test and 1mg I.M. depot for prolonged Synacthen test.
    • SFH: Now £60 per dose. Only for supply on endocrinologist approval. 20.
     
    Link  SFH: Endocrinology protocol
    Link  SFH: Paediatrics. Use approved NUH Endocrinology protocols
       
    Thyrotropin Alfa (Thyrogen®)
    View adult BNF View SPC online View childrens BNF
    Restricted Drug Restricted
    Red
    Injection- NUH only 
    Link  Click here for independent reviews
       
    06.05.01  Hypothalmic hormones
    Corticorelin
    Formulary
    Red
  • Also known as Human Corticotrophin Releasing Hormone (or Factor) - CRH (or CRF).
  • Unlicensed in the UK.
  • SFH: 100microgram/1ml available to order on consultant request, discuss with the Medicines Information Centre (SFH: 3163). 
  • Link  SFH: Endocrinology protocol
       
    Gonadorelin (HRF®)
    View adult BNF View SPC online View childrens BNF
    Restricted Drug Restricted
    Red
    100 microgram injection
  • Secondary Care Only - specialist use for diagnostic purposes
     
  • Link  SFH: Protocol for paediatric glucagon stimulation test
       
    Protirelin (TRH)
    View adult BNF View SPC online View childrens BNF
    Restricted Drug Restricted
    Red
    Injection
  • Secondary Care Only - specialist use for diagnostic purposes following approved guidelines
  • Long term manufacturing problem, currently sourcing unlicensed product from Europe. Please note strength change, now receiving 200mcg/ml.
     
  • Link  SFH: Endocrinology protocol
    Link  SFH: Protocol for paediatric glucagon stimulation test
       
    06.05.02  Posterior pituitary hormones and antagonists
    Tolvaptan (Jinarc®)
    View adult BNF View SPC online View childrens BNF
    Restricted Drug Restricted
    Red
    High Cost Medicine
    Tablet
    NUH: Approved in accordance with NICE TA358 for treating autosomal dominant polycystic kidney disease.
    Ensure all prescriptions specify brand. 
    Link  NICA TA358: Autosomal dominant polycystic kidney disease - tolvaptan
       
    06.05.02  Posterior pituitary hormones
    Desmopressin
    View adult BNF View SPC online View childrens BNF
    Formulary Tablets, S/L tablets, nasal spray, solution, injection.
  • Generic tablets now cover all indications.
  • Brands for specific indications are much more expensive. See BNF.
  • Traffic light classifications:
    Amber Traffic Light - Nasal spray for diabetes insipidus
    Amber Traffic Light - Oral for diabetes insipidus
    Green Traffic Light - Oral for nocturnal enuresis 
  • Link  Brand specific drug list (SFH)
    Link  Link to reviews
    Link  NUH Lite Bite: Desmopressin for diabetes insipidus (Nov 18)
    Link  Patient Safety Alert: Omission of desmopressin can be fatal
    Link  Price comparison of desmopressin products
       
    Desmopressin (Noqdirna)
    View adult BNF View SPC online
    Formulary
    Amber 2
    • For the treatment of nocturia due to idiopathic nocturnal polyuria in adults.
     
    Link  Notts APC: Noqdirna prescribing information sheet
       
    Terlipressin
    View adult BNF View SPC online View childrens BNF
    Restricted Drug Restricted
    Red
    Injection-Secondary care only 
       
    Vasopressin (argipressin) (Pitressin®)
    View adult BNF View SPC online View childrens BNF
    Restricted Drug Restricted
    Red
    Injection - For specialist use only.
  • Also known as argipressin.
  • Pituitary diabetes insipidus; bleeding from oesophageal varices.
  • For intramyometrial injection: 20 units vasopressin diluted to 20 ml in normal saline. (Reference
  • Link  Link to reviews
    Link  SFH: Guidelines on the use of vasopressor therapy
       
    06.05.02  Antidiuretic hormone antagonists
     note  Demeclocycline see section 5.1.3
    06.06  Drugs affecting bone metabolism to top
    06.06  Osteoporosis
    06.06.01  Calcitonin and parathyroid hormone
    Calcitonin (salmon) / Salcatonin
    (Injection)
    View adult BNF View SPC online View childrens BNF
    Restricted Drug Restricted
    Red
    Injection
  • For specialist use only following approved guidelines. Secondary care only
  • Classified red for hypercalcaemia of malignancy, Paget's disease of bone, prevention of acute bone loss due to sudden immobility
  • Name changed from salcatonin to calcitonin
  • EMA recommendation limiting long term use of calcitonin
  • Restrictions on use of calcitonin
     
  • Link  Click here for independent reviews
       
    Teriparatide (Forsteo®)
    View adult BNF View SPC online View childrens BNF
    Restricted Drug Restricted
    Red
    High Cost Medicine
    Homecare

    Injection

    • Approved for use in Women for a 24 month course as per NICE guidelines
    • Available at NUH and Nottingham Treatment Centre only for the secondary prevention of osteoporotic fragility fractures in Men as per commissioning policy
    • Red - By specialist clinic only - osteoporosis
    • Only available through Homecare companies - for NUH patients please contact pharmacy medicines homecare team or at SFH click here for ordering information
     
    Link  Click here for independent reviews
    Link  NICE: Raloxifene and teriparatide for the secondary prevention of osteoporotic fragility fractures in postmenopausal women (TA161)
       
    06.06.02  Bisphosphonates and other drugs affecting bone metabolism
    Burosumab  (Crysvita®)
    View adult BNF View SPC online View childrens BNF
    Restricted Drug Restricted
    Red
    Homecare

    Subcutaneous injection

    NUH only in collaboration with Birmingham Children's Hospital: Approved in accordance with HST8 for treating X-linked hypophosphataemia in children and young people.

    Available through homecare for NUH patients. Please contact pharmacy medicines homecare team for further information.

     
    Link  HST8: Burosumab for treating X-linked hypophosphataemia in children and young people
       
    06.06.02  Bisphosphonates
    Alendronic Acid
    (Once-Weekly)
    View adult BNF View SPC online View childrens BNF
    First Choice
    Green

    Tablet, effervescent tablet

    • Green - Treatment of post menopausal osteoporosis.
    • Follow local osteoporosis guidelines and NICE guidance.
    • Effervescent tablets (Binosto®) available for patients unable to swallow the tablets. Liquid also available, but less cost effective. 
    • If necessary, tablets disperse in 10 mL of water within 2–5 minutes to give very fine particles that disperse easily (unlicensed). Further general information on dispersing tablets.
     
    Zoledronic Acid
    (5mg - Osteoporosis/Paget's)
    View adult BNF View SPC online View childrens BNF
    Formulary
    Red
    Homecare

    Infusion 5mg/100mL

    • Approved for Paget's disease.
    • Osteoporosis (once a year). May be initiated only by osteoporosis specialists as per local osteoporosis guidelines.
    • Primary care administration only where CCG pathway exists.

    • Available through homecare for NUH patients. Please contact pharmacy medicines homecare team for further information
     
    Link  Link to reviews
    Link  Osteonecrosis of the jaw patient reminder cards
    Link  MHRA: osteonecrosis of the jaw - risk minimisation (July 15)
       
    Risedronate
    (once weekly)
    View adult BNF View SPC online View childrens BNF
    Formulary
    Green

    Tablet

    • Second line behind generic alendronate / zoledronic acid
    • Licensed for treatment of osteoporosis. Prevention of osteoporosis post menopause only daily licensed
    • Green - Treatment of post menopausal osteoporosis.
    • Follow local osteoporosis guidelines and NICE guidance.
     
       
    Clodronate
    View adult BNF View SPC online View childrens BNF
    Formulary
    Amber 2

    Capsule - 400mg
    Tablet - 520mg or 800mg

    • Amber 2 - Hypercalcaemia, bone pain associated with metastases
    • Not licensed for osteoporosis
     
       
    Ibandronic Acid
    (osteoporosis)
    View adult BNF View SPC online View childrens BNF
    Restricted Drug Restricted
    Amber 2

    150mg tablet (monthly)

     
    Link  Link to reviews
       
    Ibandronic Acid
    (oncology)
    View adult BNF View SPC online View childrens BNF
    Restricted Drug Restricted
    Amber 2
    50mg tablet (daily)
  • Restricted for oncology patients
  • Amber 2 - Reduction of bone damage in bone metastases in breast cancer  
  •    
    Ibandronic Acid injection (Bonviva®)
    View adult BNF View SPC online View childrens BNF
    Restricted Drug Restricted
    Red
    Injection
    NUH:
  • Restricted for osteoporosis in patients intolerant of oral bisphosphonate or in place of disodium pamidronate, which is unlicensed
    SFH:
  • For initiation only by osteoporosis specialist for patients in whom yearly zoledronic acid isn't suitable.
  • Red - as per local osteoporosis guidance and notes above
     
  • Link  Click here for independent reviews
    Link  MHRA: osteonecrosis of the jaw - risk minimisation (July 15)
       
    Pamidronate
    View adult BNF View SPC online View childrens BNF
    Restricted Drug Restricted
    Red
    Infusion. Secondary care only, not licensed for osteoporosis
  • NUH: First line for tumour-induced hypercalcaemia
  • SFH: Stocked for use in paediatrics (unlicensed) and Paget's disease.
  • SFH: Administration information
     
  • Link  MHRA: osteonecrosis of the jaw - risk minimisation (July 15)
       
    Risedronate
    (daily for Paget's)
    View adult BNF View SPC online View childrens BNF
    Restricted Drug Restricted
    Amber 2
    Tablet
  • For Paget's disease of the bone
     
  •    
    Zoledronic Acid (4mg - hypercalcaemia/malignancy)
    View adult BNF View SPC online View childrens BNF
    Formulary
    Red
    Infusion - 4mg
  • SFH: First line for tumour-induced hypercalcaemia
  • Reduction of bone damage in advanced malignancies involving bone, hypercalcaemia of malignancy
     
  • Link  Osteonecrosis of the jaw patient reminder cards
    Link  SFH: Zoledronic acid for hypercalcaemia
       
    06.06.02  Denosumab to top
    Denosumab (Prolia®)
    (osteoporosis)
    View adult BNF View SPC online View childrens BNF
    Restricted Drug Restricted
    Red
  • For initiation only by osteoporosis specialists in post menopausal women as per NICE guidance for patients in whom IV bisphosphonates aren't suitable.
  • Use in men is awaiting confirmation of secondary care funding at both NUH and SFHFT.
  • Amber Traffic Light (Amber 2) For a limited number of patients (maximum of 5 patients over 12 months) within Rushcliffe CCG. 
  • Link  MHRA Drug Safety Update (June 2017)
    Link  NICE TA204: Osteoporotic fractures - denosumab
    Link  SFH: Denosumab order form for MCH osteoporosis service
    Link  Link to independent reviews
       
    Denosumab (XGEVA®)
    (metastases)
    View adult BNF View SPC online View childrens BNF
    Restricted Drug Restricted
    Red

    Solution for injection

    • Restricted for preventing skeletal related events in adults with bone metastases from breast cancer and from solid tumours other than prostate in accordance with NICE.
    • Denosumab is not recommended for preventing skeletal-related events in adults with bone metastases from prostate cancer, (this is in line with NICE).
    • ONCOLOGY patients treated on WTC: XGEVA brand only. Denosumab and calcium supplements are prescribed on ChemoCare. Pharmacists to screen per SPC. Denosumab stocked on WTC (no need to dispense). Adcal D3 or Calcichew D3 tablets both can be supplied (Chemocare prescriptions can be amended according to the brand availability)

     
    Link  MHRA Drug Safety Update (June 2017)
    Link  Denosumab for giant cell tumour of bone - hypercalcaemia risk after stopping
    Link  Drug Safety Update June 2018- risk of primary malignancy
    Link  Link to reviews
    Link  NICE: Bone metastases from solid tumours - denosumab: guidance (TA265 )
       
    06.06.02  Strontium ranelate
    06.07  Other endocrine drugs
    06.07.01  Bromocriptine and other dopaminergic drugs
    Bromocriptine
    (Hyperprolactinaemia)
    View adult BNF View SPC online View childrens BNF
    Formulary
    Amber 2

    Tablet 2.5mg

    • Not recommended in post partum lactation suppression: BNF62 - Should not be used postpartum or in puerperium in women with high blood pressure, coronary artery disease, or symptoms (or history) of serious mental disorder; monitor blood pressure carefully (especially during first few days) in postpartum women. Very rarely hypertension, myocardial infarction, seizures or stroke (both sometimes preceded by severe headache or visual disturbances), and mental disorders have been reported in postpartum women given bromocriptine for lactation suppression—caution with antihypertensive therapy and avoid other ergot alkaloids. Discontinue immediately if hypertension, unremitting headache, or signs of CNS toxicity develop
    • Amber 2 - Parkinson's disease see section 4.9.1
     
    Link  See unexpectedly expensive medicines list
       
    Cabergoline
    (Hyperprolactinaemia)
    View adult BNF View SPC online View childrens BNF
    Formulary
    Amber 2
    Tablet
  • BNF 62 - Suppression of lactation. Although bromocriptine and cabergoline are licensed to suppress lactation, they are not recommended for routine suppression (or for the relief of symptoms of postpartum pain and engorgement) that can be adequately treated with simple analgesics and breast support. If a dopamine-receptor agonist is required, cabergoline is preferred.
  • Amber 2 - Parkinson's disease see section 4.9.1 
  •    
    06.07.02  Drugs affecting gonadotrophins
     note 

    GnRH analogues (including goserelin) for the treatment of patients with gender dysphoria are classified as Amber 2 (Specialist initiation) in line with NHS England guidance (pg 30-31) Dosing and monitoring information is contained in the Royal College of Psychiatrists guidelines (see page 39 onwards).

    Cetrorelix (Cetrotide®)
    View adult BNF View SPC online View childrens BNF
    Restricted Drug Restricted
    Red
    Injection
    Restricted for use by Nurture clinic
    Red - Treatment of infertility
     
       
    Danazol
    View adult BNF View SPC online View childrens BNF
    Formulary
    Amber 2
    Capsule
     
       
    06.07.02  Gonadorelin analogues to top
    Buserelin
    (Infertility/ endometriosis)
    View adult BNF View SPC online View childrens BNF
    Restricted Drug Restricted
    Red
    Nasal spray - for endometriosis restricted to NUH only
    Injection - Restricted to Nurture clinic only as per approved guidelines
  • For malignant disease indications See section 8.3.4.2 
  •    
    Nafarelin
    View adult BNF View SPC online View childrens BNF
    Restricted Drug Restricted
    Red
    Nasal spray
  • Restricted for use by Nurture clinic
  • Red - Treatment of infertility, restricted to Nuture clinic 
  •    
    Triptorelin
    (Non- malignant indications)
    View adult BNF View SPC online View childrens BNF
    Formulary
    Red
    Decapeptyl® SR:
    Injection MR 3mg - 1 monthly
    Injection MR 11.25mg - 3 monthly
    (The slightly different doses are due to whether or not it includes the overage and is caused by European labelling rules)
  • Traffic light classifications:
    Red - Gynae indications
    Red - Chronic pain of unknown origin
    Red - Precocious puberty
  • For malignant disease indications see section 8.3.4.2 
  • Link  Click here for independent reviews
       
    Ulipristal (Esmya®)
    (fibroids)
    View adult BNF View SPC online View childrens BNF
    Formulary
    Red

    Tablets.

    • Updated licensed indication and restrictions Aug 18 -see MHRA advice
    • SFH: Send prescriptions to SFH Pharmacy for supply. Normally initially supplied in monthly instalments in case of intolerance.
    • Request for traffic light re-classification to Amber 2 not supported by commissioners, July 2017
     
    Link  Link to reviews
    Link  MHRA safety alert - Esmya (ulipristal acetate) for symptoms of uterine fibroids: restrictions to use and requirement to check liver function before, during and after treatment
    Link  NICE guidelines on heavy menstrual bleeding
       
    06.07.02  Breast pain (mastalgia)
    06.07.03  Metyrapone
    Metyrapone (Metopirone®)
    View adult BNF View SPC online View childrens BNF
    Restricted Drug Restricted Capsule
    Restricted for endocrinology use only
    Amber 2 - Cushings syndrome
    Grey - resistant oedema due to increased aldosterone secretion in cirrhosis, nephrotic syndrome, and congestive heart failure (with glucocorticoid replacement therapy) 
       
    06.07.04  Somatomedins
     ....
     Non Formulary Items
    Abaloparatide

    View adult BNF View SPC online View childrens BNF
    Non Formulary
    Grey
    No formal assessment (APC March 2016)
     
    Albiglutide  (Eperzan®)

    View adult BNF View SPC online View childrens BNF
    Non Formulary
    Grey
    Global discontinuation July 2018
    Link  Link to reviews
     
    Alendronic Acid
    (Once Daily)

    View adult BNF View SPC online View childrens BNF
    Non Formulary
    Grey
     
    Alendronic Acid with colecalciferol  (Fosavance®)

    View adult BNF View SPC online View childrens BNF
    Non Formulary
    Grey
    Tablet
  • Needs to be given with daily calcium, and Adcal D3 contains sufficient vit D.
  • Costs £23pm. (vs £1.30 for alendronate alone)
  •  
    Alogliptin / pioglitazone  (Incresync®)

    View adult BNF View SPC online View childrens BNF
    Non Formulary
    Grey
  • Non formulary. Grey traffic lighted (APC Jan14)
  •  
    Angeliq®  (Combined continuous HRT tablet)

    View adult BNF View SPC online View childrens BNF
    Non Formulary
    Grey
    Contains estradiol 1mg and drospirenone 2mg
    Link  Link to reviews
     
    Armour thyroid®

    View adult BNF View SPC online View childrens BNF
    Non Formulary
    Grey
  • Combination of levothyroxine and liothyronine
  • Not Recommended
  • Link  UKMI Q&A: What clinical evidence is there for “Armour thyroid” or desiccated thyroid extract?
     
    Bazedoxifene/conjugated oestrogens  (Duavive®)

    View adult BNF View SPC online View childrens BNF
    Non Formulary
    Grey
    • No formal assessment
    • Due to be discontinued Decmeber 2019
    Link  Link to reviews
     
    Bedol®  (Oestrogen only HRT tablet)

    View adult BNF View SPC online View childrens BNF
    Non Formulary
    Grey
     
    Betamethasone  (Betnelan®)

    View adult BNF View SPC online View childrens BNF
    Non Formulary
    Grey
    Tablet
    Soluble tablets available as Betnesol® (APC: July 2011)
     
    Betamethasone  (Betnesol®)
    (injection - systemic)

    View adult BNF View SPC online View childrens BNF
    Non Formulary
    Red
    Injection
    Link  Withdrawal of steroids advice (BNF)
     
    Biosimilar Insulin Lispro 100 units/ml

    View adult BNF View SPC online View childrens BNF
    Non Formulary
    Grey

    No formal assessment.

     
    Biphasic Isophane Insulin  (Hypurin® Porcine 30/70 Mix)

    View adult BNF View SPC online View childrens BNF
    Non Formulary
    Grey
    10ml vial
    3ml cartridge
     
    Biphasic Isophane Insulin  (Mixtard® 30)

    View adult BNF View SPC online View childrens BNF
    Non Formulary
    Grey
  • Discontinued from 31 December 2010
  • Mixtard® 10, 20, 40 and 50 and Pork Mixtard 30 all discontinued prior to 2010.
  • Link  Notts County PCT letter to clinicians on Mixtard discontinuation
     
    Calcitonin (salmon) / Salcatonin
    (Nasal spray)

    View adult BNF View SPC online View childrens BNF
    Non Formulary
    Grey
  • Due to be withdrawn. More info
  • Link  Link to reviews
    Link  MHRA recall (April13) - product withdrawn throughout EU
     
    Canagliflozin / metformin IR  (Vokanamet®)

    View adult BNF View SPC online View childrens BNF
    Non Formulary
    Grey
  • GREY, no formal assessment (APC Horizon Scanning July 2014)
  • Link  Link to reviews
     
    Chlorpropamide

    View adult BNF View SPC online View childrens BNF
    Non Formulary
    Grey
     
    Chorionic Gonadotrophin  (Choragon®)

    View adult BNF View SPC online View childrens BNF
    Non Formulary
    Grey
     
    Climagest®  (Combined cyclical HRT tablet)

    View adult BNF View SPC online View childrens BNF
    Non Formulary
    Grey
    Discontinued
     
    Climaval®  (Oestrogen only HRT tablet)

    View adult BNF View SPC online View childrens BNF
    Non Formulary
    Grey
    Discontinued Jan 2016
     
    Climesse®  (Combined continuous HRT tablet)

    View adult BNF View SPC online View childrens BNF
    Non Formulary
    Grey
    Discontinued
     
    Clinorette®  (Combined cyclical HRT tablet)

    View adult BNF View SPC online View childrens BNF
    Non Formulary
    Grey
    Contains same active ingredients as Elleste Duet® (see above).
     
    Corifollitropin Alfa  (Elonva®)

    View adult BNF View SPC online View childrens BNF
    Non Formulary
    Grey
     
    Cortisone Acetate
    (Cortisone)

    View adult BNF View SPC online View childrens BNF
    Non Formulary
    Grey
     
    Cyclo-Progynova®  (Combined cyclical HRT tablet)

    View adult BNF View SPC online View childrens BNF
    Non Formulary
    Grey
     
    Dapagliflozin / metformin  (Xigduo®)

    View adult BNF View SPC online View childrens BNF
    Non Formulary
    Grey
    • Use components separately
    Link  Link to reviews
     
    Deflazacort  (Calcort®)

    View adult BNF View SPC online View childrens BNF
    Non Formulary
    Grey
     
    Dienogest

    View adult BNF View SPC online View childrens BNF
    Non Formulary
    Grey
  • No formal submission
  • UK launch expected Q3 2012
  •  
    Disodium Etidronate  (Didronel PMO®)

    View adult BNF View SPC online View childrens BNF
    Non Formulary
    Grey
     
    Droplet
    (Needles for insulin pens)

    View adult BNF View SPC online View childrens BNF
    Non Formulary
    Grey
    • Replaced by BD Viva, July 18
     
    Dydrogesterone  (Duphaston®)

    View adult BNF View SPC online View childrens BNF
    Non Formulary
    Grey
    Tablet
     
    Elleste-Duet Conti®  (Combined continuous HRT tablet)

    View adult BNF View SPC online View childrens BNF
    Non Formulary
    Grey
    Contains same active ingredients as Kliofem®- see above (APC July 2011).
     
    Empagliflozin + linagliptin  (Glyxambi®)

    View adult BNF View SPC online View childrens BNF
    Non Formulary
    Grey

    No formal assessment

     
    Empagliflozin and Metformin  (Synjardy®)

    View adult BNF View SPC online View childrens BNF
    Non Formulary
    Grey

    No formal assessment

     
    Ertugliflozin + metformin  (Segluromet®)

    View adult BNF View SPC online View childrens BNF
    Non Formulary
    Grey

    No formal assessment

     
    Ertugliflozin + sitagliptin  (Steglujan®)

    View adult BNF View SPC online View childrens BNF
    Non Formulary
    Grey

    No formal assessment

     
    Estracombi®  (Combined cyclical HRT patch)

    View adult BNF View SPC online View childrens BNF
    Non Formulary
    Grey
    Discontinued
     
    Estraderm MX®
    (Oestrogen only HRT patch)

    View adult BNF View SPC online View childrens BNF
    Non Formulary
    Grey
     
    Estraderm TTS®  (Oestrogen only HRT patch)

    View adult BNF View SPC online View childrens BNF
    Non Formulary
    Grey
    TTS 25 and TTS 100 Discontinued Jan 2012
     
    Estradiol implant

    View adult BNF View SPC online View childrens BNF
    Non Formulary
    Green
  • Discontinued July 2011. See SFH memo July 2011.
  • Unlicensed 25mg and 50mg implants were available from abroad but do not have satisfactory quality assurance.
  •  
    Femapak®
    (Combined cyclical HRT)

    View adult BNF View SPC online View childrens BNF
    Non Formulary
    Grey
    Discontinued
     
    Fematrix®  (Oestrogen only HRT patch)

    View adult BNF View SPC online View childrens BNF
    Non Formulary
    Grey
    Discontinued Aug 2012
     
    FemSeven®  (Oestrogen only HRT patch)

    View adult BNF View SPC online View childrens BNF
    Non Formulary
    Grey
     
    FemSeven® Conti  (Combined continuous HRT patch)

    View adult BNF View SPC online View childrens BNF
    Non Formulary
    Grey
     
    FemSeven® Sequi  (Combined cyclical HRT patch)

    View adult BNF View SPC online View childrens BNF
    Non Formulary
    Grey
     
    FemTab®  (Oestrogen only HRT tablet)

    View adult BNF View SPC online View childrens BNF
    Non Formulary
    Grey
    Discontinued
     
    FemTab® Sequi
    (Combined cyclical HRT tablet)

    View adult BNF View SPC online View childrens BNF
    Non Formulary
    Grey
    Discontinued
     
    FinePoint
    (Needles for insulin pens)

    View adult BNF View SPC online View childrens BNF
    Non Formulary
    Grey
    • Replaced by GlucoRx Carepoint July 18
     
    Follitropin Alfa and Beta  (Puregon®)

    View adult BNF View SPC online View childrens BNF
    Non Formulary
    Grey
     
    Follitropin delta  (Rekovelle®)

    View adult BNF View SPC online View childrens BNF
    Non Formulary
    Grey
    No formal assessement (APC March 2016)
     
    Ganorelix  (Orgalutran®)

    View adult BNF View SPC online View childrens BNF
    Non Formulary
    Grey
     
    Gestrinone  (Dimetriose®)

    View adult BNF View SPC online View childrens BNF
    Non Formulary
    Grey
     
    Glibenclamide

    View adult BNF View SPC online View childrens BNF
    Non Formulary
    Grey
    • Glibenclamide tablets discontinued - see link below for details
    • Tablets disperse in water if needed. See here for general advice on dispersing tablets.
    • Also known as glyburide
    Link  SPS: Discontinuation of glibenclamide
     
    Glimepiride

    View adult BNF View SPC online View childrens BNF
    Non Formulary
    Grey
     
    Glipizide

    View adult BNF View SPC online View childrens BNF
    Non Formulary
    Grey
     
    Gliquidone  (Glurenorm®)

    View adult BNF View SPC online View childrens BNF
    Non Formulary
    Grey
     
    Goserelin
    (Non- malignant indications)

    View adult BNF View SPC online View childrens BNF
    Non Formulary
    Red
  • Triptorelin preferred for all indications except breast cancer
  • For malignant disease indications See section 8.3.4.2
  • Classified Red for the treatment of infertility and Gynaecological conditions
  • See notes above for the treatment of patients with gender dysphoria
  •  
    Harmogen®
    (Oestrogen only HRT tablet)

    View adult BNF View SPC online View childrens BNF
    Non Formulary
    Grey
    Discontinued
     
    Hormonin®
    (Oestrogen only HRT tablet)

    View adult BNF View SPC online View childrens BNF
    Non Formulary
    Grey
    Discontinued
     
    Human Menopausal Gonadotrophins  (Menogon®)

    View adult BNF View SPC online View childrens BNF
    Non Formulary
    Grey
     
    Hydrocortisone MR  (Plenadren)

    View adult BNF View SPC online View childrens BNF
    Non Formulary
    Grey
  • No formal submission
  • Link  Link to reviews
    Link  Surgery and steroids advice (BNF)
    Link  Withdrawal of steroids advice (BNF)
     
    Ibandronic acid IV infusion  (Bondronat®)

    View adult BNF View SPC online View childrens BNF
    Non Formulary
    Grey
    Reduction of bone damage in bone metastases in breast cancer
     
    Indivina®
    (Combined continuous HRT tablet)

    View adult BNF View SPC online View childrens BNF
    Non Formulary
    Grey
     
    Injection Devices  (Autopen®)

    View adult BNF View SPC online View childrens BNF
    Non Formulary
    Grey
    Link  MHRA: Recall of certain batches of Autopen, Dec 14
     
    Injection Devices  (HumaPen® Ergo)

    View adult BNF View SPC online View childrens BNF
    Non Formulary
    Grey
     
    Injection Devices  (HumaPen® Luxura)

    View adult BNF View SPC online View childrens BNF
    Non Formulary
    Grey
     
    Injection Devices  (mhi-500®)

    View adult BNF View SPC online View childrens BNF
    Non Formulary
    Grey
     
    Injection Devices  (NovoPen®)

    View adult BNF View SPC online View childrens BNF
    Non Formulary
    Grey
     
    Injection Devices  (OptiPen Pro 1®)

    View adult BNF View SPC online View childrens BNF
    Non Formulary
    Grey
     
    Injection Devices  (SQ-PEN®)

    View adult BNF View SPC online View childrens BNF
    Non Formulary
    Grey
     
    Insulin  (Exubera®)

    View adult BNF View SPC online View childrens BNF
    Non Formulary
    Grey
    Inhaled insulin. Withdrawn from market 2007.
    Link  Link to reviews
     
    Insulin  (Insuman® Infusat)

    View adult BNF View SPC online View childrens BNF
    Non Formulary
    Grey
  • No formal assessement
  •  
    Insulin  (Pork Actrapid®)

    View adult BNF View SPC online View childrens BNF
    Non Formulary
    Grey
     
    Insulin  (Velosulin®)

    View adult BNF View SPC online View childrens BNF
    Non Formulary
    Grey
     
    Insulin bovine  (Hypurin® Bovine Neutral)

    View adult BNF View SPC online View childrens BNF
    Non Formulary
    Grey
    • Discontinued 2017.
     
    Insulin degludec and liraglutide  (Xultophy®)

    View adult BNF View SPC online View childrens BNF
    Non Formulary
    Grey
  • Classified in APC Jan 2016
  • Link  Link to reviews
     
    Insulin degludec with insulin aspart  (DegludecPlus)

    View adult BNF View SPC online View childrens BNF
    Non Formulary
    Grey
  • No formal submission
  •  
    Insulin Lispro 200 units/ml  (Humalog®)

    View adult BNF View SPC online View childrens BNF
    Non Formulary
    Grey
    No formal assessment
     
    Isophane Insulin  (Pork Insulatard®)

    View adult BNF View SPC online View childrens BNF
    Non Formulary
    Grey
     
    Ketoconazole  (Ketoconazole HRA)

    View adult BNF View SPC online View childrens BNF
    Non Formulary
    Grey
    No formal submission
     
    Leuprorelin
    (Non- malignant indications)

    View adult BNF View SPC online View childrens BNF
    Non Formulary
    Red
  • Triptorelin preferred
  • For malignant disease indications see section 8.3.4.2
  • Classified red for the treatment of infertility and Gynaecological conditions
  •  
    Liothyronine (oral)
    (Triiodothyronine)

    View adult BNF View SPC online View childrens BNF
    Non Formulary
    Grey

    Tablets

    Link  NHS England: Items which should not be routinely prescribed in primary care
    Link  RMOC Liothyronine guidance
    Link  See unexpectedly expensive medicines list
    Link  Switching liothyronine to levothyroxine PrescQIPP advice
    Link  Switching T3 to T4 - Frequently Asked Questions for GP’s (British Thyroid Association)
    Link  Switching T3 to T4 - Frequently Asked Questions for patients (British Thyroid Association)
    Link  Switching T3 to T4 - Information for Endocrinologists (British Thyroid Association)
    Link  Switching T3 to T4 - Notts APC guide for patients
     
    Lixisenatide+ insulin glargine  (Suliqua®)

    View adult BNF View SPC online View childrens BNF
    Non Formulary
    Grey

    No formal assessment

     
    Lucozade®

    View adult BNF View SPC online View childrens BNF
    Non Formulary
    Grey
  • Sugar content reduced by 50% from 1st April 2017 so no longer recommended for glucose tolerance tests - consider Polycal®.
  • Link  SFH: Glucose Tolerance Test
     
    Lutropin Alfa  (Luveris®)

    View adult BNF View SPC online View childrens BNF
    Non Formulary
    Red
     
    Mecasermin  (Increlex®)

    View adult BNF View SPC online View childrens BNF
    Non Formulary
    Grey
    High Cost Medicine
    Link  Commissioning Policy - Mecasermin in Growth Failure
     
    Mesterolone  (Pro-Viron®)

    View adult BNF View SPC online View childrens BNF
    Non Formulary
    Grey
    Classified grey for androgen deficiency and male infertility associated with hypogonadism
     
    Metformin & pioglitazone  (Competact®)

    View adult BNF View SPC online View childrens BNF
    Non Formulary
    Grey
     
    Nandrolone  (Deca-Durabolin®)

    View adult BNF View SPC online View childrens BNF
    Non Formulary
    Grey
    Classified grey for osteoporosis in post menopausal women
     
    Nateglinide  (Starlix®)

    View adult BNF View SPC online View childrens BNF
    Non Formulary
    Grey
     
    Novofem®
    (Combined cyclical HRT tablet)

    View adult BNF View SPC online View childrens BNF
    Non Formulary
    Grey
    Contains same active ingredients as Elleste Duet® (see above).
     
    Nuvelle®  (Combined cyclical HRT tablet)

    View adult BNF View SPC online View childrens BNF
    Non Formulary
    Grey
    Discontinued
     
    Ovestin®
    (Oestrogen only HRT tablet)

    View adult BNF View SPC online View childrens BNF
    Non Formulary
    Grey
    Discontinued
     
    Parathyroid Hormone  (Natpar®)

    View adult BNF View SPC online View childrens BNF
    Non Formulary
    Grey

    Injection

     
    Parathyroid Hormone  (Preotact®)

    View adult BNF View SPC online View childrens BNF
    Non Formulary
    Grey
    High Cost Medicine

    Injection

    Withdrawal of the marketing authorisation for Preotact® brand in the EU in 2014.

     
    Pasireotide

    View adult BNF View SPC online View childrens BNF
    Non Formulary
    Grey
    High Cost Medicine
    Link  Link to reviews
     
    Pegvisomant  (Somavert®)

    View adult BNF View SPC online View childrens BNF
    Non Formulary
    Red
    High Cost Medicine
    Link  Link to reviews
     
    Penfine classic
    (Needles for insulin pens)

    View adult BNF View SPC online View childrens BNF
    Non Formulary
    Grey
    • Replaced by BD Viva, July 18
     
    Pioglitazone and Metfomin  (Competact®)

    View adult BNF View SPC online View childrens BNF
    Non Formulary
    Grey
     
    Prednisone MR
    (Lodotra)

    View adult BNF View SPC online View childrens BNF
    Non Formulary
    Grey
    Link  Link to reviews
    Link  Surgery and steroids advice (BNF)
    Link  Withdrawal of steroids advice (BNF)
     
    Progesterone  (Crinone®)

    View adult BNF View SPC online View childrens BNF
    Non Formulary
    Grey
     
    Progesterone  (Lubion®)

    View adult BNF View SPC online View childrens BNF
    Non Formulary
    Grey

    No formal assessment

     
    Progestogen (microionised) oral/ vaginal capsules  (Utrogestan ®)

    View adult BNF View SPC online View childrens BNF
    Non Formulary
    Grey
    No formal submission
     
    Progynova®  (Oestrogen only HRT tablet)

    View adult BNF View SPC online View childrens BNF
    Non Formulary
    Grey
    APC July 2011
     
    Progynova® TS
    (Oestrogen only HRT patch)

    View adult BNF View SPC online View childrens BNF
    Non Formulary
    Grey
    APC July 2011
     
    Protamine Zinc Insulin  (Hypurin® Bovine Protamine Zinc)

    View adult BNF View SPC online View childrens BNF
    Non Formulary
    Grey
  • Discontinued 2017 - possible availability until 2018
  •  
    Quinagolide

    View adult BNF View SPC online View childrens BNF
    Non Formulary
    Grey
     
    Repaglinide  (Prandin®)

    View adult BNF View SPC online View childrens BNF
    Non Formulary
    Grey
     
    Rosiglitazone  (Avandia®)

    View adult BNF View SPC online View childrens BNF
    Non Formulary
    Grey
    WITHDRAWN SEPT 2010
    Link  Link to reviews
    Link  MHRA withdrawal information
     
    Rosiglitazone and Metformin  (Avandamet®)

    View adult BNF View SPC online View childrens BNF
    Non Formulary
    Grey
     
    Sandrena®  (Estradiol gel)

    View adult BNF View SPC online View childrens BNF
    Non Formulary
    Grey
    Oestrogel® is topical oestrogen gel of choice (see above)
     
    Saxagliptin  (Onglyza®)

    View adult BNF View SPC online View childrens BNF
    Non Formulary
    Grey
    Tablet
  • Existing stable patients may continue treatment. Changed to non-formulary May 2013
  • Link  Click here for independent reviews
    Link  Link to reviews
    Link  Risk of acute pancreatitis. MHRA safety update Sept 12
    Link  Serious hypersensitivity reactions & acute pancreatitis - Dear HCP Letter
     
    Saxagliptin and dapagliflozin  (Qtern®)

    View adult BNF View SPC online View childrens BNF
    Non Formulary
    Grey
    No formal assessment
     
    Saxagliptin and metformin  (Komboglyze®)

    View adult BNF View SPC online View childrens BNF
    Non Formulary
    Grey
  • No formal submission
  • Link  Link to reviews
     
    Sermorelin  (Geref 50®)

    View adult BNF View SPC online View childrens BNF
    Non Formulary
    Red
     
    Strontium Ranelate

    View adult BNF View SPC online View childrens BNF
    Non Formulary
    Grey
    • Strontium ranelate Aristo 2g granules for oral suspension - GREY, no formal assessment.
    • Protelos brand discontinued worldwide August 2017 - Information and management. Amended to GREY following review at APC May 2017
    Link  Click here for independent reviews
    Link  DTB review (password required)
    Link  MHRA: Strontium warnings about cardiac disorders
    Link  SFH: Letter to clinicians about strontium restrictions (2014)
     
    Testosterone and Esters
    (Testosterone enantate)

    View adult BNF View SPC online View childrens BNF
    Non Formulary
    Grey

    Testogel® and Testavan® non-formulary

    Sustanon 100® injection discontinued 2009

    Andropatch® brand discontinued 2010

    Intrinsa® discontinued 2012

    Striant® SR discontinued 2013

    Virormone® discontinued 2013

    Testim® discontinued 2018

     

     

     
    Testosterone gel  (Testavan®)

    View adult BNF View SPC online View childrens BNF
    Non Formulary
    Grey

    Gel

    • Tostran® brand is the preferred product.
     
    Tiludronic Acid  (Skelid®)

    View adult BNF View SPC online View childrens BNF
    Non Formulary
    Grey
    Grey for Paget's disease of bone
     
    Tolbutamide

    View adult BNF View SPC online View childrens BNF
    Non Formulary
    Grey
    Tablet
  • Tablets disperse in water if needed. See here for general advice on dispersing tablets. Liquid can be made specially if required.
  •  
    Tolvaptan  (Samsca®)

    View adult BNF View SPC online View childrens BNF
    Non Formulary
    Grey
    High Cost Medicine
  • SFH: Not stocked in Pharmacy. In patients with intractable severe hyponatraemia due to SIADH not responding to conventional treatments, consultant endocrinologist to discuss with Medicines Information (3163). Tolvaptan is excluded from Tariff but is NOT routinely commissioned; if it is used then the Trust would bear the cost unless an IFR is approved by NHS E.
  • Costs £1000 a box of 10 tablets
  • NUH: Tolvaptan is non-formulary as it is excluded from Tariff but NOT routinely commissioned. Consultant endocrinologist should follow one off request procedure if required.
  • Link  Click here for independent reviews
    Link  Hyponatraemia treatment (flowchart)
    Link  Hyponatraemia treatment (full guideline)
    Link  NICA TA358: Autosomal dominant polycystic kidney disease - tolvaptan
     
    Treatment of hypoglycaemia  (Rapilose® gel)

    View adult BNF View SPC online View childrens BNF
    Non Formulary
    Grey
     
    Triamcinolone  (Kenalog®)
    (Hayfever)

    View adult BNF View SPC online View childrens BNF
    Non Formulary
    Grey
    Not recommended by DTB or local specialists (APC Sept 14)
     
    Tridestra®
    (Combined cyclical HRT tablet)

    View adult BNF View SPC online View childrens BNF
    Non Formulary
    Grey
     
    Trilostane  (Modrenal®)

    View adult BNF View SPC online View childrens BNF
    Non Formulary
    Grey
    Grey - Adrenal cortical hyperfunction, postmenopausal breast cancer (specialist supervision)
     
    Triptorelin  (Gonapeptyl Depot®)

    View adult BNF View SPC online View childrens BNF
    Non Formulary
    Grey
    See above for Decapeptyl SR
     
    Triptorelin  (Salvacyl®)

    View adult BNF View SPC online View childrens BNF
    Non Formulary
    Grey
     
    Trisequens®
    (Combined cyclical HRT tablet)

    View adult BNF View SPC online View childrens BNF
    Non Formulary
    Grey
     
    Urofollitropin

    View adult BNF View SPC online View childrens BNF
    Non Formulary
    Red
    Link  Link to reviews
     
    Vildagliptin

    View adult BNF View SPC online View childrens BNF
    Non Formulary
    Grey
    Link  Link to reviews
     
    Vildagliptin and Metformin  (Eucreas®)

    View adult BNF View SPC online View childrens BNF
    Non Formulary
    Grey

    Tablet

    Grey - non formulary (APC Jul19)

     
    Zumenon®
    (Oestrogen only HRT tablet)

    View adult BNF View SPC online View childrens BNF
    Non Formulary
    Grey
     
      
    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
    Cytotoxic Drug
    Cytotoxic Drug
    CD
    Controlled Drug
    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

    Grey

    Grey / Non-Formulary: Medicines, which the Nottinghamshire APC has actively reviewed and does not recommend for use at present due to limited clinical and/or cost effective data.
    Grey / Non-Formulary (undergoing assessment): Work is ongoing and will be reviewed at a future APC meeting.
    Grey / Non-Formulary (no formal assessment): APC has not formally reviewed this medicine or indication because it had never been requested for formulary inclusion. Often used for drugs new to market.
      

    Red

    Medicines which should normally be prescribed by specialists only. eg hospital only.
    For patients already receiving prescriptions in primary care - continue. No new patients to receive prescriptions in primary care.
      

    Amber 1

    Medicines that should be initiated by a specialist and prescribed by primary care prescribers only under a shared care protocol, once the patient has been stabilised.
    Prior agreement must be obtained by the specialist from the primary care provider before prescribing responsibility is transferred. The shared care protocol must have been agreed by the relevant secondary care trust Drugs and Therapeutics Committee(s) (DTC) and approved by the Nottinghamshire APC.
      

    Amber 2

    Medicines suitable to be prescribed in primary care / general practice after specialist* recommendation or initiation.
    A supporting prescribing guideline may be requested which must have been agreed by the relevant secondary care trust DTCs and approved by the Nottinghamshire APC.
    *Specialist is defined by the APC as a clinician who has undertaken an appropriate formal qualification or recognised training programme within the described area of practice
      

    Amber 3

    Primary care/ non specialist may initiate as per APC guideline.
    The supporting prescribing guideline must have been agreed by the relevant secondary care trust D&TC(s) and approved by the Nottinghamshire APC.
      

    Green

    Medicines suitable for routine use within primary care.
    Can be initiated within primary care within their licensed indication, in accordance with nationally recognised formularies, for example the BNF, BNF for Children, Medicines for Children or Palliative Care Formulary. Primary care prescribers take full responsibility for prescribing.   

    OTC

      

    netFormulary