Formulary Chapter 6: Endocrine system - Full Chapter
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Chapter Links... |
NICE NG28: Type 2 diabetes in adults: management |
DVLA guidance |
NICE Guidance on prescribing |
Details... |
06.01.02 |
Antidiabetic drugs |
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06.01.02.01 |
Sulphonyureas |
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Gliclazide (Oral presentations)
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Formulary
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- Tablets
- Modified Release Tablets
Check OptimiseRx for most cost effective brand
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NG28 :Type 2 diabetes in adults: management
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Tolbutamide
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Formulary
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Glimepiride
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Formulary
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06.01.02.02 |
Biguanides |
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Metformin (Powder)
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Second Choice
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Patients with swallowing difficulties
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NICE NG28: Type 2 diabetes in adults: management
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Metformin (Oral Solution SF)
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Second Choice
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For patients with swallowing difficulties only.
Tablets more cost effective.
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NICE NG28: Type 2 diabetes in adults: management
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Metformin (Tablets)
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Formulary
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NICE NG28: Type 2 diabetes in adults: management
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Metformin (M/R tablets)
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Formulary
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Check Optimise Rx for most cost effective brand
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NICE NG28: Type 2 diabetes in adults: management
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06.01.02.03 |
Other antidiabetic drugs |
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Alogliptin with Metformin (Vipdomet)
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Formulary
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A variety of combinations tablets (dual therapies) of oral diabetes medication can be prescribed and are available in the Drug Tariff.
Overall, they may improve compliance in patients, however some combinations would then not allow the flexibility in dosing that is required for diabetes management and in some cases increase the tablet burden. There are specific sick-day rules related to stopping certain medication which would be further complicated where they are not prescribed in their separate formulations.
Furthermore, for the overall health economy not all combination therapies are cost-effective and this will be increasingly so as the patents expire over the near future.
There are some combination therapies that are not recommended in the oral guidance and clinicians are guided to review and discuss these with patients as part of shared -care decision making.
There are complexities also around the lack of licensing of dual therapies in specific cohorts of patients, related to prescribing for the indication of heart failure or renal disease, making this a complex area for prescribing in primary care.
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Canagliflozin/Metformin (Vokanamet)
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Formulary
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Dapagliflozin / Metformin (Xigduo)
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Formulary
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Empagliflozin / Metformin (Synjardy )
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Formulary
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Linagliptin/ Metformin (Jentadueto )
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Formulary
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A variety of combinations tablets (dual therapies) of oral diabetes medication can be prescribed and are available in the Drug Tariff.
Overall, they may improve compliance in patients, however some combinations would then not allow the flexibility in dosing that is required for diabetes management and in some cases increase the tablet burden. There are specific sick-day rules related to stopping certain medication which would be further complicated where they are not prescribed in their separate formulations.
Furthermore, for the overall health economy not all combination therapies are cost-effective and this will be increasingly so as the patents expire over the near future. There are some combination therapies that are not recommended in the oral guidance and clinicians are guided to review and discuss these with patients as part of shared -care decision making.
There are complexities also around the lack of licensing of dual therapies in specific cohorts of patients, related to prescribing for the indication of heart failure or renal disease, making this a complex area for prescribing in primary care
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Sitagliptin and Metformin
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Formulary
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A variety of combinations tablets (dual therapies) of oral diabetes medication can be prescribed and are available in the Drug Tariff.
Overall, they may improve compliance in patients, however some combinations would then not allow the flexibility in dosing that is required for diabetes management and in some cases increase the tablet burden. There are specific sick-day rules related to stopping certain medication which would be further complicated where they are not prescribed in their separate formulations.
Furthermore, for the overall health economy not all combination therapies are cost-effective and this will be increasingly so as the patents expire over the near future. There are some combination therapies that are not recommended in the oral guidance and clinicians are guided to review and discuss these with patients as part of shared -care decision making.
There are complexities also around the lack of licensing of dual therapies in specific cohorts of patients, related to prescribing for the indication of heart failure or renal disease, making this a complex area for prescribing in primary care
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06.01.02.03 |
DPP-4 inhibitors |
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06.01.02.03 |
Alpha glucosidase inhibitors |
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06.01.02.03 |
GLP-1 mimetics |
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06.01.02.03 |
DPP4 inhibitors (gliptins) |
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Sitagliptin
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First Choice
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To be used in line with NICE
First line treatment option where a DPP-4 inhibitor is indicated.
No significant clinical benefit when used in combination with Insulin – avoid using together
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MHRA: Dipeptidylpeptidase-4 inhibitors: risk of acute pancreatitis
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Alogliptin (Vipidia)
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Formulary
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In line with NICE No significant clinical benefit when used in combination with Insulin – avoid using together
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MHRA: Dipeptidylpeptidase-4 inhibitors: risk of acute pancreatitis
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Linagliptin
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Formulary
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In line with NICE Linagliptin has no significant clinical benefit or renoprotective effect in patients with CKD.
Sitagliptin should be used first line at the appropriate renal dose where a DPP4 inhibitor is indicated
No significant clinical benefit when used in combination with Insulin – avoid using together
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MHRA: Dipeptidylpeptidase-4 inhibitors: risk of acute pancreatitis
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06.01.02.03 |
SGLT2 inhibitors |
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06.01.02.03 |
GLP1 agonists |
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Dulaglutide (Trulicity)
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Formulary
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PLEASE PRESCRIBE BY BRAND - NICE Guidance on prescribing
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How to use Trulicity Pen - Video
NICE NG28: Type 2 diabetes in adults: management (Dec 2015)
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Exenatide ( prolonged-release suspension for injection)
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Formulary
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- prolonged-release suspension for injection
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NICE NG28: Type 2 diabetes in adults: management (Dec 2015)
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Liraglutide (Saxenda)
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Formulary
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PLEASE PRESCRIBE BY BRAND - NICE Guidance on prescribing
• Injection • For weight loss/ obesity • Use according to NICE guidance
The use of Liraglutide for this indication is restricted to prescribing in secondary care by a specialist multidisciplinary Tier 3 weight management service with a commercial agreement in place.
Prescribe by brand (Saxenda ®) to avoid patients inadvertently receiving a different product licensed for type 2 diabetes
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NICE TA664: Liraglutide for managing overweight and obesity
NICE NG28: Type 2 diabetes in adults: management
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Liraglutide (Victoza)
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Formulary
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PLEASE PRESCRIBE BY BRAND - NICE Guidance on prescribing
Use according to NICE guidance
For the treatment of type 2 diabetes ONLY
THIS IS FOR DIABETES ONLY. Prescribe by brand (Victoza®) to avoid patients inadvertently receiving a different product licensed for obesity.
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NICE TA664: Liraglutide for managing overweight and obesity
How to use Victoza Pen - Video
NICE NG28: Type 2 diabetes in adults: management (Dec 2015)
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Lixisenatide
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Formulary
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Semaglutide (Rybelsus▼) (Oral Tablets)
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Formulary
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PLEASE PRESCRIBE BY BRAND - NICE Guidance on prescribing
Rybelsus is a tablet for once-daily oral use but has special administration directions:
- It must be taken on an empty stomach at any time of the day.
- Patients are required to wait at least 30 minutes before eating/drinking or taking other oral medicinal products. Waiting less than 30 minutes decreases absorption.
- It should be swallowed whole with a sip of water (up to half a glass of water equivalent to 120 ml).
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Semaglutide (Wegovy )
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Formulary
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PLEASE PRESCRIBE BY BRAND - NICE Guidance on prescribing
Semaglutide is a biological medicine. Biological medicines must be prescribed and dispensed by brand name, see Biological medicines and Biosimilar medicines, under Guidance on Prescribing; manufacturer advises to record the brand name and batch number after each administration.
The use of semaglutide for this indication is restricted to prescribing by commissioned clinics in secondary care by a consultant led specialist multidisciplinary Tier 3 weight management service with a commercial agreement in place.
Prescribe by brand (Wegovy®) to avoid patients inadvertently receiving a different product licensed for type 2 diabetes.
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06.01.02.03 |
Meglitinides |
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Repaglinide
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Formulary
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06.01.02.03 |
SGL2 inhibitors |
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Canagliflozin
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Formulary
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For treating Type 2 diabetes in line with NICE, and chronic kidney disease.
Do not use SGLT2-inhibitors in patients with T1DM, regardless of CKD and/or heart failure status due to risk of DKA (diabetic ketoacidosis)
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MHRA Alert: SGLT2 inhibitors: monitor ketones in blood during treatment interruption for surgical procedures or acute serious medical illness
MHRA Alert: SGLT2 inhibitors: reports of Fourniers gangrene (necrotising fasciitis of the genitalia or perineum) (Feb 2019)
MHRA: Canagliflozin (Invokana, Vokanamet): signal of increased risk of lower extremity amputations observed in trial in high cardiovascular risk patients
MHRA: SGLT2 inhibitors (canagliflozin, dapagliflozin, empagliflozin): risk of diabetic ketoacidosis
NICE TA315: Canagliflozin in combination therapy for treating type 2 diabetes
NICE TA390: Canagliflozin, dapagliflozin and empagliflozin as monotherapies for treating type 2 diabetes
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Dapagliflozin
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Formulary
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for treating Type 2 diabetes and chronic kidney disease in line with NICE
Do not use SGLT2-inhibitors in patients with T1DM, regardless of CKD and/or heart failure status due to risk of DKA (diabetic ketoacidosis)
Treatment of all grades of symptomatic heart failure
SGLT2 inhibitors: updated advice on the risk of diabetic ketoacidosis
MHRA: SGLT2 inhibitors: updated advice on increased risk of lower-limb amputation (mainly toes)
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MHRA Alert: SGLT2 inhibitors: monitor ketones in blood during treatment interruption for surgical procedures or acute serious medical illness
NICE TA775: Dapagliflozin for treating chronic kidney disease
NICE TA679: Dapagliflozin for treating chronic heart failure with reduced ejection fraction
MHRA Alert: SGLT2 inhibitors: reports of Fourniers gangrene (necrotising fasciitis of the genitalia or perineum) (Feb 2019)
NICE TA288: Dapagliflozin in combination therapy for treating type 2 diabetes
NICE TA390: Canagliflozin, dapagliflozin and empagliflozin as monotherapies for treating type 2 diabetes
NICE TA418: Dapagliflozin in triple therapy for treating type 2 diabetes
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Empagliflozin
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Formulary
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For treating type 2 diabetes Do not use SGLT2-inhibitors in patients with T1DM, regardless of CKD and/or heart failure status due to risk of DKA (diabetic ketoacidosis)
treatment of all grades of symptomatic heart failure
SGLT2 inhibitors: updated advice on the risk of diabetic ketoacidosis
MHRA: SGLT2 inhibitors: updated advice on increased risk of lower-limb amputation (mainly toes)
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MHRA Alert: SGLT2 inhibitors: monitor ketones in blood during treatment interruption for surgical procedures or acute serious medical illness
MHRA Alert: SGLT2 inhibitors: reports of Fourniers gangrene (necrotising fasciitis of the genitalia or perineum) (Feb 2019)
MHRA: SGLT2 inhibitors (canagliflozin, dapagliflozin, empagliflozin): risk of diabetic ketoacidosis
NICE TA773: Empagliflozin for treating chronic heart failure with reduced ejection fraction
NICE TA336: Empagliflozin in combination therapy for treating type 2 diabetes
NICE TA390: Canagliflozin, dapagliflozin and empagliflozin as monotherapies for treating type 2 diabetes
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Empagliflozin/Linagliptin
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Formulary
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Ertugliflozin
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Formulary
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In line with NICE
Do not use SGLT2-inhibitors in patients with T1DM, regardless of CKD and/or heart failure status due to risk of DKA (diabetic ketoacidosis)
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MHRA Alert: SGLT2 inhibitors: monitor ketones in blood during treatment interruption for surgical procedures or acute serious medical illness
NICE TA583: Ertugliflozin with metformin and a dipeptidyl peptidase-4 inhibitor for treating type 2 diabetes
MHRA Alert: SGLT2 inhibitors: reports of Fourniers gangrene (necrotising fasciitis of the genitalia or perineum) (Feb 2019)
NICE TA572: Ertugliflozin as monotherapy or with metformin for treating type 2 diabetes
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06.01.02.03 |
Other |
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Capsaicin
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Formulary
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Duloxetine
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Formulary
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Prescribe generically as 30mg & 60mg.
90 and 120mg not cost-effective
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Irbesartan
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Formulary
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Losartan Potassium
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Formulary
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06.01.02.03 |
Thiazolidinediones |
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Pioglitazone
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Formulary
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MHRA: Insulin combined with pioglitazone: risk of cardiac failure
MHRA: Pioglitazone: risk of bladder cancer
NICE NG28: Type 2 diabetes in adults: management
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06.01.02.05 |
Glucagon-like peptide-1 receptor agonists - once weekly |
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06.01.02.07 |
Other antidiabetic drugs |
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Non Formulary Items |
Acarbose (tablets)
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Non Formulary
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Acarbose (Glucobay) (tablets)
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Non Formulary
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For existing patients ONLY |
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Chlorpropamide
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Non Formulary
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Glipizide
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Non Formulary
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Gliquidone (Glurenorm®)
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Non Formulary
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Nateglinide (Starlix)
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Non Formulary
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For existing patients ONLY |
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Pioglitazone (Actos)
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Non Formulary
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Pioglitazone should not be used in people who have heart failure or who are at higher risk of fracture. Continue Pioglitazone therapy only if there is a reduction of ≥0.5 percentage points in HbA1c in 6 months. Monitor for liver toxicity. There is risk of bladder cancer with pioglitazone. Do not use in active bladder cancer or a past history of bladder cancer, or in those who have uninvestigated macroscopic haematuria. Assess risks for bladder cancer after 3-6months of starting pioglitazone. Refer to current BNF for full contraindications and interactions. |
MHRA: Insulin combined with pioglitazone: risk of cardiac failure
MHRA: Pioglitazone: risk of bladder cancer
TA63: Glitazones in the treatment of type 2 diabetes (Review of TA9 and TA21)
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Pioglitazone and Metfomin
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Non Formulary
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Rosglitazone (Avandia)
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Non Formulary
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Rosiglitazone and Metformin (Avandamet)
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Non Formulary
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Saxagliptin
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Non Formulary
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Saxagliptin and Dapagliflozin
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Non Formulary
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Saxagliptin and Metformin
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Non Formulary
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Sitagliptin (Januvia)
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Non Formulary
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MHRA: Dipeptidylpeptidase-4 inhibitors: risk of acute pancreatitis
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Vildagliptin
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Non Formulary
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Vildagliptin/ Metformin
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Non Formulary
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Key |
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Restricted Drug |
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Unlicensed |
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Link to adult BNF
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Link to children's BNF
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Link to SPCs
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Cytotoxic Drug |
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Controlled Drug |
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High Cost Medicine |
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Cancer Drugs Fund |
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NHS England |
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Homecare |
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ICB |
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Low carbon footprint |
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Medium carbon footprint |
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High carbon footprint |
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Status |
Description |
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Medicines which are suitable for initiation and maintenance prescribing by primary and secondary care clinicians. These medicines should be initiated and prescribed within their licensed indications |
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Amber Specialist Initiation: Initiation and maintenance of prescribing by Specialists and transfer to Primary Care prescribing when appropriate. This may be supported by a RICaD, annotated within the formulary entry. |
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Amber Shared Care: Initiation and maintenance of prescribing by Specialists and transfer to Primary Care prescribing, in accordance with an ESCA, annotated within the formulary entry. |
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Amber Specialist Recommendation: Initiation and maintenance of prescribing in Primary Care following recommendation from a specialist. |
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Medicines for initiation and maintenance prescribing by Specialists (hospital or GPs with Special Interest) only |
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Positive NICE TA and /or awaiting local clarification on place in therapy; Please contact your Medicines Optimisation team for more information. |
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Non-formulary Medicines which APC/Trust DTC has actively reviewed and do not recommend for use. |
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Check Notes as varies across the area |
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