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6. Endocrine System 6.1 - Drugs Used in Diabetes Also See SIGN 116: Management of Diabetes, 2010

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6. Endocrine System 6.1 - Drugs Used in Diabetes Also See SIGN 116: Management of Diabetes, 2010 1 6. Endocrine System 6.1 - Drugs used in Diabetes Also see SIGN 116: Management of Diabetes, 2010 http://www.sign.ac.uk/guidelines/fulltext/116 Insulin Prescribing Guidance in Type 2 Diabetes http://www.fifeadtc.scot.nhs.uk/media/6978/insulin-prescribing-in-type-2-diabetes.pdf 6.1.1 Insulins (Type 2 Diabetes) 6.1.1.1 Short Acting Insulins 1st Choice S – Insuman ® Rapid (Human Insulin) S – Humulin S ® S – Actrapid ® 2nd Choice S – Insulin Aspart (NovoRapid ®) (Insulin Analogues) S – Insulin Lispro (Humalog ®) 6.1.1.2 Intermediate and Long Acting Insulins 1st Choice S – Isophane Insulin (Insuman Basal ®) (Human Insulin) S – Isophane Insulin (Humulin I ®) S – Isophane Insulin (Insulatard ®) 2nd Choice S – Insulin Detemir (Levemir ®) (Insulin Analogues) S – Insulin Glargine (Lantus ®) Biphasic Insulins 1st Choice S – Biphasic Isophane (Human Insulin) (Insuman Comb ® ‘15’, ‘25’,’50’) S – Biphasic Isophane (Humulin M3 ®) 2nd Choice S – Biphasic Aspart (Novomix ® 30) (Insulin Analogues) S – Biphasic Lispro (Humalog ® Mix ‘25’ or ‘50’) Prescribing Points For patients with Type 1 diabetes, insulin will be initiated by a diabetes specialist with continuation of prescribing in primary care. Insulin analogues are the preferred insulins for use in Type 1 diabetes. Cartridge formulations of insulin are preferred to alternative formulations Type 2 patients who are newly prescribed insulin should usually be started on NPH isophane insulin, (e.g. Insuman Basal ®, Humulin I ®, Insulatard ®). Long-acting recombinant human insulin analogues (e.g. Levemir ®, Lantus ®) offer no significant clinical advantage for most type 2 patients and are much more expensive. In terms of human insulin. The Insuman ® range is currently the most cost-effective and preferred in new patients. KEY:- H – Hospital Use Only S – Specialist Initiation or Recommendation R – Restricted Use Only Fife Formulary February 2014 Amended April 2014 2 Patients already established on insulin should not be switched to alternative products unless recommended by a diabetes specialist. Care should be taken when prescribing/dispensing insulin products as many have similar names. Always double check to ensure the correct product is prescribed and supplied. In order to avoid dosing errors, When writing prescriptions for insulin the dose should always be written as ‘units’ . Abbreviations such as ‘U’ or ‘IU’ should be avoided. Insulin glargine (Lantus ®) and insulin detemir (Levemir ®) are restricted in patients with type 2 diabetes to those who suffer from recurrent episodes of hypoglycemia, due to individual lifestyle factors e.g. shift work or to those who require assistance with their insulin injections. Insulin degludec (Tresiba ®) is non SMC approved and should not be prescribed routinely in NHS Fife without the approval of an Individual Patient Treatment Request (IPTR). 6.1.2 Other antidiabetic drugs 1st Choice Metformin Sulfonylureas 2nd Choice Gliclazide (1 st choice) , Glipizide (2 nd choice) Pioglitazone Gliptins Sitagliptin (Januvia ®) (1 st choice) Saxagliptin (Onglyza ®) (2 nd choice) 3rd Choice GLP-1 Agonists S –Lixisenatide (Lyxumia ®) (1 st choice) S –Exenatide (Byetta ®) (1 st choice) S –Liraglutide (Victoza ®) (2 nd choice) R - Exenatide (Bydureon ®) R - Dapagliflozin (Forxiga ®) Insulins (see section 6.1.1) Prescribing Points Metformin Metformin is the recommended 1 st line agent when lifestyle measures have been ineffective at controlling hyperglycaemia. Due to the risk of lactic acidosis, the dose of metformin should be reviewed in patients with an eGFR <45 ml/min/1.73m 2. Metformin should be avoided in patients with an eGFR <30 ml/min/1.73m 2. Metformin may cause gastro–intestinal adverse effects; it should be started at low dose and taken with or immediately after meals, the dose gradually increased if tolerated. Doses above 2g daily produce little added glucose lowering efficacy but do increase the risk of side effects. Metformin prolonged release tablets are expensive compared to standard metformin tablets and are restricted to use in patients unable to tolerate standard metformin at an equivalent dose or where a patient may benefit from using a once daily dose to aid compliance. Metformin prolonged release tablets should be considered in patients not able to tolerate standard KEY:- H – Hospital Use Only S – Specialist Initiation or Recommendation R – Restricted Use Only Fife Formulary February 2014 Amended April 2014 3 metformin before switching to alternative products which are more expensive. Metformin oral solution may be used in patients that are unable to swallow tablets. Sulfonylyureas Sulphonylureas are used as 2 nd line agents. Patients prescribed sulfonylureas must be made aware of the risk of hypoglycaemia. Regular monitoring of blood glucose levels is recommended. M/R gliclazide 30mg tablets (Diamicron MR ®) are more expensive than standard gliclazide tablets and should only be prescribed in patients who are unable to comply with the dosage regimen for the standard tablets. Pioglitazone Pioglitazone can be used as a 2 nd line agent in patients considered at high risk of hypoglycaemia with a sulfonylurea. Pioglitazone causes weight gain and fluid retention which can lead to heart failure. It is contraindicated in patients with heart failure, active bladder cancer or a past history of bladder cancer. Use with caution in patients with other cardiovascular disease, in the elderly and those on insulin. Advise patient of risk of osteoporosis and bladder neoplasia. Patients initiated on pioglitazone should be reviewed at 6 months and treatment should only continued if the patient has had a beneficial metabolic response (a reduction of at least 0.5% (5.5mmol/mol) in HbA1c). Gliptins Gliptins are alternative 2 nd line agents. Gliptins are preferred in patients considered at high risk of hypoglycaemia with a sulfonylurea and where weight gain is a concern. Gliptins are more expensive than sulfonylureas and pioglitazone and have limited long-term outcome and safety data. Patients initiated on gliptin therapy should be reviewed at 6 months and treatment should only continued if the patient has had a beneficial metabolic response (a reduction of at least 0.5% (5.5mmol/mol) in HbA1c). Patients prescribed gliptins should be advised to report any signs of acute pancreatitis. GLP-1 agonists GLP-1 agonists are injectable preparations used as 3rd line agents. GLP-1 agonists are more expensive than oral preparations and have limited long-term outcome and safety data. They should normally be used in patients before considering insulin. Patients initiated on GLP-1 agonists should be reviewed at 6 months and treatment should only continued if the patient has had a beneficial metabolic response (a reduction of at least 0.5% (5.5mmol/mol) in HbA1c). Lixisenatide is a once daily preparation and is cheaper than alternative GLP-1 agonists. Lixisenatide has demonstrated non-inferiority to exenatide in terms of HbA1C lowering effect. Byetta ® is a twice daily exenatide preparation. R - Bydureon ®, a once-weekly exenatide preparation, is restricted to use in patients where a weekly preparation will aid compliance, to improve tolerance to exenatide or in patients where a once weekly KEY:- H – Hospital Use Only S – Specialist Initiation or Recommendation R – Restricted Use Only Fife Formulary February 2014 Amended April 2014 4 preparation would aid administration by healthcare professionals. Liraglutide (Victoza ®) is a once daily preparation. Only the 1.2mg dose is approved for use. The 1.8mg dose is non-formulary as it is not considered to be cost-effective. Liraglutide should be considered in patients when lixisenatide/exenatide is ineffective or not tolerated. Patients prescribed GLP-1 agonists should be advised to report any signs of acute pancreatitis. Dapagliflozin R – Dapagliflozin is approved for restricted use in combination with insulin, when insulin, diet and exercise do not provide adequate glycaemic control. Dapagliflozin is a cheaper alternative to the use of GLP-1 agonists for this indication. Dapagliflozin should only be prescribed if initiated or recommended by a diabetes specialist. Dapagliflozin is not approved for use as monotherapy or in combination with metformin. 6.1.4 Treatment of Hypoglycaemia Glucose oral gel 40% Glucagon (GlucaGen ® Hypokit) Prescribing Points Following administration of glucagon and oral glucose, it is important to give supplementary carbohydrate to restore liver glycogen and prevent secondary hypoglycaemia. Glucagon may be repeated once after 10 minutes if necessary. If there is no response, then hospital admission should be considered. Patients with hypoglycaemia requiring 3 rd party intervention should be considered for admission to hospital for i.v. glucose. Oral Glucose Tolerance Test Rapilose ® (unlicensed) Prescribing Points Patients requiring an oral glucose tolerance test should be prescribed Rapilose ® rather than glucose powder which is significantly more expensive. 6.1.6 Monitoring agents for diabetes mellitus Blood Glucose Strips Type 1 Diabetes Glucomen LX Sensor Strip Type 2 Diabetes Glucomen GM (Reagent) strips Trueyou (Reagent) strips Prescribing Points The use of home blood glucose monitoring is recommended in the following circumstances - o Type 1 and Type 2 patients prescribed insulin. o Type 2 patients where control is poor KEY:- H – Hospital Use Only S – Specialist Initiation or Recommendation R – Restricted Use Only Fife Formulary February 2014 Amended April 2014 5 o Patients
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