Chapter 6: Endocrine System

Transcription

1 Chapter 6: Endocrine System Insulins Consult BNF for full details. Refer to Sheffield Guidelines on Diabetes: Insulin can be initiated in primary care for patients with type 2 diabetes with support from the community diabetes team. Patients prescribed insulin should be issued with an information booklet and insulin passport in line with the NPSA patient safety alert Short-acting insulins Insulin Humulin S : 10ml vial, 3ml cartridge (for most Autopen Classic or HumaPen ) Insulin aspart (analogue) NovoRapid : 10ml vial, 3ml cartridge (for NovoPen devices), FlexPen 3ml disposable pen Insulin lispro (analogue) Humalog : 10ml vial, 3ml cartridge (for Autopen Classic or HumaPen ), KwikPen 3ml disposable pen Intermediate and long acting insulins Isophane Insulin Humulin I : 10ml vial, 3ml cartridge (for Autopen Classic or HumaPen ), KwikPen 3ml disposable pen Insulatard : 10ml vial, 3ml cartridge (for Novopen devices) Insuman Basal: 5ml vial, 3ml cartridge (for ClikSTAR and Autopen 24), SoloStar disposable pen An Insulatard Innolet device is available which may be helpful for patients with impaired vision or peripheral neuropathy. Long acting Insulin Analogues Insulin glargine (Lantus ): 10ml vial, 3ml cartridge (for ClikSTAR and Autopen 24), SoloStar 3ml disposable pen Insulin detemir (Levemir ): 3ml Cartridge (for NovoPen devices), FlexPen 3ml disposable pen NICE guidance should be followed when prescribing long acting insulin analogues. For patients requiring insulin treatment for type II diabetes: Begin with human isophane insulin injected at bed-time or twice daily according to need Consider as an alternative, using a long acting insulin analogue if: o the person needs assistance to inject insulin, and use of long-acting insulin analogue would reduce administration to once daily, or o the person s lifestyle is restricted by recurrent symptomatic hypoglycaemic episodes, or o the person would otherwise need twice-daily isophane insulin injections in combination with oral glucoselowering drugs, or o the person cannot use the device to inject isophane insulin. See NICE CG87: Biphasic Isophane Insulin Humulin M3 : 10ml vial, 3ml cartridge (for most Autopen Classic or HumaPen ), KwikPen 3ml disposable pen Biphasic Analogue Insulin Humalog mix 25: 10ml vial, 3ml cartridge (for Autopen Classic or HumaPen ), KwikPen 3ml disposable pen Humalog mix 50: 3ml cartridge (for Autopen Classic or HumaPen ), KwikPen 3ml disposable pen NovoMix 30: 3ml cartridge (for NovoPen devices), FlexPen 3ml disposable pen 6 th Edition July 2012 updated 6.6 Vitamin D June

2 Hypodermic equipment Needles Omnican Fine needles 4mm, 6mm, 8mm, 10mm, 12mm GlucoRx FinePoint needle 5mm Syringes U100 Insulin Syringe (with needle) 0.3ml (8mm), 0.5ml (12.7mm), 1ml (8mm, 12.7mm) Accessories B-D Safe-Clip needle chopping device Sharpsguard 1 litre sharpsbin Sulphonylureas Gliclazide 80mg not m/r preparation Glibenclamide should be avoided in the elderly due to the risk of hypoglycaemia Biguanides Metformin 500mg, 850mg tabs Metformin oral powder 500mg, 1g (for swallowing difficulties) Metformin m/r 500mg, 750mg, 1g tabs Metformin A slow increase of dose may improve gastrointestinal (GI) tolerability. Consider metformin m/r (given twice a day) as an option for patients who cannot tolerate standard tablets (e.g. due to GI upset). Avoid metformin in patients with renal impairment (serum creatinine >150 micromol/l), severe heart failure or severe liver disease because of increased risk of lactic acidosis. Note maximum dose of the m/r preparation is 2g/day. Above this dose only standard release metformin should be used. Standard release maximum 3g in daily divided doses Other antidiabetic drugs For place in therapy see NICE pathway: Managing type 2 diabetes diabetes.xml&content=close Pioglitazone 15mg, 30mg, 45mg tabs Linagliptin 5mg tabs Sitagliptin 25mg, 50mg, 100mg tabs Lixisenatide 50 microgram/ml, 100 microgram/ml injection Exenatide 5 microgram, 10 microgram injection Exenatide m/r 2mg once weekly injection Liraglutide 6mg/ml (0.6mg and 1.2mg doses only) injection The MHRA have warned about a small increase risk of bladder cancer with pioglitazone. Patients with active bladder cancer or with a history of bladder cancer, and those with uninvestigated haematuria, should not receive pioglitazone Treatment of hypoglycaemia Glucose (Glucogel ) 10g per 25g tube P=25g Glucagon 1mg injection P= Blood Glucose Monitoring CareSens N blood glucose monitoring system P=50 Recommended that people with diabetes who are using insulin should be trained in the use of blood glucose monitoring equipment and to take appropriate action on the results obtained. For people with Type 2 diabetes on oral treatment, blood sugar self-monitoring is not generally recommended unless it is specified as part of their individual self care plan. See Sheffield Guidelines on Diabetes If a patient needs to test for blood glucose or ketones the meter should be supplied by the prescriber. 6 th Edition Patients July should 2012 not updated buy their 6.6 own Vitamin meters. D June For DVLA guidance see: "At a glance guide to current medical standards of fitness to drive"

3 6.2.1 Thyroid hormones Levothyroxine sodium 25 micrograms, 50 micrograms, 100 micrograms tabs Glucocorticoid therapy Prednisolone 1mg, 5mg tabs Prednisolone soluble 5mg tabs Dexamethasone 500 micrograms, 2mg tabs; 2mg/5ml oral solution Avoid night time use. Patients should be given a steroid card where appropriate. Steroid cards are available from the NHS Free Forms Assistant at South Yorkshire Primary Care Agency CSM warning. All patients receiving oral or parenteral corticosteroids for purposes other than replacement should avoid close personal contact with chickenpox or herpes zoster and seek urgent medical attention if they are exposed Female Sex Hormones Oestrogens and Hormone Replacement Therapy (HRT) Hormonal Replacement Therapy (HRT): See Appendix 1 Deciding about HRT for prescribing guidelines On grounds of cost effectiveness oral therapy should be considered first line and transdermal second line See Appendix 2 for product selection Oestrogens for HRT Conjugated Oestrogens with progestogen Sequential combined Tablet Prempak-C 0.625, 1.25 Continuous combined Tablet Premique Premique Low Dose P=3x40 Estradiol with progestogen Sequential combined Tablet Elleste-Duet 1mg, 2 mg Femoston 1/10, 2/10 Patch Everol Sequi P=8 Continuous combined Tablet Kliovance Femoston -conti Conjugated oestrogen only Tablet Premarin 625 micrograms, 1.25mg Estradiol only Tablet Elleste-Solo 1mg, 2mg Patch Evorel 25 micrograms, 50 micrograms, 75 micrograms, 100 micrograms P=8, 24 Tibolone Tibolone 2.5mg tabs P=28, 84 Tibolone has oestrogenic, progestogenic and weak androgenic activity. It is given continuously without cyclical progestogen; unsuitable for use in perimenopause or within 12 months of the last period. 6 th Edition July 2012 updated 6.6 Vitamin D June

4 Raloxifene Raloxifene is not included in the formulary. It does not reduce menopausal vasomotor symptoms and is licensed only for the treatment and prevention of postmenopausal osteoporosis. It should normally be initiated by specialists in bone metabolism. NICE does not recommend raloxifene as a treatment option for primary prevention of osteoporotic fragility fractures in postmenopausal women. It may be considered as an alternative option to the bisphosphonates for secondary prevention Progestogens Norethisterone 5mg tabs P=30 Medroxyprogesterone acetate 2.5mg, 5mg, 10mg tabs Male sex hormones and antagonists Testosterone esters oily injection (Sustanon 250 ) 250mg/ml Testosterone undecanoate oily injection (Nebido ) 250mg/ml Testosterone 50mg/5g gel (Testogel ) Testosterone 2% gel (Tostran ) 10mg/metered application 1ml amp 4ml amp 30 x 5g sachets 60g Androgens should not be a treatment for impotence or impaired spermatogensis unless there is associated hypogonadism, which should be properly investigated. Tostran may be preferred to Testogel for those patients who require doses different from the standard Testogel sachet size or who prefer smaller gel volumes. Anti-androgens Cyproterone acetate 50mg tabs P=56 Prescribing for prostatic cancer (BNF ) or male hypersexuality: specialist use only. Used at low dose in co-cyprindiol (e.g. Dianette ) for acne and hirsutism see BNF Finasteride 5mg tabs P=28 For benign prostatic hyperplasia may take up to 6 months to be effective. Finasteride may cause feminisation of male foetus and as it is excreted in semen the use of condoms is advised if the partner is pregnant or likely to become pregnant. Women of child bearing potential should avoid handling crushed or broken tablets. Finasteride can decrease serum PSA levels and reference values may need adjustment Posterior pituitary hormones and antagonists Desmopressin 100 micrograms, 200 micrograms tabs for nocturnal enuresis - see section Prescribing for diabetes insipidus: specialist initiation Do not use intranasal preparations for nocturnal enuresis due to increased incidence of side-effects 6.6 Drugs affecting bone metabolism Calcium and Vitamin D - Refer to chapter and see advice below Calcium 1 1.2g and vitamin D 800IU per day should be considered for all institutionalised or housebound elderly and those with a prior hip fracture. Supplementation at these doses does not require routine monitoring. 6 th Edition July 2012 updated 6.6 Vitamin D June

5 Vitamin D Risk groups The CMO wrote to healthcare professionals in February 2012 highlighting the risks of vitamin D deficiency. Local guidance is available here Healthy Start children s drops (children) Healthy Start women s vitamin tablets (for pregnant and breast feeding mothers) Children and pregnant and breast feeding mothers - Healthy Start vitamins are available from all Children s Centres for those with vouchers. A growing number of centres can now sell them to those not eligible for vouchers. (Vouchers are issued from birth to the child s 4 th birthday). Alternatively patients can obtain suitable preparations from their local pharmacy. To find your nearest Healthy Start distribution centre click here Patients over 65 years or those with low exposure to sunlight a preparation containing 10 micrograms of vitamin D should be obtained from their community pharmacy or local health shop. NB. See note above for institutionalised or housebound elderly and those with a prior hip fracture. Deficiency - Refer to local Adults and Children s guidance. Children Pro D3 2,000IU/ml liquid Pro D3 10,000IU capsules suitable for those 12 years and older. Adults Pro D3 20,000IU capsules Note: Pro D3 is an unlicensed nutritional supplement manufactured in the UK Insufficiency Refer to local Adults and Children s guidance. Children Healthy Start children s drops (obtained from Children s Centres see above) Abidec multivitamin drops* Dalivit multivitamin drops (see below) Dalivit contains 5000IU/14 drops (0.6ml) of vitamin A - advise patients not to exceed the stated dose. When using this multivitamin preparation, they should also take into consideration vitamin A that is obtained from the diet, in order to prevent excessive intake Adults Adults - Patients should obtain suitable preparations containing 1000IU vitamin D from their local community pharmacy or health food store. For those who require medical overview then the following can be prescribed. Desunin 800IU tablets (POM) *Contains arachis oil 6 th Edition July 2012 updated 6.6 Vitamin D June

6 6.6.2 Bisphosphonates and other drugs affecting bone metabolism Alendronic acid 70mg (once weekly) tabs P=4 Risedronate 35mg (once weekly) tabs P=4 Alendronate once weekly should be the first line agent for all osteoporosis patients. All patients receiving a bisphosphonate should have an adequate calcium intake and be vitamin D replete. If these criteria are not met then calcium and vitamin D supplementation should be considered. (Refer to chapter 9.6.4) Additional information can be accessed from NICE TA160 (primary prevention) and NICE TA161 (secondary prevention). Note NICE TA 160 / 161 apply only to post menopausal women with osteoporosis. Atypical femoral fractures have been reported rarely with bisphosphonate therapy. MHRA advises that the need to continue bisphosphonate treatment for osteoporosis should be re-evaluated periodically based on the benefits and potential risks of bisphosphonate therapy for individual patients, particularly after 5 or more years of use. Referrals to the Metabolic Bone Centre can be made using this form Strontium ranelate 2g can be prescribed in patients intolerant of bisphosphonates (currently amber in the traffic light drugs list). See recent MHRA advice on strontium Denosumab can be prescribed under the SCP for the prevention of osteoporotic fractures in post menopausal women in patients that are unable to take bisphosphonates (because of compliance problems, intolerance or contra-indications). See 6 th Edition July 2012 updated 6.6 Vitamin D June

7 Appendix 1 Deciding about HRT For all women the balance of risks and benefits of treatment should be carefully weighed. HRT effectively treats menopausal vasomotor symptoms. Previous confirmed venous thromboembolism (VTE) or active or recent arterial thromboembolic disease (e.g. angina or MI) are each contra-indications for use of HRT. Increased risk of breast cancer, VTE and stroke are associated with use of combined HRT. There is a smaller increase in risk of breast cancer and VTE with oestrogen-only therapy. Tibolone increases risk of stroke but limited data do not suggest an increased risk of VTE. The increase in breast cancer risk is less than with combined HRT. Increased risk of coronary heart disease in women who start combined HRT more than 10 years after menopause. There is insufficient data on the risk with tibolone. Sources for further information see next page Summary of HRT advice for prescribers from the MHRA: For the treatment of menopausal symptoms the benefits of short-term HRT are considered to outweigh the risks in the majority of women. Each decision to start HRT should be made on an individual basis with a fully informed woman. In all cases, it is good practice to use the lowest effective dose for the shortest possible time and to review the need to continue treatment at least annually. This review should take into account new knowledge and any changes in a woman s risk factors and personal preferences. For postmenopausal women who are at an increased risk of fracture and are aged over 50 years, HRT should be used to prevent osteoporosis only in those who are intolerant of, or contraindicated for, other osteoporosis therapies. Women who are receiving HRT for their menopausal symptoms will benefit from the effect of HRT on osteoporosis prevention whilst on treatment. Evidence for the risks of HRT in women who have premature menopause is limited. However, the baseline risk of adverse events in these younger women is very low, and the balance of benefits and risks may therefore be more favourable than in older women. Healthy women who have no menopausal symptoms should be advised against taking HRT as the risks outweigh the benefits. HRT does not prevent coronary heart disease or a decline in cognitive function and should not be prescribed for these purposes. HRT remains contraindicated in women who have had breast cancer. For women without a uterus, oestrogen-only therapy is appropriate. For women with a uterus, oestrogen plus progestogen is recommended. The benefits of the lower risk of endometrial disorders, including cancer, with combined HRT needs to be weighed against the increased risk of breast cancer. Women should be fully informed of the added risk of breast cancer and be involved in the decision-making process. 7

8 Sources for further information Appendix 1 Deciding about HRT (cont d) MHRA Hormone Replacement Therapy specificinformationandadvice/product-specificinformationandadvice-g- L/Hormonereplacementtherapy%28HRT%29/index.htm MHRA Drug Safety Update Hormone-replacement therapy: updated advice Sept MHRA Drug Safety Update Tibolone: benefit-risk balance September MHRA Drug Safety Update September 2007 volume 1 issue 2 Prodigy clinical topic Menopause HRT patient information leaflets available from Prodigy National Prescribing Centre Patient Decision Aids Combined hormone replacement therapy (HRT) Oestrogen only hormone replacement therapy (HRT) 8

9 Appendix 2 Product Summary: HORMONE REPLACEMENT THERAPY see next page for notes Preparation Formulation Oestrogen Progestogen Dose Bleed Women without uterus No. script charges Unopposed oestrogen preparations (NB in endometriosis foci may remain despite hysterectomy and addition of progestogen should be considered) Elleste-Solo Tablet Estradiol 1mg, 2mg N/A One tablet daily N/A 1 Evorel Premarin 0.625, 1.25 Patch Tablet Estradiol 25/50/75/100micrograms over 24hrs Conjugated oestrogens 0.625mg, 1.25mg N/A One patch twice weekly N/A 1 N/A One tablet daily N/A 1 Women with uterus (oestrogen-only preparations may also be considered depending on risks) Sequential combined Elleste-Duet 1mg, 2mg Femoston 1/10, 2/10 Evorel Sequi Two separate tablets Two separate tablets Two separate patches Estradiol 1mg Estradiol 2mg Estradiol 1mg Estradiol 2mg Estradiol 50micrograms/24hrs Estradiol 50micrograms/24hrs Norethisterone 1mg Dydrogesterone 10mg Norethisterone 170micrograms/24hrs Estradiol daily x 16 days Estradiol+norethisterone daily x 12 days Estradiol daily x 14 days Estradiol+dydrogesterone daily x 14 days Estradiol patch twice weekly x 2 weeks Combined patch twice weekly x 2 weeks M 2 M 2 M 2 Prempak-C Two separate tablets Conjugated oestrogens 0.625mg, 1.25mg Norgestrel 150micrograms Conjugated oestrogens x 28 days Norgestrel x 12 days M 2 Continuous combined (unsuitable for use in perimenopause or within 12 months of the last period) Kliovance Norethisterone Tablet Estradiol 1mg 500micrograms Femoston -conti Tablet Estradiol 1mg Dydrogesterone 5mg Evorel Conti Premique, Premique Low Dose Other Preparations Patch Tablet Estradiol 50micrograms/24hrs Conjugated oestrogens 0.625mg, 0.3mg Norethisterone 170micrograms/24hrs Medroxyprogesterone acetate 5mg,1.5mg One tablet daily One tablet daily X 1 X 1 One patch twice weekly X 1 One tablet daily x 1 Tibolone (unsuitable for use in the perimenopause or within 12 months of the last period) Tibolone Tablet N/A N/A 2.5mg daily X 1 9

10 Appendix 2 Product Summary: HORMONE REPLACEMENT THERAPY (cont d) Notes Increased risk of breast cancer with all HRT preparations, but significantly higher risk with combined oestrogen-progestogen therapy. For osteoporosis prophylaxis, usual recommended dose estradiol 2mg daily or 50microgram / 24hr patch; for conjugated oestrogens 0.625mg daily Lower doses are an option in women intolerant of higher doses. First choice preparation of each type indicated in bold. Patch should be reserved for those patients who cannot tolerate oral therapy / patients with liver dysfunction. Tibolone should be reserved for those patients in whom HRT not tolerated. Abbreviations Bleed: N/A = Not applicable M = Monthly X = No bleed 10