BNF CHAPTER 6: ENDOCRINE SYSTEM. References: Current BNF NICE including Guidance, Clinical Knowledge Summaries

Transcription

1 BNF CHAPTER 6: ENDOCRINE SYSTEM References: Current BNF NICE including Guidance, Clinical Knowledge Summaries 1

2 BNF 6.1 Antidiuretic hormone disorders These medications are initiated by secondary care and can be continued by GPs if they are confident to prescribe. The monitoring will be retained by SUHFT BNF 6.2 Corticosteroid responsive conditions Choice and dose of corticosteroid will depend on the condition being treated. Prednisolone Enteric coated tablets were thought to help prevent irritation of the stomach lining by the steroid. Recent evidence has shown that this is not the case, and the coating may be preventing the medication from being absorbed properly. We recommend that EC preparations are no longer used (Southend hospital no longer stock Prednisolone EC.) Consider titrating up or down from 2.5mg to 3 or 2mg depending on clinical need and response. BNF 6.2.1Cushing s syndrome and disease These medications are initiated by secondary care and can be continued by GPs if they are confident to prescribe. The monitoring will be retained by SUHFT 2

3 BNF 6.3 Diabetes Mellitus and Hypogylcaemia Diabetes mellitus Biguanides Comments Metformin Initiate at low dose and titrate up slowly over several weeks. Only use SR, after trying ordinary release, if patient needs once daily dosage 1 Max SR dose 2g, if dose higher than this required use ordinary release tablets Metformin should be used as a 1st line agent particularly in overweight patients. DPP4 Inhibitors 1 st Choice Comments Alternative Comments Alogliptin Dose of concomitant sulfonylurea Not renally excreted, Does not need dose Linagliptin may need to be reduced reduction in renal impairment Patients should be informed of the characteristic symptoms of acute pancreatitis Active switching to Alogliptin, where appropriate, is encouraged as it is the lowest acquisition cost DPP4 inhibitor 3

4 GLP1 Agonists 1st choice Comments Alternative Dulaglutide - Trulicity Once weekly dose Easy to use administration system. The choice of GLP1 agonist should be based on cost effectiveness and patient acceptability, as there are clear differences in frequency of dosing. Patient compliance with the dosing regimen should be the major factor influencing choice of product. Exenatide -Byetta twice daily dose Lixisenatide - Lyxumia - once daily dose Liraglutide -Victosa - once daily dose Exenatide - Bydureon once weekly dose GLP1 agonists may be preferable if BMI 35kg/m² in people of European descent (adjust BMI for other ethnic groups) and there are problems associated with high weight. Or BMI 35kg/m² and insulin is unacceptable because of occupational implications or weight loss would benefit other co morbidities¹. GLP1 agonists should only be continued if HbA1c is reduced by at least 11mmol/mol within 6 months of starting treatment, and 3% weight loss is achieved¹. Patients should be informed of the characteristic symptoms of acute pancreatitis Dose of concomitant sulfonylurea may need to be reduced 4

5 INSULINS First Choice Comments Alternatives Comments Neutral Protamine Hagedorn (NPH) insulin or Premixed biphasic insulin Insuman range is lowest acquisition cost in class. Insulin should be prescribed by Brand to ensure patient safety. Insulin analogue Abasaglar is lowest acquisition cost in class Ensure patients are supplied with Insulin passport and information, on initiation and any change of product. NICE guidance states that Type 2 diabetics should be initiated on NPH insulin and analogue considered if required outcome is not achieved 1. NICE guidance states that people with Type 1 diabetes choice of insulin should be guided by the patient s lifestyle, compliance and ability. People with type 1 diabetes should be offered multiple daily injection basal bolus insulin regimens from diagnosis. 5 Meglitanides First Choice Repaglinide Comments Clinically and cost effective for patients in whom metformin is contra-indicated or not tolerated. Dose to be taken within 30 mins of meals, three times a day. Needs to be titrated up at 1-2 week intervals Care with drivers to avoid hypoglcaemia 5

6 SGLT2 Inhibitors First Choice Empagliflozin 4 Comments In the EMPA REG OUTCOME study, empagliflozin reduced the primary major adverse cardiac event end point (CV death, nonfatal myocardial infarction, and nonfatal stroke), and caused a reduction in hospitalization for heart failure. EMPA-REG OUTCOME Study SGLT2 inhibitors may add to the diuretic effect of thiazide and loop diuretics and may increase the risk of dehydration and hypotension. MHRA has recently warned about the risk of diabetic ketoacidosis with SGLT2 inhibitors. SGLT2 inhibitors : risk of diabetic ketoacidosis Empagliflozin and Canagliflozin should not be initiated if egfr is below 60 but if patient is already taking, then ensure dose is adjusted or maintained at lowest strength if egfr falls below 60. Dapagliflozin should not be used in patients with egfr below 60 A signal of increased lower limb amputation (primarily of the toe) in people taking canagliflozin compared with placebo in a clinical trial in high cardiovascular risk patients is currently under investigation. drug-safety-update - canagliflozin in high cardiovascular risk patients 6

7 Sulfonylureas First Choice Typical Dose Comments Gliclazide Initiate 40-80mg daily and titrate dose up as required Doses of 160mg and below can be give as single daily dose Only use SR, after trying ordinary release, if patient needs once daily dosage and dose is above 160mg ordinary release. Sulfonylureas may be used if Metformin is contraindicated or not tolerated in patients who are not overweight Avoid in patients at significant risk of Hypoglycaemia e.g. elderly, renal or hepatic impairment. Consider lifestyle / occupation of patients. Avoid in patients with risk of hypoglycaemia, where this could put them or others at risk. E.g. use of machinery, driving, etc. Diabetes and driving - GOV.UK Thiazolidinediones Pioglitazone Pioglitazone should only be used as monotherapy for overweight patients for whom metformin is inappropriate or those intolerant to metformin and sulfonylurea. Pioglitazone may be preferable to sulfonylurea if patient has marked insulin insensitivity or significant risk of hypoglycaemia¹ Pioglitazone should only be continued if HbA1c is reduced by at least 5mmol/mol within 6 months of starting treatment¹. Pioglitazone should be avoided in patients at risk of osteoporosis or being investigated for or with a history of bladder cancer Dose of concomitant sulfonylurea or insulin may need to be reduced Monitor for signs of heart failure or liver problems 7

8 BNF Diagnosis and monitoring Blood monitoring BGTS Cost for 50 strips Cost per 100 for meters lancets Contour Black Glucomen Areo One Touch Select plus Tee Lindac@spirit-healthcare.co.uk True you and mini Tasha.chiew@nipro-europe.com The Blood Glucose Test Strip Quick Reference Guide (BGTS QRG) is available on the CCG websites, listing cost effective and Iso compliant meters. The CCG preferred choices are highlighted in green. Policies and guidance - NHS Southend CCG Policies and guidance - Castle Point and Rochford CCG To fit DVLA requirements, meters must have memory function with no delete facility. Diabetes and driving - GOV.UK Children using blood glucose testing strips will have teaching staff, child minders, parents and other family members or carers who require training on use of the meter. Please ensure discussion with the specialist diabetes service looking after the child before switching to a low cost meter. If patient requires any meter with strips over 10 per 50, the clinical reason should be documented and GP informed of reason. Please see local guideline on Diabetes in Pregnancy and NICE guidance 3 for information on blood glucose testing in pregnancy 6 8

9 Insulin Pen Needles Low acquisition cost brands sizes Mylife Penfine Classic 4mm, 32G GlucoRx FinePoint 4mm and 5mm both 31G Microdot Droplet 4mm, 32G Omnicom Fine 4mm 31G Best practice recommendation is to use 4mm and 5mm needles. BNF Hypoglycaemia Glucagon hypokit 1mg Initially, patients who are conscious and can swallow should be given sugary drinks, granulated sugar or sugar cubes. ¹NICE Guidance 28 Type 2 diabetes in adults : management ²NICE technology appraisal 288 Dapagliflozin in combination therapy for treating type 2 diabetes ³NICE technology appraisal 315 Canagliflozin in combination therapy for treating type 2 diabetes 4 NICE technology appraisal 366 Empagliflozin in combination therapy for treating type 2 diabetes 5 NICE Guidance 18 Diabetes (type 1 and 2) in children and young people : diagnosis and management 6 NICE Guidance 3 Diabetes in pregnancy ; management from preconception to the postnatal period NICE Guidance 17 Type 1 diabetes in adults : diagnosis and management See BNF, Summary of product characteristics (SPC) or NICE for specific information on individual products 9

10 BNF 6.4 Disorders of bone metabolism Bisphosphonates First Choice Typical Dose Alternative Typical Dose Alendronic acid 70mg once a week Risedronate sodium 35mg once a week Review patient s dietary calcium intake and consider co-prescribing calcium and Vitamin D for all patients receiving bisphosponate prescriptions. Calceos or Adcal D3 are the formulary choices or Calfovit D3 sachets. See CCG Assessment and management of osteoporosis guideline. Bone formation stimulants. Strontium Ranelate Strontium should only be initiated by specialists in treatment of severe osteoporosis in postmenopausal women, or men at high risk of fracture for whom other treatments are contraindicated or not tolerated. Refer to MHRA safety guidance concerning prescribing of this medication. Strontium ranelate: cardiovascular risk restricted indication and new monitoring requirements : MHRA Monoclonal Antibodies. Denosumab Desosumab can be continued in primary care after specialist initiation following the local Shared care protocol 10

11 BNF 6.5 Dopamine responsive conditions Dopamine receptor agonists. These medications are initiated by secondary care and can be continued by GPs if they are confident to prescribe. The monitoring will be retained by SUHFT. BNF 6.6 Gonadotrophin responsive conditions Gonadotrophin releasing hormone analogues Medications for prostatic and breast cancer are initiated by secondary care and will depend on the diagnosis of the patient, and can be continued by GPs if they are confident to prescribe Medication for female infertility is provided by the secondary care centre treating the patient. GPs in Southend or Castle Point and Rochford CCGs should not be prescribing infertility drugs on the NHS. BNF 6.7 Hypothalmic and anterior pituitary hormone related disorders Prescribing of these medications should be retained by secondary care 11

12 BNF 6.8 Sex hormone responsive disorders Female Sex hormone responsive disorders HRT treatment should be given at the lowest dose and for the shortest possible time. Treatments should be reviewed annually (consult BNF or NICE guidance for HRT Risk tables) A 2 month break should be tried to see if treatment is still required. HRT is no longer recommended purely for the prophylaxis of osteoporosis UNOPPOSED OESTROGEN Formulation Product Components Vaginal Oestrogens Tablet Gynest Cream Ortho-Gynest Pessary Estring Vaginal Ring Elleste Solo 1 & 2mg Premarin Estriol 0.01% Estriol 0.5mg Estradiol 7.5mcg/24hours Estradiol 1 & 2mg Conjugated oestrogens 300, 625mcg, 1.25mg Patch Evorel 25, 50, 75, &100mcg Oestradiol 25, 50, 75, &100mcg per 24hours Gel Sandrena Estradiol 0.5 or 1mg gel Appropriate for hysterectomised women. Low dose vaginal oestrogen can be used in perimenopausal women who do not wish to take or cannot tolerate HRT Older women are less tolerant to oestrogens and so need lower doses. 12

13 SEQUENTIAL COMBINED THERAPY Formulation 1 st Choice Components Alternatives Components Tablet Ellest Duet Estradiol 1mg, 2mg Norethsterone 1mg Patch Evorel Sequi 50mcg Oestradiol 50mcg per 24 hours/oestradiol 50mcg per 24 hours & Norethisterone 170mcg per 24 hours Patch & Tablet Evorel-Pak Oestradiol Patch 50mcg per 24hrs/ Norethisterone 1mg tabs Femoston 1/10 2/10 or 2/20 Femapak 40 Oestradiol 1mg/ Oestradiol 1mg & Dydrogesterone 10mg Oestradiol 2mg/ Oestradiol 2mg & Dydrogesterone 10mg Oestradiol 2mg/ Oestradiol 2mg & Dydrogesterone 20mg Oestradiol Patch 40mcg per 24hrs/ Dydrogesterone 10mg tabs Use in women with intact uterus who are perimenopausal. Maximum benefit is usually seen in 3 months and treatment would generally be continued for up to 5 years. Dydrogesterone and medroxyprogesterone may be better tolerated than Norethisterone and levonorgestrel as they are less androgenic. 13

14 CONTINUOUS COMBINED THERAPY Formulation First Choice Components Second Choice Components Tablet Kliofem / Kliovance Estradiol 2mg Northisterone 1mg Estradiol 1mg Northisterone 500mcg Indivina Estradiol 1mg or 2mg Medroxyprogesterone 2.5mg or 5mg Patch Evorel Conti Oestradiol 50 microgram & Norethisterone 170mcg/24hrs - Use in post-menopausal women with intact uterus, who have had amenorrhea for at least 12 months May cause irregular bleeding or spotting in the first 3-4 months if this continues after 6 months, investigate and if no serious gynecological pathology consider switching to cyclical HRT NICE guideline 23 Menopause: diagnosis and management 14

15 BNF 6.9 Thyroid disorders First Choice Alternatives Hypothyroidism Levothyroxine Hyperthyroidism Carbimazole Propranolol 40mg BD can be useful for initial relief of thyrotoxic symptoms or as an adjunct to antithyroid drugs in preparation for thyroidectomy. Do not prescribe unlicensed natural thyroxine e.g Armour thyroid. These are not medicinal products and do not have sufficient evidence to warrant NHS prescribing. See CCG guideline about prescribing of non-medicinal products. Formulary Chapter 6 ENDOCRINE SYSTEM Date ratified by D&T Committee February 2016 Next review date February