Repaglinide & Nateglinide |
|
Repaglinide and nateglinide stimulate insulin release. They have a rapid onset of action and short duration of activity, |
and only need to be taken at mealtimes (shortly before each main meal). This makes them particularly useful alternatives |
to sulphonylureas for patients with irregular meal patterns or lifestyles (where hypoglycaemia would otherwise pose a risk). |
Repaglinide may be given as monotherapy for patients who are not overweight or for those in whom metformin is |
contra-indicated or not tolerated, or it may be given in combination with metformin. |
GREEN Nateglinide, tablets 60mg, 120mg, 180mg |
GREEN Repaglinide, tablets 1mg, 2mg |
|
Thiazolidinediones (Glitazones) |
Glitazone Safety Concerns |
Pioglitazone causes weight gain and increases the risk of heart failure (especially in combination with insulin). |
It may also be worse in existing heart failure. Do not start or continue pioglitazone if the patient has current evidence or a |
history or heart failure, or is at a higher risk of fracture. If prescribing pioglitazone, warn about significant oedema and tell |
the patient what to do if this happens. Patients should be closely monitored for signs of heart failure. There are no |
restrictions on the use of pioglitazone in acute coronary syndrome, ischaemic heart disease or peripheral arterial disease. |
|
The European Committee on Medicinal Products for Human Use has recommended the suspension of the marketing |
authorisations of Rosiglitazone (Avandia®) and it's combination product with metformin (Avandamet®) across the |
European Union. Full details can be found under Drug Alerts & Withdrawals - Click Here |
|
Pioglitazone to be prescribed in accordance with NICE guidance (CG87). LFT measurements are needed prior to treatment |
and periodically thereafter. It should be remembered that control of modifiable cardiovascular risk factors such as smoking |
cessation, lipids and blood pressure are the most important interventions to be made in patients with type II diabetes. |
GREEN Pioglitazone tablets 15mg, 30mg, 45mg (generic only) |
|
Intestinal alpha glucosidase inhibitor |
Consider acarbose for a person unable to use other oral glucose-lowering medications. Delays the digestion and |
absorption of starch and sucrose. Timing of doses is crucial: tablets should be chewed or swallowed whole with the first |
mouthful of food. |
GREEN Acarbose tablets 50mg, 100mg (Glucobay®) |
|
Gliptins |
GREEN Sitagliptin 25mg, 50mg,100mg tablets (Januvia®) |
GREEN Linagliptin 5mg (Trajenta®) |
GREEN Alogliptin 6.25mg, 12.5mg, 25mg tablets (Vipidia®) |
|
Glucagon-like Peptide-1 receptor agonists |
Shortage of GLP-1 receptor agonists licensed in the management of type 2 diabetes (semaglutide, dulaglutide, liraglutide, |
exenatide) JULY 2023 - See Prescribing Hot Topic and click here for for further information from Specialist Pharmacy Service. |
|
Back to main page |
Exenatide |
It should be remembered that control of modifiable cardiovascular risk factors such as lipids and blood pressure are |
the most important interventions to be made in patients with type II diabetes. |
Consider adding exenatide to metformin and a sulfonylurea if a person has: |
> a body mass index (BMI) ≥ 35 kg/m2 in those of European descent, with appropriate adjustment in tailoring this |
advice for other ethnic groups and other specific psychological or medical problems associated with high body |
weight |
> a BMI < 35 kg/m2 and for whom initiation of insulin therapy would have significant occupational implications, or |
where |
> a weight loss would benefit other significant comorbidities such as sleep apnoea. |
> Continue exenatide only if beneficial response occurs and is maintained (≥ 1.0 percentage point HbA1c reduction in 6 |
months and weight loss ≥ 5% at 1 year). |
|
Exenatide is licensed for use with metformin, sulphonylurea and pioglitazone. Exenatide is not licensed for use with |
any other oral antidiabetic drug. Up to 50% of patients experience nausea and vomiting, and due to its effects on slowing |
gastric emptying, may interact with a variety of drugs including the contraceptive pill and antibiotics. |
|
Exenatide 5mcg and 10mcg only is licensed as adjunct to basal insulin. |
Exenatide 2mg is a long acting formulation administered once a week | |
GREEN Exenatide pre-filled pen 5 micrograms, 10 micrograms (Byetta®) |
Exenatide 2mg pre-filled disposable syringe (Bydureon®) |
|
GREEN Liraglutide[Victoza® pre-filled pen] |
Liraglutide is a treatment option for patients whose diabetes is not controlled with Metformin, and or sulphonylurea |
and/or glitazone. Patients prescribed liraglutide should be regularly reviewed and treatment should be in line with the |
recommendations of NICE NG28 (replaced TAG203): only continue liraglutide if reduction in HbA1c of at least |
1 percentage point and weight loss of at least 3% of initial body weight at 6 months. Liraglutide should only be used at a |
maximum dose of 1.2mg daily, the 1.8mg/day dose should not be used. |
GREEN Liraglutide pre-filled pen 18mg (Victoza®) PRESCRIBE BY BRAND |
|
RED Liraglutide [Saxenda® solution for injection] Specialist medicine |
NICE TA664 Recommended as an option for managing overweight and obesity alongside a reduced-calorie diet and |
increased physical activity in adults, only if: |
> they have a body mass index [BMI] of at least 35 kg/m2 (or at least 32.5 kg/m2 for members of minority ethnic |
groups known to be at equivalent risk of the consequences of obesity at at a lower BMI than the white population) and |
> they have non-diabetic hyperglycaemia (defined as a haemoglobin A1c level of 42 mmol/mol to 47 mmol/mol |
[6.0% to 6.4%] or a fasting plasma glucose level of 5.5 mmol/litre to 6.9 mmol/litre) and |
> they have a high risk of cardiovascular disease based on risk factors such as hypertension and dyslipidaemia and |
> it is prescribed in secondary care by a specialist multidisciplinary tier 3 weight management service and |
> the company provides it according to the commercial arrangement. |
RED Liraglutide 6mg/ml solution for injection 3ml pre-filled pens [Saxenda®] |
|
Dulaglutide |
Appropriate for initiation and ongoing prescribing in both primary and secondary care when prescribed in the following |
clinical circumstances (see NICE NG28): |
> after second intensification of therapy fails to achieve targets combined with metformin and a sulfonylurea if |
the patient: |
> has a BMI of >35kg/m2 and specific psychological or other medicinal problems associated with obesity |
(adjust accordingly for people from black, Asian and other minority ethnic groups) or |
> has a BMI <35kg/m2 and |
> if insulin therapy would have significant occupational implications or |
> if weight loss would benefit other significant obesity related comorbidities |
Or, with specialist care advice and on going support from a consultant-led multidisciplinary team: |
> combined with insulin at second intensification of treatment in patients who cannot take metformin |
|
Dulaglutide may only be continued if the person has a beneficial metabolic response, defined as follows: |
> a reduction of HbA1c by at least 11 mmol/mol [1.0%] and |
> a weight loss of at least 3% of initial body weight in 6 months |
|
GREEN Dulaglutide (Trulicity®) |
0.75mg/0.5mL solution for injection/pre-filled pen |
1.5mg/0.5mL solution for injection/pre-filled pen |
3mg/0.5mL solution for injection/pre-filled pen |
4.5mg/0.5mL solution for injection/pre-filled pen |
|
Semaglutide solution for injection pre-filled pens [Ozempic®] CCG Commissioned |
The GLP‑1 agonist Semaglutide is indicated in adults with type 2 diabetes mellitus to improve glycaemic control. NICE Guideline 28 only recommends the prescribing of GLP‑1 agonists in the add-on therapy setting; therefore Semaglutide was reviewed only in the add-on therapy setting. |
GREEN Semaglutide solution for injection pre-filled pens [Ozempic®] [in line with NICE Guideline 28] [PRESCRIBE BY BRAND] |
|
Back to main page |
Semaglutide tablets [Rybelsus®] CCG Commissioned |
Semaglutide is indicated for the treatment of adults with insufficiently controlled type 2 diabetes mellitus to improve |
glycaemic control as an adjunct to diet and exercise. |
GREEN (restricted) as an alternative GLP-1 receptor agonist for patients who are unable to use subcutaneous |
formulations or patients who prefer oral administration. The effectiveness of semaglutide should be monitored 6 |
months after initiation in line with the targets below: |
|
Semaglutide is an appropriate treatment option for initiation and ongoing prescribing in both primary and secondary care |
when prescribed in the following clinical circumstances: |
º after second intensification of therapy fails to achieve targets*: |
° has a BMI of ≥35 kg/m2 and specific psychological or other medical problems associated with obesity (adjust |
accordingly for people from Black, Asian and other minority ethnic groups) or |
° has a BMI ˂ 35 kg/m2 and |
¤ if insulin therapy would have significant occupational implications or |
¤ if weight loss would benefit other significant obesity related comorbidities |
|
Or, with specialist care advice and ongoing support from a consultant-led multidisciplinary team: |
º combined with insulin at second intensification of treatment in patients who cannot take metformin |
|
Semaglutide may only be continued if the person has a beneficial metabolic response, defined as follows: |
º a reduction of HbA1c by at least 11 mmol/mol [1.0%] and |
º weight loss of at least 3% of initial body weight in 6 months |
|
See NICE Guideline NG28 |
Please also see Antihyperglycaemic guidelines |
|
GREEN [restricted] Semaglutide tablets (Rybelsus®) |
[see key] |
|
SGLT2 Inhibitors - See SGLT2i Desktop Guide |
NICE technology appraisals guidance (TA390) |
Canagliflozin (Invokana,), Dapagliflozin (Forxiga,) and Empagliflozin (Jardiance,) are all selective sodium‑glucose |
cotransporter 2 (SGLT‑2) inhibitors, which block the reabsorption of glucose in the kidneys and promote excretion of excess |
glucose in the urine. |
Through this mechanism these drugs may help control glycaemia independently of insulin pathways. |
They all have UK marketing authorisations for treating type 2 diabetes to improve glycaemic control in adults: |
|
> as monotherapy: when diet and exercise alone do not provide adequate glycaemic control in people for whom the |
use of metformin is considered inappropriate due to intolerance or contraindications |
> as add‑on combination therapy: with other glucose–lowering medicinal products including insulin, when these, |
together with diet and exercise, do not provide adequate glycaemic control. |
|
Dapagliflozin reversibly inhibits sodium-glucose co-transporter 2 (SGLT2) in the renal proximal convoluted tubule to reduce |
glucose reabsorption and increase urinary glucose excretion. Dapagliflozin is not recommended for people with moderate |
to severe renal impairment (people with a creatinine clearance rate of less than 60 ml/min or an eGFR of less than |
60ml/min/1.73m2) |
For full details of adverse reactions and contraindications, see the summary of product characteristics. |
|
GREEN Dapagliflozin (as propanediol monohydrate), 5 mg, 10 mg tablets (Forxiga®) |
|
Back to main page |
Canagliflozin |
The recommended starting dosage of canagliflozin is 100 mg orally once daily. In people tolerating canagliflozin 100 mg |
once daily who have an estimated glomerular filtration rate (eGFR) of at least 60 ml/minute/1.73 m2 or creatinine clearance |
of at least 60 ml/minute and who need tighter glycaemic control, the dose can be increased to 300 mg once daily. |
For people with renal impairment, canagliflozinshould not be started in people with an eGFR of less than60 ml/minute/1.73 m2 |
or creatinine clearance of less than 60 ml/minute. |
In people tolerating canagliflozin whose eGFR persistently falls below 60ml/minute/1.73m² or whose creatinine clearance |
persistently falls below 60 ml/minute, the dose of canagliflozin should be adjusted to or maintained at 100 mg once daily. |
Canagliflozin should be discontinued when eGFR is persistently below 45 ml/minute/1.73 m2 or creatinine clearance is |
persistently below 45 ml/minute. |
|
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. Click here for prescribing advice. |
|
GREEN Canagliflozin 100mg, 300 mg, tablets (Invokana®) as an option for Dual or Triple Therapy. |
|
Dapagliflozin for treating chronic kidney disease as by NICE TA 775 |
Dapagliflozin is recommended as an option for treating chronic kidney disease [CKD] in adults. |
It is recommended only if: |
> it is an add-on to optimised standard care including the highest tolerated licensed dose of angiotensin-converting |
enzyme (ACE) inhibitors or angiotensin-receptor blockers (ARBs), unless these are contraindicated, and |
> people have an estimated glomerular filtration rate (eGFR) of 25 ml/min/1.73 m2 to 75 ml/min/1.73 m2 at the start of |
treatment and: |
> have type 2 diabetes or |
> have a urine albumin-to-creatinine ratio [uACR] of 22.6 mg/mmol or more |
GREEN Dapagliflozin tablets 5mg, 10mg [Forxiga] CCG Commissioned |
|
Empagliflozin |
The recommended starting dosage is 10 mg orally once daily for monotherapy. The dose can be increased to a maximum of |
25 mg daily for people who tolerate empagliflozin well and need tighter glycaemic control, if they have an eGFR of |
60 ml/min/1.73 m2 or more. |
|
GREEN Empagliflozin 10mg, 25mg tablets (Jardiance®) |
|
June 2017 - Position Statement (reference EMPA REG OUTCOME study) |
|
Empagliflozin for treating chronic heart failure with reduced ejection fraction as by- NICE TA773 |
1. Empagliflozin is recommended as an option for treating symptomatic chronic heart failure with reduced ejection fraction |
in adults, only if it is used as an add-on to optimised standard care with: |
> an angiotensin-converting enzyme (ACE) inhibitor or angiotensin 2 receptor blocker (ARB), with a beta blocker and, |
if tolerated, a mineralocorticoid receptor antagonist (MRA), or |
> sacubitril valsartan with a beta blocker and, if tolerated, an MRA. |
2. Start empagliflozin for treating symptomatic heart failure with reduced ejection fraction on the advice of a heart failure |
specialist. Monitoring should be done by the most appropriate healthcare specialist |
AMBER Empagliflozin 10mg, 26mg tablets [Jardiance®] CCG Commissioned |
|
Ertugliflozin CCG Commissioned |
NICE TA572 Ertugliflozin as monotherapy is recommended as an option for treating type 2 diabetes in adults for |
whom metformin is contraindicated or not tolerated and when diet and exercise alone do not provide adequate |
glycaemic control, only if: |
> a dipeptidyl peptidase 4 (DPP‑4) inhibitor would otherwise be prescribed and |
> a sulfonylurea or pioglitazone is not appropriate. |
|
Ertugliflozin in a dual-therapy regimen in combination with metformin is recommended as an option for |
treating type 2 diabetes, only if: |
> a sulfonylurea is contraindicated or not tolerated or |
> the person is at significant risk of hypoglycaemia or its consequences. |
|
NICE TA583 Ertugliflozin with metformin and a dipeptidyl peptidase‑4 (DPP‑4) inhibitor is recommended as an option |
fortreating type 2 diabetes in adults when diet and exercise alone do not provide adequate glycaemic control, |
only if: |
> the disease is uncontrolled with metformin and a DPP-4 inhibitor, and |
> a sulfonylurea or pioglitazone is not appropriate |
|
GREEN Ertugliflozin (Steglatro®) 5mg, 15mg tablets |
|
Sotagliflozin CCG Commissioned |
NICE TA622 Recommended as an option with insulin for treating Type 1 diabetes in adults with a body mass index of at |
at least 27kg/m², when insulin alone is does not provide adequate glycaemic control despite optimal insulin |
therapy, only if: |
> sotagliflozin is given as one 200 mg tablet daily |
> they are on insulin doses of 0.5 units/kg of body weight/day or more and |
> they have completed a structured education programme that is evidence based, quality assured, |
delivered by trained |
> educators and includes information about diabetic ketoacidosis, such as: |
> how to recognise its risk factors, signs and symptoms |
> how and when to monitor blood ketone levels |
> what actions to take for elevated blood ketones and |
|
GREEN Sotagliflozin (Zynquista®) * NOTE: as at 28.5.20 sotagliflozin is not yet available in the NHS |
|
Back to main page |
|
All material in this section is aimed at health care professionals, but is information currently held in the public domain, members of the | public seeking advice on medicine-related matters are advised to speak withtheir GP, pharmacist, nurse or contact NHS111 Service. | Email: info.elmmb@nhs.net | Copyright© 2019 - 2023 East Lancashire Medicines Management Board. | All rights reserved. Disclaimer/Terms and conditions | |
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|