Dbh formulary section 6.1.2

Doncaster & Bassetlaw Medicines Formulary
Section 6.1.2 Antidiabetic Drugs
Gliclazide 80mg Tablets
Glimepiride 1mg, 2mg, 3mg and 4mg Tablets
Tolbutamide 500mg Tablets
Metfomin 500mg and 850mg Tablets
Metfomin 500mg, 750mg and 1g MR Tablets
Metformin 500mg and 1g Sachets
Acarbose 50mg Tablets
Dapagliflozin 10mg Tablets
Exenatide 5microgram/dose and 10microgram/dose
Injection
Liraglutide 6mg/ml Injection
Pioglitazone 15mg, 30mg and 45mg Tablets
Repaglinide 500microgram, 1mg and 2mg Tablets
Sitagliptin 100mg Tablets
Saxagliptin 2.5mg and 5mg Tablets
Approved by Drug and Therapeutics Committee: Nov 2013
Review Date: October 2016

Prescribing Guidance:
NICE guidance:
Sulphonlyureas should be used in combination with metformin in overweight
or obese people when glucose control becomes unsatisfactory
Sulphonylureas should be considered as an option for first line therapy when:
 Metformin is not tolerated or is contraindicated Clinicians, and those using a Sulphonylurea, should be aware of the risk of hypoglycaemia and be alert to it In people who are overweight and whose blood glucose is inadequately controlled using lifestyle interventions alone, Metformin should be normally used as the first-line glucose-lowering therapy. Metformin should be considered as an option for first-line or combination therapy for people who are not overweight. Metformin is contraindicated in those with renal impairment Prescribing outside this formulary should only take place via New Product Request  Gliclazide should generally be considered the first line sulphonylurea, when used in the situations outlined above.  Glimepiride should be reserved as a second-line sulphonylurea.  Tolbutamide is shorter acting than the other two sulphonylureas listed. Metformin may cause abdominal cramps and diarrhoea on initiation. This may be minimised if it is given with food, starting low and increasing gradually. Metformin MR is available but should only be prescribed where there is gastrointestinal intolerance to standard release Metformin, despite the measures outlined above.Metformin is contraindicated in renal and hepatic impairment due to the risk of lactic acidosis. NICE advise stopping Metformin if serum creatinine is greater than 150mmol/l or if eGFR falls below 30ml/min/1.73m2. Lactic acidosis is a very rare clinical condition, but is associated with high mortality rates (approaching 50%). Interaction between Metformin and radiological contrast media: Metformin should be discontinued at the time of, or prior to, the procedure and withheld for 48 hours subsequent to the procedure and re-instituted only after renal function has been re-evaluated and found to be normal. Sitagliptin or saxagliptin can be considered as additional therapies in patients with type 2 diabetes mellitus not controlled on maximum tolerated doses of metformin and/or sulfonylureas (see also the review). Exenatide can be considered as an alternative to insulin in patients with type 2 diabetes mellitus on maximum tolerated doses of metformin and/or sulfonylureas with HbA1c more than 7.5%, where BMI is more than 35kg/m2. The drug should be stopped if HbA1c has not been reduced (by 1% or more) and weight has not been reduced by 5% after six months of therapy. The drug is classified as Amber G on the Doncaster and District Traffic Light System indicating that it is prescribable in primary care by GPs following initiation by a specialist in secondary care. Liraglutide can be considered as an alternative incretin mimetic where once daily dosing may improve patient compliance. Pioglitazone can be considered as an additional therapy in patients with type 2 diabetes mellitus not controlled on maximum tolerated doses of metformin and/or sulfonylureas. Before prescribing, the prescriber should warn of the possibility of significant oedema and advise on the action to take if it develops. Pioglitazone should not be commenced or continued in people who have evidence of heart failure or who are at higher risk of fracture. Prescribing outside this formulary should only take place via New Product Request Repaglinide may have a limited place in patients with irregular meal times where glycaemic control has proved difficult with conventional therapy. Acarbose can be considered in patients unable to use other oral glucose-lowering therapies. Flatulence can deter some patients from taking this medication. Patients should be counselled that the tablets should be chewed with the first mouthful of food. Acarbose delays the absorption and digestion of sucrose and starch. Those patients having insulin and sulphonylurea as well as acarbose may need to carry glucose (and not sucrose) to counteract possible hypoglycaemia. Dapagliflozin in a dual therapy regimen in combination with metformin is recommended for the treatment of type 2 diabetes, only if glycaemic control is inadequate, and the patient has a significant risk of hypoglycaemia or if a sulfonylurea is contra-indica). Dapagliflozin in combination with insulin (alone or with other antidiabetic drugs) is an option fo Dapagliflozin should be avoided if eGFR is less than 60ml/minute/1.73m2, and therefore is unsuitable for a significant proportion of diabetic patients. For guidance on management of blood pres.
Items for Restricted Prescribing (by or on the advice of a Consultant
Endocrinologist or Renal Physician):

Linagliptin can be considered as an additional therapy in patients with type 2
diabetes mellitus not controlled on maximum tolerated doses of either
metformin alone or metformin and a sulfonylurea. Use is restricted to those
with CKD stage 5 (creatine clearance less than 15ml/minute), where other
drugs are contraindicated.
Prescribing outside this formulary should only take place via New Product Request

Source: http://www.dbh.nhs.uk/Library/Pharmacy_Medicines_Management/Formulary/Formulary_S6/Section%206.1.2.pdf