6.1. Drugs used in diabetes
6.1.1. Insulins
6.1.1.1. Short-acting insulins
Restrictions:
Restricted to initiation by clinicians, either in primary care or the acute setting, experienced in the treatment of diabetes.
Restrictions:
Restricted to initiation by clinicians, either in primary care or the acute setting, experienced in the treatment of diabetes.
Restrictions:
Restricted to initiation by clinicians, either in primary care or the acute setting, experienced in the treatment of diabetes.
Prescribing Notes:
Insulin aspart preparations may differ in terms of speed of onset of action and should therefore be prescribed by brand name.
Different devices and presentations for administration of the same insulin may differ in cost. When prescribing for the 1st time, use the most cost-effective device that best meets the patient's needs.
Restrictions:
Restricted to initiation by clinicians, either in primary care or the acute setting, experienced in the treatment of diabetes.
Prescribing Notes:
Currently, only the 100 units/ml preparations have been considered and added to Formulary. Other strengths are currently non-Formulary
Restrictions:
Restricted to initiation by clinicians, either in primary care or the acute setting, experienced in the treatment of diabetes.
Restrictions:
Restricted to initiation by clinicians, either in primary care or the acute setting, experienced in the treatment of diabetes and for use in patients where regular human soluble insulin is inappropriate.
6.1.1.2. Intermediate- and long-acting insulins
Restrictions:
Restricted to initiation by clinicians, either in primary care or the acute setting, experienced in the treatment of diabetes.
Restrictions:
Restricted to initiation by clinicians, either in primary care or the acute setting, experienced in the treatment of diabetes.
Restrictions:
Restricted to initiation by clinicians, either in primary care or the acute setting, experienced in the treatment of diabetes.
Restrictions:
Restricted to initiation by clinicians, either in primary care or the acute setting, experienced in the treatment of diabetes.
Restrictions:
Restricted to initiation by clinicians, either in primary care or the acute setting, experienced in the treatment of diabetes. Restricted to use in accordance with local guidance which includes information on preferred alternative options.
Prescribing Notes:
Note: Insulin degludec is available in two strengths and caution should be taken in prescribing, dispensing and administration to ensure the correct strength is received.
Restrictions:
Insulin detemir (Levemir®) is restricted to use in children, adolescent and adult patients with severe/ frequent nocturnal hypoglycaemia. Not for routine use in type 2 diabetes unless patients suffers from recurrent episodes of hypoglycaemia. Restricted to initiation by clinicians, either in primary care or the acute setting, experienced in the treatment of diabetes.
Restrictions:
Restricted to initiation by clinicians, either in primary care or the acute setting, experienced in the treatment of diabetes.
Restrictions:
Restricted to initiation by clinicians, either in primary care or the acute setting, experienced in the treatment of diabetes.
Restrictions:
Restricted to patients with type 1 diabetes who are at risk of or experience unacceptable frequency and/or severity of nocturnal hypoglycaemia on attempting to achieve better hypoglycaemic control during treatment with established insulins. It is also acceptable as a once daily insulin therapy for patients who require carer administration of their insulin. In patients with type 2 diabetes it should be restricted to those who suffer from recurrent episodes of hypoglycemia or require assistance with their insulin injections.
Restricted to initiation by clinicians, either in primary care or the acute setting, experienced in the treatment of diabetes.
Prescribing Notes:
It is good practice to prescribe biosimilar insulins by brand name. The current preferred brand in NHSGGC is Semglee®
Please note: Insulin glargine is available in two strengths and caution should be taken in prescribing, dispensing and administration to ensure the correct strength is received.
Insulin glargine 300 units/ml (Toujeo®) is further restricted to use in patients where the use of high-strength insulin is appropriate.
6.1.2. Antidiabetic drugs
6.1.2.2. Biguanides
Please see the NHSGGC Diabetes Guidelines for further information.
6.1.2.4. Dipeptidylpeptidase-4 Inhibitors
This class of medicines are not considered the most cost-effective choice when used as first-line therapy, and even when used as 2nd or 3rd line, they may only result in a modest reduction of HbA1c. In some situations, alternative therapy, such as insulin or GLP-1 analogue may be more appropriate. Stop medication if individualised target not achieved AND HbA1c falls less than 0.5% (5.5mmol/mol). Please see the NHSGGC Diabetes Guidelines for further information.
Restrictions:
Formulary indications are summarised in the Prescribing notes below:
Prescribing Notes:
Indications and restrictions for use in type 2 diabetes mellitus:
- Sitagliptin is the preferred DPP4-inhibitor in NHSGGC.
- Monotherapy is restricted to patients for whom both metformin and sulphonylureas are inappropriate due to contraindications or intolerance.
- Combination with a sulphonylurea is restricted to patients in whom metformin is contraindicated or not tolerated.
- Combination with both metformin and a sulphonylurea (i.e triple therapy) is restricted to patients who are inadequately controlled on their respective maximal tolerated doses of metformin and sulphonylurea.
- Add-on treatment to insulin (with or without metformin).
This class of medicines is not considered the most cost-effective choice when used as first-line therapy, and even when used as 2nd or 3rd line, they may only result in a modest reduction of HbA1c. In some situations, alternative therapy, such as insulin or GLP-1 analogue may be more appropriate
Patients initiated on gliptin therapy should be reviewed at 6 months and treatment should stop medication if individualised target not achieved AND HbA1c falls less than 0.5% (5.5mmol/mol). Please see the NHSGGC Diabetes Guidelines for further information (link here).
Restrictions:
Restricted to the treatment of type 2 diabetes mellitus as outlined in the prescribing notes section.
Prescribing Notes:
Linagliptin may be a more suitable choice for those patients likely to be subject to increasing renal impairment.
Formulary indications are as follows:
- as monotherapy in patients for whom both metformin and sulphonylureas are inappropriate due to contradictions or intolerance
- in combination with metformin when diet and exercise plus metformin alone does not provide adequate glycaemic control in patients for whom the addition of a sulphonylurea is inappropriate.
- as combination therapy with a sulphonylurea and metformin when diet and exercise plus dual therapy does not provide adequate glycaemic control
- in combination with insulin, with or without metformin when this regimen alone, with diet and exercise, does not provide adequate glycaemic control
This class of medicines is not considered the most cost-effective choice when used as first-line therapy, and even when used as 2nd or 3rd line, they may only result in a modest reduction of HbA1c. In some situations, alternative therapy, such as insulin or GLP-1 analogue may be more appropriate.
Patients initiated on gliptin therapy should be reviewed at 6 months and treatment should stop medication if individualised target not achieved AND HbA1c falls less than 0.5% (5.5mmol/mol)
. Please see the NHSGGC Diabetes Guidelines for further information (link here).
Prescribing Notes:
- This class of medicines is not considered the most cost-effective choice when used as first-line therapy, and even when used as 2nd or 3rd line, they may only result in a modest reduction of HbA1c. In some situations, alternative therapy, such as insulin or GLP-1 analogue may be more appropriate
- Patients initiated on gliptin therapy should be reviewed at 6 months and treatment should stop medication if individualised target not achieved AND HbA1c falls less than 0.5% (5.5mmol/mol). Please see the NHSGGC Type 2 Diabetes Guideline for further information (link here).
Restrictions:
It is restricted to use in patients for whom this fixed dose combination of alogliptin and metformin is an appropriate choice of therapy and only when the addition of a sulphonylurea to metformin monotherapy is not appropriate. Combination preparations are further restricted to use only in those patients who have demonstrable compliance issues with the separate constituents.
Prescribing Notes:
This class of medicines is not considered the most cost-effective choice when used as first-line therapy, and even when used as 2nd or 3rd line, they may only result in a modest reduction of HbA1c. In some situations, alternative therapy, such as insulin or GLP-1 analogue may be more appropriate
Patients initiated on gliptin therapy should be reviewed at 6 months and treatment should stop medication if individualised target not achieved AND HbA1c falls less than 0.5% (5.5mmol/mol)
. Please see the NHSGGC Type 2 Diabetes Guidelines for further information (link here).
Restrictions:
For restrictions of this combination product please see prescribing notes below.
Prescribing Notes:
For the treatment of type 2 diabetes mellitus
- in patients for whom a combination of linagliptin and metformin is an appropriate choice of therapy and these fixed-doses are considered appropriate and where there is demonstrable compliance issues with the separate constituents.
- in combination with insulin (i.e. triple therapy) as an adjunct to diet and exercise when insulin and metformin alone do not provide adequate glycaemic control. It is restricted to use in patients for whom a combination of linagliptin and metformin is an appropriate choice and these fixed-doses are considered appropriate and where there is demonstrable compliance issues with the separate constituents.
This class of medicines is not considered the most cost-effective choice when used as first-line therapy, and even when used as 2nd or 3rd line, they may only result in a modest reduction of HbA1c. In some situations, alternative therapy, such as insulin or GLP-1 analogue may be more appropriate
Patients initiated on gliptin therapy should be reviewed at 6 months and treatment should stop medication if individualised target not achieved AND HbA1c falls less than 0.5% (5.5mmol/mol). Please see the NHSGGC Diabetes Guidelines for further information (link here).
Restrictions:
For restrictions please see prescribing notes below
Prescribing Notes:
- Dual therapy: Use in combination with metformin when a sulphonylurea is contraindicated or not tolerated.
- Triple therapy: In combination with metformin and a sulphonylurea when this regimen alone, with diet and exercise, does not provide adequate glycaemic control is restricted to use in patients who are inadequately controlled on their respective maximal tolerated doses of metformin and sulphonylurea.
- The use in combination with insulin (with or without metformin), when this regimen alone, with diet and excercise, does not provide adequate glycaemic control.
- The use as monotherapy is not recommended by SMC and remains non-Formulary
This class of medicines is not considered the most cost-effective choice when used as first-line therapy, and even when used as 2nd or 3rd line, they may only result in a modest reduction of HbA1c. In some situations, alternative therapy, such as insulin or GLP-1 analogue may be more appropriate
Patients initiated on gliptin therapy should be reviewed at 6 months and treatment should stop medication if individualised target not achieved AND HbA1c falls less than 0.5% (5.5mmol/mol). Please see the NHSGGC Diabetes Guidelines for further information (link here).
Restrictions:
Restricted to the treatment of type 2 diabetes in adults in combination with metformin when the use of a sulphonylurea is inappropriate.
Prescribing Notes:
NHSGGC Diabetes Guidelines click here
Restrictions:
For restrictions please see prescribing notes below
Prescribing Notes:
This combined preparation is Formulary for these restricted indications:
- Use in patients for whom a combination of saxagliptin and metformin is an appropriate choice of therapy and only when the addition of sulphonylureas to metformin monotherapy is not appropriate.
- In combination with a sulphonylurea (i.e. triple combination therapy) as an adjunct to diet and exercise to improve glycaemic control in adult patients with type 2 diabetes mellitus when the maximally tolerated dose of both metformin and the sulphonylurea does not provide adequate glycaemic control.
In addition this preparation is restricted to those patients who have demonstrated compliance issues with the separate constituents.
This class of medicines is not considered the most cost-effective choice when used as first-line therapy, and even when used as 2nd or 3rd line, they may only result in a modest reduction of HbA1c. In some situations, alternative therapy, such as insulin or GLP-1 analogue may be more appropriate
Patients initiated on gliptin therapy should be reviewed at 6 months and treatment should stop medication if individualised target not achieved AND HbA1c falls less than 0.5% (5.5mmol/mol). Please see the NHSGGC Diabetes Guidelines for further information (link here).
Restrictions:
Restricted to use in patients for whom a combination of Sitagliptin and metformin is an appropriate choice of therapy and only when the addition of a sulphonylurea to metformin monotherapy is not appropriate. Combination preparations are further restricted to use only in those patients who have demonstrable compliance issues with the separate constituents.
Prescribing Notes:
This class of medicines is not considered the most cost-effective choice when used as first-line therapy, and even when used as 2nd or 3rd line, they may only result in a modest reduction of HbA1c. In some situations, alternative therapy, such as insulin or GLP-1 analogue may be more appropriate
Patients initiated on gliptin therapy should be reviewed at 6 months and treatment should stop medication if individualised target not achieved AND HbA1c falls less than 0.5% (5.5mmol/mol). Please see the NHSGGC Diabetes Guidelines for further information (link here).
Restrictions:
Restricted to the treatment of type 2 diabetes mellitus as outlined in the prescribing notes section
Prescribing Notes:
Formulary indications are as follows:
- use as monotherapy is restricted to use in patients for whom both metformin and sulphonylureas are inappropriate due to contraindications or intolerance
- use in combination with metformin or a sulphonylurea for patients with insufficient glycaemic control despite maximum tolerated dose of monotherapy with metformin or a sulphonylurea.
- use as triple oral therapy in combination with a sulphonylurea and metformin when diet and exercise plus dual therapy with these medicinal products do not provide adequate glycaemic control. It is restricted to use in patients who are inadequately controlled on their respective maximal tolerated doses of metformin and sulphonylurea.
All other licensed indications remain non-Formulary.
This class of medicines is not considered the most cost-effective choice when used as first-line therapy, and even when used as 2nd or 3rd line, they may only result in a modest reduction of HbA1c. In some situations, alternative therapy, such as insulin or GLP-1 analogue may be more appropriate
Patients initiated on gliptin therapy should be reviewed at 6 months and treatment should stop medication if individualised target not achieved AND HbA1c falls less than 0.5% (5.5mmol/mol). Please see the NHSGGC Diabetes Guidelines for further information (link here).
Restrictions:
For restrictions please see prescribing notes below
Prescribing Notes:
Current Formulary indications are:
- Restricted to use only when the addition of a sulphonylurea is not appropriate for patients with insufficient glycaemic control despite maximum tolerated dose of monotherapy with metformin.
- Combination preparations are further restricted to use only in those patients who have demonstable compliance issues with the separate constituents.
All other licensed indications remain non-Formulary.
This class of medicines is not considered the most cost-effective choice when used as first-line therapy, and even when used as 2nd or 3rd line, they may only result in a modest reduction of HbA1c. In some situations, alternative therapy, such as insulin or GLP-1 analogue may be more appropriate
Patients initiated on gliptin therapy should be reviewed at 6 months and treatment should stop medication if individualised target not achieved AND HbA1c falls less than 0.5% (5.5mmol/mol). Please see the NHSGGC Diabetes Guidelines for further information (link here).
6.1.2.6. GLP-1 agonists
Please see the NHSGGC Diabetes Guidelines for further information.
Restrictions:
Restricted to initiation by clinicians, either in primary care or the acute setting, experienced in the treatment of diabetes as part of a triple therapy in patients with inadequate glycaemic control on two oral anti-diabetic drugs.
Prescribing Notes:
- Dulaglutide is a biological medicine. Biological medicines must be prescribed and dispensed by brand name; the manufacturer advises to record the brand name and batch number after each administration.
Restrictions:
Restricted to initiation by clinicians, either in primary care or the acute setting, experienced in the treatment of diabetes for the following indications:
- as a third-line antidiabetic agent in combination with metformin and a sulphonylurea or metformin and a thiazolidinedione
- in combination with basal insulin, with or without metformin. when this regimen alone, with diet and exercise, does not provide adequate glycaemic control.
Prescribing Notes:
- Liraglutide is a biological medicine. Biological medicines must be prescribed and dispensed by brand name; the manufacturer advises to record the brand name and batch number after each administration.
For use in the management of obesity, see section 4.5.2
Restrictions:
Use in the treatment of type 2 diabetes mellitus (T2DM) is restricted to initiation by clinicians, either in primary care or the acute setting, experienced in the treatment of diabetes for use in addition to other oral anti-diabetic medicines, or as an add-on to basal insulin, as an alternative glucagon-like peptide-1 receptor agonist option.
Prescribing Notes:
- Semaglutide is a biological medicine. Biological medicines must be prescribed and dispensed by brand name; the manufacturer advises to record the brand name and batch number after each administration.
Restrictions:
Restricted to initiation by clinicians, either in primary care or the acute setting, experienced in the treatment of diabetes in accordance with the prescribing notes below.
Prescribing Notes:
The once-weekly preparation (Bydureon Bcise®)is restricted to third line treatment of type-2 diabetes mellitus in combination with other agents.
Restrictions:
Restricted to initiation by Consultant Diabetologists for use in patients who are uncontrolled on basal insulin analogues (glycosylated haemoglobin [HbA1c] >7.5% [59mmol/mol]) and for whom a GLP-1 receptor agonist is appropriate as an add-on intensification therapy to basal insulin to obtain glucose control.
Prescribing Notes:
Liraglutide is a biological medicine. Biological medicines must be prescribed and dispensed by brand name; the manufacturer advises to record the brand name and batch number after each administration.
Restrictions:
Restricted to initiation by Consultant Diabetologists for use in patients who are uncontrolled on basal insulin analogues (glycosylated haemoglobin [HbA1c] >7.5% [59mmol/mol]) and for whom a GLP-1 receptor agonist is appropriate as an add-on intensification therapy to basal insulin analogues.
Prescribing Notes:
Lixisenatide is a biological medicine. Biological medicines must be prescribed and dispensed by brand name; the manufacturer advises to record the brand name and batch number after each administration.
Restrictions:
Use in the treatment of type 2 diabetes mellitus (T2DM) is restricted to initiation by clinicians, either in primary care or the acute setting, experienced in the treatment of diabetes for use in addition to other anti-diabetic medicines, or as an add-on to basal insulin.
Prescribing Notes:
- Semaglutide is a biological medicine. Biological medicines must be prescribed and dispensed by brand name; the manufacturer advises to record the brand name and batch number after each administration.
6.1.2.7. Other Antidiabetic Drugs
Restrictions:
Restricted to initiation by clinicians, either in primary care or the acute setting, experienced in the treatment of diabetes. Acarbose is restricted to use in patients refractory or intolerant to treatment with metformin.
6.1.2.5. SGLT2 Inhibitors
Please see the NHSGGC Diabetes Guidelines for further information.
Restrictions:
Restricted to use in adults aged 18 years and older with type 2 diabetes mellitus to improve glycaemic control as add-on therapy with other glucose-lowering medicinal products including insulin, when these, together with diet and exercise, do not provide adequate glycaemic control in the following situations:
- monotherapy where metformin is contraindicated or not tolerated
- dual therapy in combination with metformin when a sulphonylurea is inappropriate
- triple therapy in combination with metformin plus standard of care
- as an add-on to insulin therapy in combination with insulin plus standard of care.
Restrictions:
Restricted to the treatment of type 2 diabetes only in adult patients for whom a combination of canagliflozin and metformin is appropriate and who have demonstrated compliance issues with the separate constituents.
Restrictions:
Type 2 diabetes mellitus:
Restricted to the treatment of type 2 diabetes in adult patients as:
- Monotherapy in adults for whom use of metformin is contraindicated or not tolerated and when diet and exercise alone do not provide adequate glycaemic control only if a DDP-4 inhibitor would otherwise be prescribed AND a sulphonylurea or pioglitazone is not appropriate
- Dual therapy in combination with metformin, when metformin alone with diet and exercise does not provide adequate glycaemic control and a sulphonylurea is inappropriate
- Triple therapy in combination with metformin and sulphonylurea, as an alternative to dipeptidyl peptidase-4 (DPP-4) inhibitor
- In combination with insulin, when insulin with diet and exercise, does not provide adequate glycaemic control
Prescribing Notes:
Please click hyperlinks for formulary information on use in chronic heart failure and chronic kidney disease.
Restrictions:
Restricted to use only in adult patients for whom a combination of dapagliflozin and metformin is appropriate and who have demonstrated compliance issues with the separate constituents.
Restrictions:
It is restricted to initiation in adult patients:
- As monotherapy in adults for whom use of metformin is contraindicated or not tolerated and when diet and exercise alone do not provide adequate glycaemic control and only if a DDP-4 inhibitor would otherwise be prescribed and a sulphonylurea or pioglitazone is not appropriate
- As dual therapy in combination with metformin, when a sulphonylurea is inappropriate
- As triple therapy in combination with metformin plus standard of care or as add-on to insulin therapy in combination with insulin plus standard of care.
Restrictions:
Restricted to the treatment of type 2 diabetes mellitus when metformin and/or a sulfonylurea and one, or both, of the two components do not provide adequate glycaemic control.
Prescribing Notes:
NHSGGC Diabetes Guidelines click here
Restrictions:
Restricted to use in patients with type 2 diabetes mellitus for whom this fixed dose combination is considered appropriate or for use as duel therapy when a sulfonylurea is inappropriate. Additionally, it is restricted to patients who have demonstrated compliance issues with the separate constituents.
Restrictions:
Restricted to use as monotherapy and add-on therapy. When used as monotherapy, it is restricted to patients who would otherwise receive a dipeptidyl peptidase-4 inhibitor and in whom a sulfonylurea or pioglitazone is not appropriate.
6.1.2.1. Sulfonylureas
Please see the NHSGGC Diabetes Guidelines for further information.
Restrictions:
Restricted to patients who cannot tolerate immediate-release gliclazide or for whom immediate-release preparations are inappropriate
6.1.2.3. Thiazolidinediones
Please see the NHSGGC Diabetes Guidelines for further information.
Restrictions:
Monotherapy is restricted to type 2 diabetes mellitus patients in whom consideration is otherwise being given to commencing insulin therapy. It is not recommended as monotherapy in any other group of patients.
Triple therapy (in combination with metformin and a sulphonylurea) in type 2 diabetes is restricted to initiation and monitoring only by physicians experienced in the treatment of diabetes mellitus who will be able to identify and manage patients who might benefit.
Restrictions:
Restricted to use in patients who cannot be treated or controlled with a sulphonylurea in combination with metformin.