BNF Chapter 6

1. Gastro-Intestinal System | 2. Cardiovascular System | 3. Respiratory System | 4. Central Nervous System | 5. Antimicrobials | 6. Endocrine System | 7. Obstetrics, Gynaecology & Urology | 8. Malignant Disease & Immunosuppression | 9. Nutrition & Blood | 10. Musculoskelatal & Joint Diseases | 11. Opthalmology | 12. Ear, Nose & Oropharynx | 13. Dermatology | 14. Immunology & Vaccines | 15. Anaesthetics |  GP Centre Home


Endocrine System

1. Antidiuretic hormone disorders
1.1 Diabetes Insipidus
PITUITARY & HYPOTHALAMIC HORMONES & ANALOGUES – Vasopressin & analogiesNOTES
DESMOPRESSINTablets 100micrograms, 200 micrograms

Nasal spray 10 micrograms

Intranasal solution 100micrograms/ml

Injection 4 micrograms in 1ml

Safety Alert – Risk of severe harm or death when desmopressin is witheld or omitted in patients with cranial diabetes insipidus

APC Policy Statement Desmopressin for noctural polyuria

APC Traffic light status: BLUE

VASOPRESSINInjection 20 units in 1mlRESTRICTED : ITU CONSULTANT ONLY (Unlicensed Use)   “For critically ill patients, within the ITU, with profound hypotension due to peripheral vasodilatation, eg septic shock/ severe infection or inflammation, in association with reduced responsiveness and effectiveness of usual catecholamine vasopressor therapy”

Approved off-licence use – reducing blood loss during myomectomy. Restricted to Obs & Gynae Consultants only, Screening checklist must be completed and sent to pharmacy with prescription

APC Traffic light status: none

1.1 Syndrome of inappropriate antidiuretic hormone secretion
PITUITARY & HYPOTHALAMIC HORMONES & ANALOGUES – Vasopressin & analogiesNOTES
TOLVAPTAN (JINARC)Tablets 15mg, 30mg, 60mg, 90mgNICE Guidance Tolvaptan for treating autosomal dominant polycystic kidney disease [TA 358]

APC Traffic light status: RED

ANTIDIURETIC HORMONE ANTAGONISTSNOTES
DEMECLOCYCLINECapsules 150mgUsed in treatment of hyponatraemia resulting from SIADH

APC Traffic light status: none

2 Corticosteroids
GLUCOCORTICOID THERAPYNOTES
Guidance
PREDNISOLONE 5mg is equivalent to the following:
Betametasone750mcg
Dexamethasone 750mcg
Hydrocortisone 20mg
Methylprednisolone 4mg
Triacinolone4mg

 WITHDRAWAL & GRADUAL TAPERING REQUIRED IN THE FOLLOWING:
1) repeated steroid courses over 3 weeks
2) short course within 1 year of stopping long term therapy
3) adrenal suppression
4) dose >40mg prednisolone equivalent
5) repeated evening doses
6) more than 3 weeks treatment course

Provide Steroid treatment card, patient information leaflet and withdrawal/tapering guidance

BETAMETHASONEDispersible tablets 500micrograms

Injection 4mg

APC Traffic light status: none
DEXAMETHASONETablets 500micrograms, 2mg

Injection 6.6mg/2ml (dexamethasone base)

 Dexamethasone memo March 2017

APC Traffic light status: GREEN

FLUDROCORTISONETablets 100microgramsVery high mineralocorticoid activity. Insignificant glucocorticoid activity.

APC Traffic light status: BLUE

HYDROCORTISONETablets 10mg, 20mgAdrenal insufficiency

APC Traffic light status: BLUE

Tablets 10mg, 20mginflammatory conditionss

APC Traffic light status: GREEN

Injection (sodium phosphate) 100mg, (sodium succinate) 100mg
METHYLPREDNISOLONETablets 2mg

Injection (sodium succinate) 40mg, 500mg, 1g, 2g

Injection (acetate) 40mg, 80mg, 120mg (IM depot)

APC Traffic light status: none
PREDNISOLONETablets 1mg, 5mg, 25mg (restricted to oncology/haematology patients

Soluble tablets 5mg

Soluble tablets restricted to paediatrics only

Enteric coated tablets are non-formulary

APC Traffic light status: GREEN

TRIAMCINOLONE ACETONIDEInjection 40mg in 1ml, 50mg in 5mlRheumatic disease and intra-articular injection.
‘Black’ for allergic rhinitis/hayfever. Not on the formulary for this indication.APC Traffic light status: none
2.1 Cushing’s syndrome and disease
ENZYME INHIBITORS                NOTES
METYRAPONECapsules 250mgAPC Traffic light status: none
3 Diabetes Mellitus and hypoglycaemia
3.1 Diabetes Mellitus
SURREY CCG DIABETES PATHWAYCCG Type 2 Diabetes Prescribing Guidelines
BLOOD GLUCOSE LOWERING DRUGS – Biguanides                NOTES
METFORMINTablets 500mg, 850mg

SR Tablets 500mg, 750mg, 1g

Liquid 500mg in 5ml (restricted to enteral tubes and patients unable to swallow tablets)

APC Traffic light status: GREEN
BLOOD GLUCOSE LOWERING DRUGS – Dipeptidylpeptidase-4 inhibitors (gliptins)               NOTES
LINAGLIPTIN Tablets 5mgRESTRICTED Use : DIABETES TEAM ONLY
NICE CG New Diabetes AgentsAPC Traffic light status: GREEN
SITAGLIPTIN Tablets 100mgRESTRICTED Use : DIABETES TEAM ONLY
NICE CG New Diabetes AgentsAPC Traffic light status: GREEN
BLOOD GLUCOSE LOWERING DRUGS – Glucagon-like-peptide-4 receptor agonistsNOTES
 DULAGLUTIDEInjection (Trucility) PF pen RESTRICTED Use: DIABETES INITIATION ONLY

PCN Dulaglutide

APC Traffic light status: GREEN

EXENATIDE PF pen (Byetta) 5micrograms, 10micrograms

Injection (Bydureon) 2mg vial, 2mg pen – once weekly administration

RESTRICTED Use : DIABETES INITIATION ONLY
NICE CG New Diabetes Agents
NICE TAG BydureonAPC Traffic light status: GREEN
LIRAGLUTIDE PF pen 6mg/ml, 3mlRESTRICTED Use : DIABETES INITIATION ONLY
NICE TA 203: LiraglutideNote: Liraglutide is consider ‘BLACK’ by APC for use in weight management and is not on the formulary for this indication.APC Policy statement: Liraglutide (Saxenda) for weight managementAPC Traffic light status: GREEN
LIXISENATIDE PF Pen 10micrograms, 20 microgramsRESTRICTED Use : DIABETES INITIATION ONLY
NICE CG New Diabetes Agents
NICE Lixisenatide ESNM
PCN Lixisenatide
APC Traffic light status: GREEN
BLOOD GLUCOSE LOWERING DRUGS – MeglitinidesNOTES
NATEGLINIDETablets 60mgRESTRICTED Use : DIABETES TEAM ONLY

APC Traffic light status: none

BLOOD GLUCOSE LOWERING DRUGS – Sodium glucose co-transporter 2 inhibitorsNOTES
 NICE GuidanceNICE Guidance Canagliflozin, Dapagliflozin and Empagliflozin as monotherapies for treating Type 2 Diabetes
CANAGLIFLOZIN Tablets 100mg, 300mgRESTRICTED Use: DIABETES INITIATION ONLY 
NICE TAG Canagliflozin
PCN Policy StatementDrug Safety Update March 2017 – updated advice on increased risk of lower limb amputation (mainly toes)APC Traffic light status: GREEN
DAPAGLIFLOZIN Tablets 5mg, 10mgRESTRICTED Use: DIABETES INITIATION ONLY 
NICE TA418 Dapagliflozin in combination therapy for treating type 2 diabetes
PCN DapagliflozinAPC Traffic light status: GREEN
Tablets 5mg, 10mgRESTRICTED Use: DIABETES INITIATION ONLY

Refer to shared care guideline. Minimum of 3 months prescribing by specialist before transfer of prescribing can be requested.

NICE TA597: Dapagliflozin with insulin for treating type 1 diabetes

APC Policy Statement 2019: Dapagliflozin in Type 1 Diabetes

APC Traffic light status: AMBER

EMPAGLIFLOZIN Tablets 10mg, 25mgRESTRICTED Use: DIABETES INITIATION ONLY
 NICE EmpagliflozinAPC Traffic light status: GREEN
 ERTUGLIFLOZIN 5mg, 15mg tabletsRESTRICTED Use: DIABETES INITIATION ONLY

NICE TA 572: Ertugliflozin as monotherapy or with metformin for treating type 2 diabetes

NICE TA 583: Ertugliflozin with metformin and a dipeptidyl peptidase-4 inhibitor for treating type 2 diabetes

APC Traffic light status: GREEN

BLOOD GLUCOSE LOWERING DRUGS – SulphonylureasNOTES
GLICLAZIDETablets 40mg, 80mgAPC Traffic light status: GREEN
MR 30mg(MR restricted use; diabetes team only)

APC Traffic light status: not preferred

GLIMEPIRIDETablets 1mg, 3mgAPC Traffic light status: none
GLIPIZIDETablets 2.5mg, 5mgAPC Traffic light status: none
BLOOD GLUCOSE LOWERING DRUGS – ThiazolidinedionesNOTES
PIOGLITIZONETablets 30mg, 45mgRESTRICTED Use : DIABETES TEAM ONLY
NICE CG New Diabetes Agents
EMEA Ruling on Glitazones (2007)
FDA Ruling on Glitazones (2007)APC Traffic light status: GREEN
PIOGLITAZONE/METFORMINTablets
INSULINS
GuidanceFor patients coming in on NonFormularyDrug (NFD) Insulins wherever possible, use patients own drugs. NFD INSULINS can be ordered to prevent patients destabilising their usual insulin therapy
INSULINS – Short actingNOTES
SOLUBLE INSULINHypurin (porcine neutral) 100units/ml vialAPC Traffic light status: none
Actrapid 100units/ml  vial APC Traffic light status: none
INSULIN ASPARTNovorapid® flexpens, penfill, vialAPC Traffic light status: GREEN
Fiasp®  flexpens, penfill, vialFiasp® RESRICTED Use to DIABETES TEAM ONLY

Fiasp for treating Diabetes Mellitus PCN Policy Statement

APC Traffic light status: BLUE

INSULIN GLULISINEApidra® Solostar penRESTRICTED Use DIABETES TEAM ONLY

APC Traffic light status: GREEN

INSULIN LISPRO
Humalog® kwikpen, cartridgesAPC Traffic light status: GREEN
INSULINS – Intermediate actingNOTES
BIPHASIC ISOPHANEHumulin M3 cartridges, KwikpenAPC Traffic light status: none
ISOPHANE INSULINInsulatard® cartridges, Innolet,APC Traffic light status: none
Insuman®Basal Solostar penAPC Traffic light status: none
BIPHASIC ASPARTNovomix® 30 flexpen, cartridges, vialAPC Traffic light status: GREEN
BIPHASIC LISPROHumalog® Mix 25 cartridges, KwikpenAPC Traffic light status: GREEN
Humalog ® Mix 50 KwikpenAPC Traffic light status: GREEN
INSULINS – Long actingNOTES
INSULIN DEGLUDECTresiba® 100 units/ml, 200 units/ml pre-filled pen

Tresiba® 100units/ml catridges

RESTRICTED USE: DIABETES TEAM ONLY

 

Tresiba® cartridges for prescribing in out-patients

APC Traffic light status: BLUE

INSULIN DETEMIRLevemir® flexpen, Innolet, cartridgesRESTRICTED USE: DIABETES TEAM ONLY

APC Traffic light status: GREEN

INSULIN GLARGINELantus® Cartridges, Solostar pensRESTRICTED USE: DIABETES TEAM ONLY
NICE Guidance on Insulin Glargine (2002)APC Traffic light status: GREEN
INSULIN GLARGINEToujeo ®  300 units /ml pre-filled penRESTRICTED USE: DIABETES TEAM ONLY

APC Traffic light status: BLUE

3.2 Hypoglycaemia
GLYCOGENOLYTIC HORMONES
GLUCAGON1mg powder for injection (pre-filled syringe)Used for acute hypoglycaemia

APC Traffic light status: none

GLUCOSE
GLUCOGELOral dextrose 40% gelUsed for acute hypoglycaemia

APC Traffic light status: none

GLUCOSE 10 % Injection (10ml)
25 % Injection (25ml)
50 % Injection (50ml)
Also used in lower UTI & prostatitis

APC Traffic light status: none

3.2a Chronic Hypoglycaemia
GLYCOGENOLYTIC HORMONES
DIAZOXIDELiquid 50mg in 1mlPaediatrics Only

APC Traffic light status: none

4 Disorders of bone metabolism
BISPHOSPHONATES
GuidancePCN Osteoporosis Treatment Pathway for Adults Algorithm 1

NICE TA464: Bisphosphonates for treating osteoporosis

NICE TA160: Raloxifene for the primary prevention of osteoporotic fragility fractures in postmenopausal women

NICE TA161: Raloxifene and teriparatide for the secondary prevention of osteoporotic fragility fractures in postmenopausal women

ALENDRONIC ACIDTablets 10mg (daily)

Tablets 70mg (weekly)

Solution 70mg in 100ml

Joint 1st line agent
Solution suitable for patients with swallowing difficultiesPCN Policy Statement – Alendronate solutionAPC Traffic light status: GREEN
IBANDRONIC ACIDTablets 150mg

Injection 3mg in 3ml

 

SMC Guidance RESTRICTED USE Consultant RHEUMATOLOGIST/ CARE of ELDERLY Only.

APC Traffic light status: GREEN

PAMIDRONATE DISODIUMInjection 5mg in 5mlAPC Traffic light status: RED
RISEDRONATE SODIUMTablets 5mg (daily)

Tablets 30mg , 35mg (weekly)

Joint 1st line agent (ALENDRONATE is also 1st line)

30mg tablet for Pagets disease of bone

APC Traffic light status: GREEN

SODIUM CLODRONATECapsules 400mg, Tablets 520mgAPC Traffic light status: none
ZOLEDRONIC ACID (ZOMETA)Injection 4mg in 5mlRESTRICTED USE
In malignancy & multiple myeloma patients only
SWISH Ca Network ApprovedAPC Traffic light status: RED
ZOLEDRONIC ACID  (ACLASTA)Injection 50micrograms/mlRESTRICTED USE
Rheumatology & Orthogeriatrics
GuidelinesAPC Traffic light status: RED
CALCIUM REGULATING DRUGS – Bone resorption inhibitors
CALCITONIN (Salmon)Injection 100 units in 1ml, 400 units in 2mlAPC Traffic light status: none
CALCIUM REGULATING DRUGS – Parathyroid hormones and analogies
TERIPARATIDEInjection 250micrograms/mlRESTRICTED USE: Consultant RHEUMATOLOGIST OnlyNICE TA161: Raloxifene and teriparatide for the secondary prevention of osteoporotic fragility fractures in postmenopausal women

APC 2019 Policy Statement – Teriparatide biosimilar

APC Traffic light status: RED

CALCIUM REGULATING DRUGS – Monoclonal antibodies
DENOSUMAB  (PROLIA)Pre-filled syringe 60mg/mlRESTRICTED USE Rheumatology & Orthogeriatrics
NICE TAG Denosumab
SASH_CCG DENOSUMAB [Green]
SASH_CCG Denosumab Rx Information
APC Traffic light status: GREEN
DENOSUMAB (XGEVA)Vial 120mgRESTRICTED USE
For solid tumour patients with bone metastases
NOT approved for patients with prostate cancer
SWISH Ca Network Approval NICE TA 265APC Traffic light status: RED
5 Dopamine responsive conditions
QUINAGOLIDEStarter pack tablets, 75 microgramsAPC Traffic light status: none
6 Gonadotrophin responsive conditions
PITUITARY & HYPOTHALAMIC HORMONES & ANALOGUES – Gonadotropin-releasing hormonesNOTES
GuidanceGonadorelin analogues used in treatment of endometriosis, precocious puberty, infertility, breast cancer and prostate cancer.
BUSERELIN150micrograms/dose nasal spray

1mg/ml vial for injection

APC Traffic light status: none
GOSERELINZoladex 3.6mg implantS/C Injection every 4 weeks

Prostate cancer APC Traffic light status: BLUE

Infertility APC Traffic light status: RED

LEUPRORELIN ACETATEProstap SR 3.75mgS/C or IM  injection every 4 weeks

Prostate cancer APC Traffic light status: BLUE

NAFARELIN200 microgram Nasal Spray (Synarel)Infertility APC Traffic light status: RED
TRIPTORELIN3.75 mg Injection Injection (Gonapeptyl Depot)S/C or IM injection : dose dependant on clinical indication

Prostate cancer APC Traffic light status: BLUE

Precocious puberty APC Traffic light status: AMBER

6.1 Hereditary angiodema
PITUITARY & HYPOTHALAMIC HORMONES & ANALOGUES – Anti-gonadotropin-releasing hormonesNOTES
DANAZOLCapsules 200mgAPC Traffic light status: none
7 Hypothalamic & anterior pituitary hormone related disorders
7.1 Adrenocortical function testing
PITUITARY & HYPOTHALAMIC HORMONES & ANALOGUES – CorticotrophinsNOTES
TETRACOSACTIDEInjection 250micrograms in 1ml

Injection (Depot) 1mg in 1ml

APC Traffic light status: none
7.3 Gonadotrophin replacement therapy
 GONADOTROPHINSNOTES
CHORIONIC GONADOTROPHIN(CHORAGON) 5000 units Injection

(BREVACTID) 1500 units vials

Specialist prescribing only

Induction of spermatogenenis in men with hypogonadism who desire fertility (following Pregnyl discontinuation).

Endocrine testing: 3 week HCG test

Brevactid is unlicensed product. To prescribe when other products are unavailable.

Note: Pregnyl discontinued.

APC Traffic light status: none

MENOTROPHIN(MENOPUR) 75 units Injection

(MERIONAL) 75 units Injection

(MENOGON) 75 units Injection

APC Traffic light status: none
7.4 Growth hormone disorders
PITUITARY & HYPOTHALAMIC HORMONES & ANALOGUES – Human growth hormonesNOTES
SOMATROPINInjection 12mg (36 units) (Genotropin) Refill Cartridge

SimpleXx Refill Injection 15mg (45 units) (Norditropin)

MiniQuick Injection 0.4mg (1.2 units), 1.2mg (3.6units)(Genotropin) Syringe

Growth failure adults & children APC Traffic light status: AMBER

Growth Hormone Shared Care Guidance

8 Sex hormone responsive conditions
8.1 Female sex hormone responsive conditions
CALCIUM RELATING DURGS – bone resorption inhibitorsNOTES
Raloxifene60mg TabletNICE TA160: Raloxifene for the primary prevention of osteoporotic fragility fractures in postmenopausal women

NICE TA161: Raloxifene and teriparatide for the secondary prevention of osteoporotic fragility fractures in postmenopausal women

Osteoporosis APC Traffic light status: GREEN

OESTROGENSNOTES
CSM – REASONS TO STOP HRT
severe chest pain, sudden breathlessness, severe calf pain or stomach painneurological effects (prolonged headache/epileptic seizure/loss of vision/marked numbness)hepatitis/jaundice, severe depression, BP>160/100CSM – risk of breast cancer with HRT
CSM – risk of venous thromboembolism with HRT
CSM – risk of endometrial and ovarian cancer with HRT
CSM – risk of stroke and possibly coronary disease with HRTMHRA WARNING
CONJUGATED OESTROGENS (equine)PREMARIN 625 microgram TabletsHRT APC Traffic light status: GREEN
ESTRADIOL2mg Tablets

(ESTRADERM MX) 50 microgram Patches

EVOREL 25, 50 & 100 Patches

FEMSEVEN 50 microgram in 24hr Patches

HRT APC Traffic light status: GREEN
ETHINYLESTRADIOLTablets
10micrograms, 50 micrograms & 1mg
HRT APC Traffic light status: GREEN
TIBOLONE2.5 mg TabletsHRT APC Traffic light status: GREEN
ESTRADIOL + NORETHISTERONE EVOREL CONTI Patches

CLIMAGEST 2mg Tablets

KLIOVANCE Tablets

TRISEQUENS Tablets

HRT APC Traffic light status: GREEN
ESTRADIOL + NORGESTRELCYCLO-PROGYNOVA 2 mg TabletsAPC Traffic light status: none
CONJUGATED OESTROGENS + MEDROXYPROGESTERONEPREMIQUE TabletsHRT APC Traffic light status: GREEN
PROGESTOGENSNOTES
MEDROXYPROGESTERONETablets 5mg, 10mgAPC Traffic light status: none
NORETHISTERONETablets 1mg, 5mgAPC Traffic light status: none
PROGESTERONEPessaries 200mg, 400mg

Injection 50mg in 1ml, 100mg in 2ml

APC Traffic light status: none
8.1a Anti-oestrogens
CLOMIFENETablets 50mgInfertility APC Traffic light status: RED
8.2 Male sex hormone responsive conditions
TESTOSTERONETestosterone Decanoate Injection (Sustanon 250)

Undecanoate capsules 40mg

2% gel 10mg/application (Tostran)

Implant 100mg, 200mg

male hypogonadism APC Traffic light status: BLUE

low libido in women APC Traffic light status: BLUE

9 Thyroid disorders
PROTIRELIN200 micrograms in 2ml InjectionAPC Traffic light status: none
9.1 Hyperthyroidism
ANTITHYROID DRUGSNOTES
CARBIMAZOLETablets 5mg, 20mgCSM WARNING
Observe for NEUTROPENIA & AGRANULOCYTOSIS
Monitor for signs of infection & blood cell count.Hyperthyroidism APC Traffic light status: GREEN
PROPYLTHIOURACILTablets 50mgHyperthyroidism APC Traffic light status: GREEN
IODINE(Lugol’s Oral Solution)
Iodine 5%, potassium iodide 10%
 Visualisation in Surgery / Diagnostics

Total Iodine 130mg/ml

APC Traffic light status: none

9.2 Hypothyroidism
LEVOTHYROXINE SODIUMTablets 25micrograms, 50micrograms, 100microgramsUKMi Interaction between Orlistat & Thyroxine

Hypothyrodism APC Traffic light status: GREEN

LIOTHYRONINETablet 20microgramsHypothyroidism with inadequate response or intolerance to levothyroxine APC Traffic light status: AMBER

Liothyronine MONOTHERAPY Amber shared care guidelines – Dec 2019 Shared Care Agreement Communication Form

APC statement: Liothyronine for hypothyroidism

Monotherapy in oncology – thyroid and parathyroid disease APC Traffic light status: RED

APC statement: Liothyronine in oncology

Thyrotoxicosis APC Traffic light status: RED

APC policy statement – Liothyronine for thyrotoxicosis – June 2019

Depression APC Traffic light status: RED

APC policy statement – Liothyronine for depression – June 2019

Injection 20microgramsMore rapid onset of action than levothyroxine
In hypothyroid coma though always check for adrenal sufficiencyComa of Myxoedema APC Traffic light status: REDAPC policy statement – Liothyronine myxoedema coma – June 2019

 

1. Gastro-Intestinal System | 2. Cardiovascular System | 3. Respiratory System | 4. Central Nervous System | 5. Antimicrobials | 6. Endocrine System | 7. Obstetrics, Gynaecology & Urology | 8. Malignant Disease & Immunosuppression | 9. Nutrition & Blood | 10. Musculoskelatal & Joint Diseases | 11. Opthalmology | 12. Ear, Nose & Oropharynx | 13. Dermatology | 14. Immunology & Vaccines | 15. Anaesthetics |  GP Centre Home