FOR USE IN HOSPITAL ONLY

Diagnosis of Conn's syndrome(3 days after initiation of slow sodium : IV infusion of 50micrograms per hour starting one hour before adrenal vein sampling.

• Barts Endocrine Protocol
• Barts Endocrine webpage

FOR HOSPITAL USE ONLY

FOR HOSPITAL USE ONLY

Used by fertility services

For Dose and Administration please see: https://www.medicines.org.uk/emc/product/384/smpc 

FOR HOSPITAL USE ONLY

Last line treatment for acromegaly

Approved at NEL FPG December 2022 (shared care where GPs are willing to Rx)

Omnitrope approved at NEL FPG  as growth hormone replacement therapy in adult patients. 

Omnitrope will be available as an option or GH in suitable patients who can not use Genotropin

0.2mg – 0.5mg daily lifelong

FOR HOSPITAL USE ONLY

• Octreotide is a licensed long acting somatostation analogue used in the treatment of acromegaly & neuroendocrine neoplasms. Injections are administered once a month once patients have been converted from regular Octreotide.

FOR HOSPITAL USE ONLY

Used for neuroendocrine tumours (carcinoid syndrome)

see attached

• The Management of Type II Diabetes

Approved at DTC meeting for type 2 diabetes mellitus as dual therapy in adults as combination with either metformin, pioglitazone, a sulfonylurea or insulin (when treatment with these drugs alone fails to achieve glycaemic control), or as triple therapy in combination with metformin and either pioglitazone or insulin.

First-line choice in both Primary and Secondary Care. The case for removing saxagliptin from the Formulary was well made, and accepted by Committee members from both Primary and Secondary Care. Some patients might continue on saxagliptin where their clinical status was stable, although the opportunity for switching away from it would be grasped by all prescribers where it arose.

Dapagliflozin approved at NEL FPG for treating chronic heart failure with preserved or mildly reduced ejection fraction in line with NICE TA.

• NICE TA 902

Prescribing and monitoring according to NICE Guidance

https://www.nice.org.uk/guidance/ng28

Empagliflozin approved at NEL FPG for treating chronic heart failure with preserved or mildly reduced ejection fraction

Formulary Status: Amber

– To be initiated by or on the recommendation of a specialist

• NICE TA 929

Empaglifozin approved at NEL FPG for the treatment of Type 2 Diabetes Mellitus in Children and Young People.

First line SGLT2 Inhibitor in line with NICE Guidance (NG18) 

Formulary Status: Amber – specialist initiated 

• NG18

Approved at DTC July 2022 for the treatment of symptomatic chronic heart failure with reduced ejection fraction

• NICE TA 793

Empagliflozin Approved at NEL FPG for treating chronic kidney disease

Formulary Status: Amber

– To be initiated by or on the recommendation of a specialist

• NICE TA 942

https://www.nice.org.uk/guidance/ta572

NICE TA583 : Ertugliflozin with metformin and a dipeptidyl peptidase-4 inhibitor for treating type 2 diabetes (June 2019)

see attached

• The Management of Type 2 Diabetes

First line Sulphonylurea

see attached

• Management of Type 2 Diabetes

HIGH STRENGTH 500 units per mL

Hospital only

• Humulin RU500 insulin 4 page leaflet Barts health version.docx
• High Strength Insulin Procedure - BH May 2014.docx

NICE Type 1 Diabetes

• NICE Type 1 Diabetes

BLT Diabetes Handbook

• Diabetes Handbook.doc

HIGH STRENGTH 500 units per mL

Hospital only

• High Strength Insulin Procedure - BH May 2014.docx

This brand should only be prescribed under specialist supervision for patients under the care of tier 3 obesity services

Polycystic Ovary Syndrome (PCO): 500mg three times a day (starting at 250mg daily for 1-2weeks, then 500mg once a day for 1-2 weeks, increasing by 500mg every 1-2 weeks)

see attached

• Management of Type 2 Diabetes

Semaglutide subcutaneous injection was APPROVED for DIABETES MELLITUS in the Drugs and Therapeutics Committee (DTC) in November 2020. 

Semaglutide oral tablets for Diabetes mellitus approved for use in May 2022 DTC.

 Semaglutide approved at NEL FPG as Hospital only as part of specialist Tier 3 or equivalent weight management service.

NB-Contact the formulary team for NEL ICB supply position statement.

• NICE TA 875

see attached

• Management of Type 2 Diabetes

Tirzepatide approved at NEL FPG for treating type 2 diabetes in line with NICE TA.

Formulary Status: Amber

– to be initiated either:

• by or on the recommendation of a specialist

• by primary care prescriber(s) with specialist knowledge and/or has received training to prescribe this medicine

**Please contact the procurement team before prescribing to ensure stock availability. 

• NICE TA 924

• NICE Type II Diabetes

Duloxetine is used for diabetic neuropathy.

Renal patients: Hypertension or post MI and heart failure.

see attached

• Trust Core Policy Hypoglycaemia in Adults

FOR HOSPITAL USE ONLY

Hospital only drug

Hospital only drug

50mg/ml oral solution available by 'special order'

IV FORMULATION IS FOR HOSPITAL USE ONLY

Approved at NEL FPG (Nov 2022)

Betesil® 2.250mg medicated plaster is the only potent corticosteroid indicated in adults for the treatment of inflammatory skin disorders.

The plaster is licensed to use for a maximum of 30 days at a time, with a maximum of 6 plasters being used at any one time. Plasters may be changed once every 24 hours.

Amber-may be prescribed by or on the advice of a specialist 

Approved at NEL FPG in line with NICE TA 824.

Dexamethasone intravitreal implant (Ozurdex) is recommended as an option for treating visual impairment caused by diabetic macular oedema in adults only if their condition has not responded well enough to, or if they cannot have non-corticosteroid therapy.

This is an update and replacement of TA 349

• NICE TA 824

Second line steroid replacement-usual dose is 500 micrograms in the morning and 250 micrograms in the evening

Injection is HOSPITAL ONLY

First line for mineralcorticoid replacement (rarely required for ACTH deficiency).
usual dose: 50 to 100 micrograms twice a day

First line for glucocorticoid replacement therapy.

Usual dose: 10-50mg per day but can be highly variable and depends on individual patient's needs.
The standard regimen is 10mg on waking, 5mg at lunchtime and 5mg with the evening meal (usually no later than 7pm to mimic normal dinural rhythm).

Steroid cover in surgery

On the day of surgery, 100mg IM hydrocortisone is given as pre-medication and then every 6 hours for the duration of therapy. During surgery, cover lasts 4 hours so further doses may be required for  long operations.

An intravenous infusion of 4mg/hour can be set up until swapping to IM injections

• Short procedures- one dose of 100mg IM hydrocrtisone
• Minor operations-  24 hours of therapy
• Major operations- 72 hours of therapy

• Cold sore, sore throat (without fever)- no alteration to dose regimen
• Pyrexia- double the usual oral replacemnt dose
• Severe illness-100mg hydrocortisone IM injection

see attached

• CF Prescribing Pathway Final Version 5 Dec 2015.doc

Second line for glucocorticoid replacement (usual dose 5mg in the morning and 2.5mg in the evening)

Polycystic Ovary Syndrome (PCO): reverse circadian rhythm dosing (2.5mg on rising and 5mg at bedtime)

Steroid therapy for supression of ACTH secretion

In adrenal hyperplasia, adrenal carcinoma, polycystic ovaries and ectopic ACTH secretion, Prednisolone is used in doses reverse to replacement therapy i.e. two-thirds of the dose before bedtime (to supress the normal cortisol surge beginning at 3am). Some corticosteroid is required during the day and the remaining one-third of the dose is given at the time of waking.

Idiopathic Pulmonary Fibrosis (IPF)

For full monograph-see section 6.3.2

Prednisolone G/R tablets are non-formulary, predisolone normal release should be used instead

corticoterlin

• Barts Endocrine webpage

FOR HOSPITAL USE ONLY

Screening test for Cushing's syndrome (un-licensed)

• Alopecia Pathway 03.pdf

Cushing's syndrome dosing range:  between 1-6 grams per day, most frequently 2-3 grams per day.

Following an initial test dose, the usual dose is 250mg-500mg three times a day with food, increased according to response.

Treatment can be continued long-term or prior to surgery.

Metyrapone capsules can be opened and the contents swallowed or  sprinkled onto food. (unlicensed use)

Hypercortisol emergency (un-licensed) for short-term use on recommendation of endocrine consultants only

Clonidine transdermal patches approved at NEL FPG for dystonia in paediatrics (unlicensed).

For severe dystonia in patients who could not be adequately managed on oral medications either due to side effects from
higher doses or the burden of increased frequency of dosing administered by carers and families

Formulary Status: Hospital Only

Hospital only for ADHD

Clonidine Patches are for specialist initation only within the hypertension clinic. These are used for the  treatment of hypertension where the oral route is inappropriate or there is a lactose allergy to tablets. Doses are initated and titrated within clinic.

Dienogest approved at NEL FPG for treatment of endometriosis.

Formulary status: Amber (specialist initiation) 

-GP to continue prescribing following the first month of supply by the specialist. Patient to be reviewed by the specialist team at 1 month and at 6 months.  

Approved at December 2021 DTC 

Lenzetto is a transdermal estrogen spray indicated as Hormone Replacement Therapy (HRT) for oestrogen deficiency symptoms in postmenopausal women (in women at least 6 months since last menses or surgical menopause, with or without a uterus).

The experience in treating women older than 65 years is limited.

Striant® SR is non-formulary and not available in the UK therefore is an unlicensed product. If required please complete a DTC Chairman's Action Form. Please note that this is a controlled substance and will require import permit so lead time can be upto 8 weeks.

Testogel: ONE sachet contains 6.25mg testosterone/day- When used in Women for menopausal symptoms control use a peasize daily, with the aim to use a total of one full sachet in a week, not per day.

Hirsutism: 50mg daily for the first 10 days of  each cycle of Co-Cyprindol

Acromegaly: build up dose from 1.25mg at 2-3 day intervals usually up to 10-60mg per day.

NOT used for supression of lactation

First line for prolactinoma as better side effect profile compared to bromocriptine

For acromegaly-use on alternate days (or even daily) in some circumstances

The use of Binosto has been approved for use within its licensed indication in line with SMC recommendations as well as patients treated by specialist Rheumatologist Consultant who deems them to have failed to tolerate generic Alendronic acid due to Gastrointestinal Side effects.

HOSPITAL only untill DTC review in Jan 2018. ( Review still pending August 2018 no change to hospital only status)

• Binosto SMC.pdf

IV FORMULATION IS FOR  HOSPITAL USE ONLY

Skeletal related events in cancer

 Following the MHRA Drug Safety Updates for denosumab in September 14 and July 15 the guideline for management of SRE in cancer has been updated with the following recommendations:

• Patients need to have their calcium levels checked within 2 weeks of the initial dose of denosumab.  The patient can be bled locally, or as an outpatient, but please ensure the patient is booked into the day unit with a follow-up appointment  2 weeks after their 1^st dose so the bloods are reviewed and actioned accordingly.
• Patient to be made aware of the symptoms of hypocalcaemia so they know when to report them and further investigations can be carried out as appropriate.
• The patient is to be given the patient reminder card for denosumab, providing safety information they need to be aware of before and during treatment.  Available at https://www.medicines.org.uk/emc/RMM.240.pdf
• Denosumab 120mg is contraindicated to patients with unhealed lesions from dental or oral surgery.

Approved  in hospital for secondary prevention of osteoporosis in men and women 60 years or over, who meet the following inclusion criteria:

1.    Patients with severe renal impairment.

2.    Patients who are intolerant and with contraindications to bisphosphonate therapy.

3.    Patients with severe vertebral osteoporosis.

IV FORMULATION IS FOR HOSPITAL USE ONLY

Pamidronate is the bisphosphonate of choice as bone protection post renal transplant.

FOR HOSPITAL USE ONLY

Hypercalcaemia-will decrease calcium after 24 hours (5-6 days for the full effect). Effects last 14-21 days

Approved via chair's action 11th August 2022 DTC for treating severe osteoporosis in line with NICE TA 791

Hospital Only

FOR HOSPITAL USE ONLY

Severe post menopausal osteoporosis

Barts Health uses generic zoledronic acid for osteoporosis

DESMOSPRAY^® & INJECTION FORMULATIONS ARE FOR HOSPITAL USE ONLY

In renal patients the Trust uses the injection to minimise bleeding complications during insertion of CVCs and taking biopsy samples. 

Cranial diabetes Insipidus

Approved by December 2019 DTC for use in Nocturnal Enuresis

FOR HOSPITAL USE ONLY

Currently there is a shortage of Potassium Iodate tablets and therefore Potassium Iodide tablets have been procured instead. Potassium Iodate 85mg tablet provided approximately 50mg of Iodine as does Potassium Iodide 65mg tablet.

Reduction of thyroid gland vascularity prior to surgery (thyroidectomy):   85mg twice daily for ten days

For radioactive diagnostic scans (I-123 mIBG): 85mg twice a day starting one hour prior to the  scan for a total of 6 doses.

For 1-131 mIBG therapy of tumours:  85mg twice a day starting one day prior to the  scan for a total of 12 doses.

Reduction of thyroid gland vascularity prior to surgery (thyroidectomy):   85mg twice daily for ten days

For radioactive diagnostic scans (I-123 mIBG): 85mg twice a day starting one hour prior to the  scan for a total of 6 doses.

For 1-131 mIBG therapy of tumours:  85mg twice a day starting one day prior to the  scan for a total of 12 doses.

First line for management of elevated thyroid hormones

Initiation for atrial fibrillation, hypertension, secondary prevention of MI, heart failure, stable angina.

Note: Metoprolol initiated until stable and then changed to a less frequent dosage regime.

Alternative for hypertension in pregnancy.

https://www.nice.org.uk/guidance/ng185

https://www.nice.org.uk/guidance/ng196

https://www.nice.org.uk/guidance/ng133

https://www.nice.org.uk/guidance/cg126

Phaechromocytoma (usually started 24 hours after Phenoxybenzamine)

Also used orally for cutaneous haemangioma where topical timolol not appropriate.

For use in the management of acute alcohol withdrawal-see 'Alcohol dependence https://www.formularycomplete.com/view/treatmentsummary/monograph/848264 

Symptomatic relief of thyrotoxicosis-

Alternative treatment  to carbimazole for elevated thyroid hormones.

Preferrable to Carbimazole in first trimester in women who are pregnant

First line for hypothyroidism
usually initiated at 50micrograms/day (or alternate days if patient is elderly).  Younger patients may start at 100micrograms/day

HOSPITAL USE ONLY (for infertility)

HOSPITAL USE ONLY (for infertility)

FOR HOSPITAL USE ONLY

FOR HOSPITAL USE ONLY for All indications except for treatment of prostate cancer 

Used for endometriosis and fibroids

• Urology- Goserelin 10.8mg prescription.pdf
• Urology- Goserelin 3.6mg prescription.pdf

HOSPITAL USE ONLY for ALL indications except for treatment of prostate cancer 

HOSPITAL USE ONLY (for infertility)

Approved at NEL FPG for Oral treatment of moderate to severe symptoms of uterine fibroids in line with NICE TA 832.

Use in patients who have failed or are unsuitable for conventional therapies (first line treatments).

• NICE TA 832