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6.3 Diabetes mellitus and hypoglycaemia

First line drugs Second line drugs Specialist drugs Secondary care drugs

Traffic light status (TLS) explained:

  • Green: Routine prescribing within licensed indication
  • Amber 1: specialist recommendation followed by GP initiation and continuation
  • Amber 2: specialist or GP initiation in line with local guideline after 1st line failure followed by GP continuation
  • Amber 3: specialist initiation and stabilisation followed by GP continuation
  • Amber SCG: specialist initiation and stabilisation followed by GP continuation in line with an agreed shared care guideline
  • Red: Hospital or specialist prescribing only

 

6.3.1 Diabetes mellitus

 

Alpha-Glucosidase inhibitors

Acarbose

  • Tablets 50mg, 100mg

Note: Acarbose should be taken or chewed with the first mouthful of food or swallowed whole with liquid immediately before food. The possibility of GI side effects is reduced by lower incremental dosage increases

 

 

Biguanides

 

Metformin

  • Tablets, coated 500mg, 850mg
  • Oral solution, 500mg in 5ml

 

Metformin MR

  • Glucophage modified release tablets 500mg, 750mg, 1g

Notes:

  • Metformin MR should only be used where the standard-release tablets have been tried and are not tolerated due to GI problems, despite gradual dose titration. Any new prescription of the MR preparation should be reviewed soon after initiation and discontinued if not tolerated or ineffective.
  • NICE Guidelines NG28: Type 2 diabetes in adults - Management (December 2015)

 

 

DPP-4 (dipeptidylpeptidase-4) inhibitors (Gliptins)

Our preferred Gliptin is Sitagliptin

Sitagliptin

  • Januvia® Tablets 25mg, 50mg, 100mg

 

Sitagliptin with metformin

  • Janumet® Tablets 50mg/1g 

 

Linagliptin

  • Trajenta® Tablets 5mg

 

Linagliptin with metformin

  • Jentadueto® Tablets 2.5mg/850mg, 2.5mg/1g 

 

 

GLP-1 (Glucagon-Like Peptide-1) Receptor Agonists 

Our preferred GLP-1 agonists are Exenatide and Liraglutide

Exenatide (Amber 2)

  • Byetta® Injection 250micrograms/mL 

Notes:

 

Liraglutide (Amber 2)

  • Victoza® Injection 6mg/mL 

Notes:

    • Use as per NICE Guidelines NG28: Type 2 diabetes in adults - Management (December 2015
    • Patient must have received: appropriate lifestyle advice; including carbohydrate restriction prior to consideration and such lifestyle intervention should be continued
    • Review response at one month with discussion re continuation of prescription.
    • Licensed indications: Exenatide and Liraglutide are GLP-1 analogues licensed for the treatment of type 2 diabetes in combination with metformin and/or sulphonylureas and metformin and/or thiazolidinediones in patients who have inadequate glycaemic control on maximally tolerated doses of these drugs.
    • There are reports of pancreatitis in post marketing surveillance data. Prescribers need to be aware of the possibility of pancreatitis and, if suspected, discontinue use of exenatide as soon as possible.
  • Due to the increased risk of hypoglycaemia when exenatide is used in combination with sulphonylureas, drivers holding group 2 (LGV or PCV) licences who are taking this combination are required to notify the DVLA    

 

Dulaglutide (Amber 2)

  • Trulicity® Injection 0.75mg, 1.5mg

Notes:

 

Lixisenatide (Amber 2)

  • Injection, 50micrograms/mL (10micrograms/dose prefilled pen), 100micrograms/mL (20 micrograms/dose prefilled pen 
Notes:
 
  • Prescribers should consider stopping Lixisenatide when HbA1c has not reduced by 1% and weight by 3% of initial body weight at 6 months  
  •  

Semaglutide (Amber 2)

  • Ozempic 0.25 mg solution for injection in pre-filled pen　
  • Ozempic 0.5 mg solution for injection in pre-filled pen　
  • Ozempic 1 mg solution for injection in pre-filled pen

 

Glitazones

 

Pioglitazone (Amber 2)

  • Tablets 15mg, 30mg, 45mg

 

MHRA Drug Safety Update (January 2011)

  • Cases of cardiac failure have been reported when pioglitazone was used in combination with insulin, especially in patients with risk factors for the development of cardiac failure.
  • If the combination is used, patients should be observed for signs and symptoms of heart failure, weight gain and oedema.
  • Pioglitazone should be discontinued if any deterioration in cardiac status occurs.

 

Prandial glucose regulators

 

Repaglinide

  • Tablets 500mcg, 1mg, 2mg

 

SGLT2 (sodium-glucose co-transporter 2) inhibitors

Our preferred SGLT2 inhibitor is Empagliflozin 

MHRA Drug Safety Update SGLT2 inhibitors updated advice on the risk of diabetic ketoacidosis (April 2016)

MHRA Drug Safety Update SGLT2 inhibitors: reports of Fournier’s gangrene (necrotising fasciitis of the genitalia or perineum) (Feb 2019) 

 

 

Empagliflozin (Amber 2)

  • Jardiance® Tablets 10mg, 25mg 

Notes:  

 

Empagliflozin with metformin (Amber 2)

  • Synjardy® Tablets f/c 5mg/850mg, 5mg/1000mg, 12.5mg/850mg, 12.5mg/1000mg

 Notes:  

 

 

Ertugliflozin (Amber 2)

  • Steglatro® Tablets 5mg, 15mg

Note:

 

 

 

Canagliflozin (Amber 2)

  • Invokana® Tablets 100mg, 300mg 

Notes: 

 

Canagliflozin with metformin (Amber 2) 

  • Vokanamet® Tablets f/c 50mg/850mg, 50mg/1g  

Notes: 

 

Dapagliflozin (Amber 2)

  • Forxiga® Tablets 5mg, 10mg

Notes:

 

Dapagliflozin with metformin (Amber 2)

  • Xigduo® Tablets 5mg/850mg, 5mg/1g  

 

 

 

Sulphonylureas

Glibenclamide

  • Tablets 5mg 

 

Gliclazide

  • Tablets 80mg  

 

Glimepiride (Amber 2)

  • Tablets 1mg, 2mg, 3mg, 4mg

Note:

  • For continuation only

 

 

 

 

 

Insulins  

Important notes:

 

 

Insulin Passport

  • This Insulin Passport must be issued by the prescriber at a face to face consultation.

 

For patients using human /analogue insulin

Eli Lilly, Novo Nordisk and Sanofi - insulin safety cards.

These are plastic and therefore more durable than the paper-based passport, and have a picture of the device and packaging of the type of insulin which is ideal for many people but especially where English is not their first language (2).

Order from:

Eli Lilly: Veronica Guterres Diabetes Community Specialist Representative

Email: guterres_veronica@lilly.com or call on 07885 559471

Novo Nordisk: Sonia Chohan Diabetes Community Specialist Representative

Email: SOCA@novonordisk.com or call on 07545 938361

Sanofi Aventis: Call the 24 hour diabetes care line 08000 352525

 

 

 

Table: Insulin Preparations   

 

Insulin Preparations

Neutral Insulin Injection

Preparation

Species

Onset (approx.)

Peak activity (approx.)

Duration of action (approx.)

Actrapid

100 units per 1ml

Human

<30 minutes

1.5-3.5hr

7-8hr

Apidra (Insulin glulisine)

100 units per 1ml

Human

10-20 min

55 min

1.5-4hr

Fiasp (insulin aspart*)

Amber 3

100 units per 1ml

Human

4 min

1-3hr

3-5hr

Humalog (insulin lispro*)

100 units per 1ml

 

Humalog

(insulin lispro)

200 units per 1ml

(Amber 3)

Human

15 min

1.5hr

2-5hr

Humulin S

100 units per 1ml

Human

30 min – 1hr

1-6hr

6-12hr

Hypurine Bovine Neutral

100 units per 1ml

Bovine

30 min-1hr

1.5-4.5hr

6-8hr

Hypurine Porcine Neutral

100 units per 1ml

Porcine

30 min-1hr

1.5-4.5hr

6-8hr

Insulin Lispro Sanofi

100 units per 1ml

Human

15 min

1.5hr

2-5hr

Insuman Rapid

100 units per 1ml

Human

<30 min

1-4hr

7-9hr

NovoRapid (insulin aspart*)

100 units per 1ml

Human

10-20 mins

1-3hr

3-5hr

 

Biphasic Insulin Injection **

Preparation

Species

Onset (approx.)

Peak activity (approx.)

Duration of action (approx.)

Humalog Mix25

100 units per 1ml

Human

15 min

2hr

22hr

Humalog Mix50

100 units per 1ml

Human

15 min

2hr

22hr

Humulin M3

100 units per 1ml

Human

30 min – 1hr

1-12hr

22hr

Hypurine Porcine 30/70

100 units per 1ml

Porcine

<2hr

4-12hr

24hr

Insuman Comb 15

100 units per 1ml

Human

30 min – 1hr

2-4hr

11-20hr

Insuman Comb 25

100 units per 1ml

Human

30 min – 1hr

2-4hr

12-19hr

Insuman Comb 50

100 units per 1ml

Human

<30 min

1.5-4hr

12-16hr

NovoMix 30

100 units per 1ml

Human

10-20 min

1-4hr

24hr

 

 

Isophane Insulin Injection

Preparation

Species

Onset (approx.)

Peak activity (approx.)

Duration of action (approx.)

Humulin I

100 units per 1ml

Human

30min-1hr

1-8hr

22hr

Hypurin Porcine Isophane

100 units per 1ml

Porcine

<2hr

6-12hr

18-24hr

Insulatard

100 units per 1ml

Human

<1.5hr

4-12hr

24hr

Insuman Basal

100 units per 1ml

Human

<1hr

3-4hr

11-20hr

 

Insulin Zinc Suspension (Mixed)

Preparation

Species

Onset (approx.)

Peak activity (approx.)

Duration of action (approx.)

Hypurin Bovine Lente

100 units per 1ml

Bovine

2hr

8-12hr

30hr

 

Protamine Zinc Insulin Injection

Preparation

Species

Onset (approx.)

Peak activity (approx.)

Duration of action (approx.)

Hypurin Bovine PZI

100 units per 1ml

Bovine

4-6hr

10-20hr

24-36hr

  

Long-acting Insulin Analogues

Preparation

Species

Onset (approx.)

Peak activity (approx.)

Duration of action (approx.)

Abasaglar (insulin glargine)

100 units per 1ml

Amber 1

Human

30min – 1hr

-

24hr

Lantus (insulin glargine)

100 units per 1ml

Amber 1

Human

30min – 1hr

-

24hr

Levemir (insulin detemir)

100 units per 1ml

Amber 1

Human

30min – 1hr

-

24hr

Toujeo (insulin glargine)

300 units per 1ml

Amber 3

Human

30min – 1hr

-

24 – 36hr

Semglee

(Insulin galargine)

100 units per 1ml

Amber 1

 

Human

 

-

24hr

Tresiba (insulin degludec)

100 units per 1ml

(Amber 1)

 

Tresiba (insulin degludec)

200 units per 1ml

(Amber 3)

 

 

 

Human

 

 

30min – 1.5hr

 

 

-

 

 

>42hr

      

*Human insulin analogue

**Speed of onset is proportional to amount of soluble insulin.

 

 

Pen needles:

GlucoRx FinePoint, Microfine, Penfine and Unifine are compatible with all preloaded and reusable pens.

 

 

For patients using animal insulin 

Hypurin Wockhardt: Bethan Coles 

Email: Bethan.Coles@wockhardt.co.uk

Tel: 01978 661261 Ext:3162
Mobile:  0785 064 2916

 

Primary Care Systm1 READ Codes:

Please consider using the following READ Codes to the patient’s notes:

S1 READ Codes

Booklet:

 

Insulin alert patient information booklet given

XaYQX

Professional judgement not to engage patient with insulin alert requirements

XaYRc

Insulin alert patient information booklet information discussed

XaYQd

Passport:

Insulin passport given

XaYQZ

Insulin passport completed

XaYQh

Informed dissent not to carry insulin passport

XaYQi

For more advice regarding the Insulin Passport contact:

Julie Petzing Lead Diabetes Specialist Nurse MK Diabetes Care:

Email: julie.petzing@mkuh.nhs.uk

Janet Corbett Head of Medicines Management

Email: janet.corbett@.nhs.net

Dr Shanthi Chandran  Consultant Endocrinologist.

Email: shanthi.chandran@mkuh.nhs.uk

 

 

 

 

6.3.2 Hypoglycaemia

GlucoGel®

(formerly known as Hypostop) Glucose 40%

  • Oral gel, 3x25g tubes 

 

Glucagon 

  • Injection 1mg vial

 

Glucose infusion 

  • 10% infusion, 500ml and 1L bags
  • 20% infusion, 100ml and 500ml bags

 

Guidelines for the management of hypoglycaemia for adults:

Please refer to the BNFc for paediatric management of hypoglycaemia

  1. If conscious give one of the following options:  
    • Oral glucose - 3-7 dextrose tablets
    • 20-30ml polycal
    • 1-2 tubes of glucogel
    • 2-4 heaped teaspoons of sugar dissolved in water
    • 200ml Lucozade original      
    If not capable or cooperative give 1.5-2 tubes of glucogel or 1mg glucagon IM.
  2. If unconscious, fitting or aggressive:
    • 1mg glucagon IM (once only) or
    • 10% glucose or
    • 20% glucose infusion according to local guide;ines
    •  
    If patient has not regained consciousness immediately, then TREAT AGAIN and re-check capillary blood glucose. REPEAT up to 3 times if needed 

 

 

 

Diabetes mellitus, diagnostic and monitoring 

Glycosylated haemoglobin (HbA1c) is the preferred method to monitor overall diabetic control and should be carried out every 3-6 months.

Guidelines for Blood Glucose Monitoring

  1. Glucose monitoring should be used mainly for those on insulin therapy.
  2. A patient information leaflet about blood glucose testing is available.
  3. If these products are required regard should be given to both patient training on how to use the meter and how often the strips should be used, and the costs of prescribing (eg. diagnostic strips).
  4. Meters are not available on prescription and it is recommended that patients seek advice from their practice nurse, GP or community pharmacist prior to purchasing a meter.
  5. If the patient's diabetes is well controlled by diet or oral antidiabetic drugs, then it is suitable for the patient to do a fasting blood glucose test no more than once per week or not at all, in this situation monitoring HbA1c monthly may suffice. More frequent testing maybe advised if the patient is unwell.
  6. If the patient is insulin controlled, it is necessary to test daily. More frequent testing is required if trying to tighten control and adjust insulin or if the patient is unwell.
  7. Patients who are poorly controlled and being considered for insulin treatment may benefit from doing their own capillary blood glucose monitoring (CBGM) prior to starting insulin.
  8. NICE guidance states that self-monitoring:
    • should not be considered as a stand-alone intervention
    • should be taught if the need/purpose is clear and agreed with the patient.
    • can be used in conjunction with appropriate therapy as part of integrated self-care.
    • is not necessary for all patients

Insulin-treated patients

  1. Blood glucose monitoring should be used as a tool to assist the patient and their diabetes carer in diabetes management and insulin adjustments. A high frequency rate of monitoring, i.e. qds, or more, should be reserved for:
    • newly diagnosed type 1 patients;
    • people who are unwell (including vomiting, where urinary ketones should also be measured);
    • patients using insulin pump therapy;
    • pregnancy; pre-surgery;      
    • patients who are on intensive insulin self-management, adjusting insulin according to carbohydrate load. (eg. DAFNE - dose adjustment for normal eating).
    • frequent hypoglycaemic episodes;
    • loss of hypo warning signs
    • those on sulphonylureas who are driving or in vulnerable groups eg. frail elderly with higher risk of hypo.
  2. Home capillary blood glucose monitoring is not a substitute for laboratory testing.
  3. It is also important to measure for urinary ketones if blood glucose levels are greater than 15mmol/litre for more than 12 hours. 

 

Advice for diet and tablet controlled patients - when to test & what to do with the readings
Fasting Sugars less than 4   Fasting Sugars 4-6
This is normal range  		 Fasting Sugars 6-10   Fasting Sugars mostly 10 or over on more than 2 out of 3 occasions   Fasting Sugars mostly 15 or over  
If sugars are under 4, patient to see GP or practice nurse.   If patient is well and medication is stable then routine testing is not necessary.   Patient to test 3 times a week & check diet & activity levels. If 2 out of 3 tests are above 6 patient to see GP or practice nurse with two weeks worth of readings   Patient to test 3 times a week & check diet & activity levels. Patient to see GP or practice nurse with one week's worth of readings.   Patient to test daily & check diet & activity levels. Patient to see GP or practice nurse with 4 days worth of readings.  
  • Remind the patient to record blood readings in their record book and to bring the book for practice visits.
  • Remind the patient to test before having anything to eat or drink in the morning. Testing at other times may be helpful in specific situations.
  • Remember that when the patient's condition is well controlled and stable regular testing is unlikely to be necessary.
  • Remind the patient that in the event of illness affecting their blood sugars to see their GP as soon as possible  

 

 

Blood Glucose Meters and Test Strips

 

Blood glucose monitoring   

     Please click here for the full Quick Guide to reviewing Blood Glucose Monitors (August 2019) 

 

 

Needles

  • BD Viva

  • Tricare

  • Omnican Fine 32 gauge only

  • GlucoRx CarePoint range only

 

Lancets

 

 Blood Glucose Test Strip

Manufacturer

Compatible lancets-

TEE2

Spirit Healthcare

CareSens Lancets 0.36mm/28 Gauge

CareSens Lancets 0.31mm/30 Gauge
 If using careSens lancing pen

WaveSense Jazz

Agamatrix

AgaMatrix Ultra-Thin Lancets 0.20mm/33 Gauge
AgaMatrix Ultra-Thin Lancets 0.35mm/28 Gauge
If using Agamatrix lancing device

Mobile Accu-chek

Roche

Has integrated finger pricker so must be Fast clix lancets. These have replaced softclix and mutliclix lancets

FastClix Lancets 0.3mm/30 Gauge

GlucoMen Areo Sensor Strips / Ketone Sensor strips (Glucomen Areo 2k meter)

Menarini

Glucoject PLUS Lancets 0.20mm/33 Gauge

 

Aviva for users of Accu-Chek Aviva Expert Meter only

Roche

 
FastClix Lancets 0.3mm/30 Gauge

 

 

 

Freestyle Libre (Amber 3)

 

GPs should not initiate the use of Freestyle Libre or provide prescriptions for sensors if the patient has purchased the meter themselves.

 

The following application process must be adhered to:

 

Freestyle Libre - Flash Glucose Monitoring System – funding application for the initiation of use in adults, young people and children 4 years of age and older with diabetes mellitus as defined in NHSE criteria (March 2019).

 

Freesytle Libre - Flash Glucose Monitoring System – Application for the continuation of funding for use in adults, young people and children 4 years of age and older with diabetes mellitus as defined in NHS England criteria (March 2019).

 

Freestyle Libre - Patient Agreement Form

 

Freestyle Libre - Report Summary to GP (Template)

 

Note:

MHRA Alert to users of FreeStyle Libre flash glucose sensor (Jan 2019)

 

 

 

Useful Resources

 

Hypodermic equipment  

 

  • Note: A range of hypodermic equipment is available on NHS prescription. However, for up to date information on which lancets and other injection devices are available please refer to the latest Drug Tariff. http://www.ppa.org.uk/ppa/edt_intro.htm

 

 

 

Prevention of Sharps Injury

Safety retractable pen needles

To ensure HCW safety, safety (retractable) needles should be used where appropriate conditional upon injection zone and BMI

Our choice of retractable needles are available:

  • BD Auto Shield Duo Safety Pen Needle 5mm

These retractable needles are fitted with a sliding shield. This shield covers the needle before injection, retracts during injection, and then slides back into place to cover the needle again, locking permanently into a shielding position following insulin delivery. Once the needle has been used, the safety lock indicator turns red to indicate that the shield is now locked. This effectively blocks any accidental needle puncture wounds as well as any re-use of the needle.

These can be ordered from supplies on:

  • BD AutoShield 5mm : SBS FTR1083

 

For Further Guidance on the most appropriate needle remover device or safety retractable needles please contact: Diabetes Specialist Nursing Service

Lead Diabetes Specialist Nurse MK - Julie Petzing

                             

 

Guidelines and Technology Appraisals 

 

 

 

Traffic light status (TLS) explained:

  • Green: Routine prescribing within licensed indication
  • Amber 1: specialist recommendation followed by GP initiation and continuation
  • Amber 2: specialist or GP initiation in line with local guideline after 1st line failure followed by GP continuation
  • Amber 3: specialist initiation and stabilisation followed by GP continuation
  • Amber SCG: specialist initiation and stabilisation followed by GP continuation in line with an agreed shared care guideline
  • Red: Hospital or specialist prescribing only

 

 

 

Return to Chapter: 6. Endocrine System

Last updated by: Sheila Wood on 06-08-2019 11:39