6: Endocrine system
Please select a topic:
6.1 Drugs used in diabetes
6.2 Thyroid and antithyroid drugs
6.3 Corticosteroids
6.4 Sex hormones
6.5 Hypothalamic and pituitary hormones
6.6 Drugs affecting bone metabolism
and anti-oestrogens
6.7 Other endocrine drugs
Red = Hospital use only
Green = GP & Hospital use. Drugs not classified as Red, Amber or Amber 2 are classified as Green by default
Amber 1 = Drugs with shared care agreement
Amber 2 = Initiated by Hospital specialist only
Gateshead Health NHS Foundation Trust
Drug Formulary
Page 1 of 19
Date: 1.6.2012
Review Date: 1.6.2013
6.1 Drugs used in diabetes
Insulins
General notes

Insulin should be initiated on specialist advice only. Choice depends on the particular needs
of the individual patient, taking into account lifestyle, age, preference and capabilities.

Type of insulin, device and needle size should be specified. Care should be taken to write the
brand name in full to avoid errors such as, for example, administration of Humalog® in place
of Humalog® Mix25 or Humalog® Mix50.

Patients should not be changed from the insulin that they are currently receiving without
specialist advice; ensure that the correct insulin has been prescribed.

Insulin is available in 3mL cartridges, 10mL vials, and 3mL disposable pens. Not all insulin
cartridges fit all pens.

Pens are available on prescription.

The B-D Safe-Clip® device snaps the needle off insulin syringes and stores the needle safely
inside the clipper; this device is available on prescription.
Short-acting insulins

Human Actrapid 10ml vial

Human Novarapid 10ml vial, 3ml cartridges, 3ml flexpen

Humulin S 10ml vial, 3ml cartridges

Insulin Gluisline (Apidra®) 3ml solostar pen, 10ml vial, 3ml cartridges

Insulin Lispro (Humalog) 10ml vial, 3ml cartridges, 3ml Kwik pen
Intermediate-acting insulins

Humulin I 10ml vial, 3ml cartridges

Human Insulatard 10ml vial, 3ml cartridges, prefilled disposable pen
Long-acting insulins

Insulin Glargine (Lantus) 10ml vial, 3ml cartridges, 3ml Solostar pen

Insulin Detemir (Levemir®) 3ml cartridges, prefilled disposable pen(Flexpen)
Biphasic insulins

Human Novomix 30 3ml cartridges, prefilled disposable pen(Flexpen)

Humulin M3 10ml vial and 3ml cartridges

Humalog Mix 25 10ml vial, 3ml cartridges and prefilled disposable pens

Humalog Mix 50
Oral diabetic drugs

Acarbose 50mg tablets
Red = Hospital use only
Green = GP & Hospital use. Drugs not classified as Red, Amber or Amber 2 are classified as Green by default
Amber 1 = Drugs with shared care agreement
Amber 2 = Initiated by Hospital specialist only
Gateshead Health NHS Foundation Trust
Drug Formulary
Page 2 of 19
Date: 1.6.2012
Review Date: 1.6.2013

Exenatide 5microgram/dose and 10microgram/dose pen (Byetta®)

Exenatide MR 2mg injection (Bydureon®)

Liraglutide 18mg/3ml pen

Glibenclamide 2.5mg, 5mg tablets

Gliclazide 30mg MR tablets

Gliclazide 80mg tablets

Glimepiride 1mg and 2mg tablets

Glipizide 5mg tablets

Metformin 500mg, 850mg tablets

Metformin 500mg/5ml suspension

Metformin SR 500mg and 1000mg tablets

Metformin 500mg and 1000mg sachets

Pioglitazone 15mg and 30mg tablets

Sitagliptin 100mg tablets

Saxagliptin 2.5mg and 5mg tablets

Tolbutamide 500mg tablets
Dose
- Metformin tablets 500mg, 850mg: initially 500mg once or twice daily with meals; gradually
increased to max 2g daily divided doses.
- Metformin SR tablets 500mg, 1000mg: initially 500mg once; gradually increased to max 2g once
daily with evening meal.
- Metformin sachets 500mg: initially 500mg once; gradually increased to max 2g once daily with
evening meal.
- Acarbose tablets 50mg: initially 50mg daily; gradually increased to max 200mg three times a
day.
- Exenatide (Byetta®) injection 250micrograms/ml: initially 5micrograms twice daily within 1 hours
before 2 main meals (at least 6 hours apart), increased if necessary after at least 1 month to max
10micrograms twice daily.
- Exenatide MR (Bydureon®) injection 2mg: 2mg once a week.
- Liraglutide injection 6mg/ml: initially 0.6mg once daily, increased after at least 1 week to 1.2mg
once daily, increased if necessary after at least 1 week to max 1.8mg once daily.
- Sitagliptin tablets 100mg: 100mg once daily.
- Saxagliptin tablets 2.5mg, 5mg: usual dose is 5mg once daily.
- Tolbutamide tablets 500mg: 500mg to 1g (max 2g) daily in divided doses with or immediately
after breakfast.
- Glimepiride tablets 1mg and 2mg: initially 1mg daily with meals; adjusted according to response
up to usual max 4mg daily.
- Glibenclamide tablets 2.5mg and 5mg: initially 5mg daily with or immeditately after breakfast;
adjusted according to response up to max 15mg daily.
- Gliclazide tablets 80mg: initially 40-80mg daily, max 320mg daily; doses above 160mg daily
should be divided.
Red = Hospital use only
Green = GP & Hospital use. Drugs not classified as Red, Amber or Amber 2 are classified as Green by default
Amber 1 = Drugs with shared care agreement
Amber 2 = Initiated by Hospital specialist only
Gateshead Health NHS Foundation Trust
Drug Formulary
Page 3 of 19
Date: 1.6.2012
Review Date: 1.6.2013
- Glipizide tablets 2.5mg, 5mg: initially 2.5-5mg daily, max 20mg daily; doses above 10mg daily
can be divided.d to usual maintenance dose 1g twice daily; max 3g daily in divided doses.
- Pioglitazone tablets 15mg, 30mg: in combination with metformin or a sulphonylurea, 15-30mg
once daily.
Prescribing notes
General notes

First-line treatment for management of type 2 diabetes is usually a trial of dietary therapy
unless there is intercurrent infection, severe hyperglycaemia or severe osmotic symptoms.

Patients commencing blood glucose lowering agents should inform the DVLA and their car
insurance company.

Those with type 2 diabetes may require treatment with insulin, either alone or in combination
with oral agents.

Newer hypoglycaemic agents are substantially more expensive than the older hypoglycaemic
agents.
Biguanides and sulphonylureas

Metformin is the first choice oral hypoglycaemic drug. It is the only oral antidiabetic drug
which has a proven survival advantage. It does not need to be limited to overweight patients.

Due to the rare but serious risk of lactic acidosis, metformin must be avoided in patients
with: significant renal impairment (estimated glomerular filtration rate (eGFR) less than
30mL/min); alcoholism with previous pancreatitis; severe cardiac/respiratory disease
producing tissue hypoxia; severe liver disease with potential for hepatic failure.

The precipitant of a lactic acid crisis is often in the eGFR range 30 to 45mL/min when the
patient develops what would have been a trivial illness (such as diarrhoea and vomiting)
which compromises renal function and causes acute renal failure. This is compounded if the
patient is also taking diuretics and/or ACE inhibitors in combination with metformin. Unlike
acute illnesses in type 1 diabetes (where insulin treatment MUST be continued) stopping the
above cocktail of drugs for a day or two will NOT cause any immediate problem for the
patient and will protect renal function until the patient improves. Blood glucose estimation
should be used to assess any glycaemic deterioration. In circumstances where renal
impairment is suspected, NSAIDs should NOT be used as they can further compromise renal
function.

Metformin may cause gastro-intestinal adverse effects; it should be started at low dose and
taken after meals, and the dose gradually increased every 10-15 days if tolerated.
Hypoglycaemia is not a problem with metformin monotherapy.

Metformin prolonged release tablets (Glucophage SR®) are restricted for use in patients who
are unable to tolerate immediate release metformin, and in whom the continued use of
metformin offers a clinically significant benefit. They are more expensive than the immediate
release tablets but les expensive than other newer oral agents.

Sulphonylureas should be taken before meals

Gliclazide 30mg m/r (Diamicron® MR) should be reserved for patients with demonstrable
compliance problems.

Patients should be informed that sulphonylureas can cause hypoglycaemia. The risk of
hypoglycaemia increases with age.
Red = Hospital use only
Green = GP & Hospital use. Drugs not classified as Red, Amber or Amber 2 are classified as Green by default
Amber 1 = Drugs with shared care agreement
Amber 2 = Initiated by Hospital specialist only
Gateshead Health NHS Foundation Trust
Drug Formulary
Page 4 of 19
Date: 1.6.2012
Review Date: 1.6.2013
Glitazones (thiazolidinediones)

Pioglitazone can be used in combination with insulin in patients with type 2 diabetes mellitus,
who have insufficient glycaemic control on insulin, in whom metformin is inappropriate
because of contraindications or intolerance.

Glitazones can cause weight gain and fluid retention. They must not be used in patients with
heart failure or history of heart failure.

Glitazones reduce bone mineral density in post-menopausal women with a subsequent
increase in fracture risk. They should be avoided in elderly women with high fracture risk,
irrespective of cardiovascular risk.

Liver function should be checked before initiating glitazones and periodically thereafter based
on clinical judgement. Glitazones should not be used in patients with hepatic impairment.

There is an increased risk of hypoglycaemia when combined with a sulphonylurea.
Dipeptidyl peptidase-4 inhibitor (DDP-4 inhibitor)

Sitagliptin is approved for use by prescribers with a special interest in diabetes. It should be
used in combination with metformin where the addition of a sulphonylurea is not appropriate.

Saxagliptin should be reserved for use in patients with moderate to severe renal impairment,
at a reduced dose of 2.5mg once daily.

DDP-4 inhibitors are considered to be weight neutral.

DPP-4 inhibitors have been shown to reduce Hb1Ac levels but there is not data on morbidity,
mortality, or long-term adverse effects.
Incretin mimetic

Exenatide is administered by subcutaneous injection, twice daily, within 1 hour of eating 2
main meals. Doses should be at least 6 hours apart.

Exenatide therapy should be initiated at 5 micrograms per dose, administered twice daily for
at least one month and can then be increased to 10 micrograms twice daily.

Needle guage and length must be specified when prescribing exenatide.

10-20% of patients experience upper gastro-intestinal side effects with exenatide. Acute
pancreatitis has been reported with exenatide, patients should be informed of the warning
signs to look for.

Liraglutide may be an option in those experiencing excessive side-effects with exenatide. It is
administered once a day independent of food intake, which may suit those with irregular
working patterns.

There is an increased risk of hypoglycaemia when combined with a sulphonylurea.

Long term studies are needed to determine the effects of exenatide and liraglutide on disease
related morbidity and mortality.

Gastric emptying may be delayed, therefore the rate and extent of absorption of other drugs
administered at the same time may be affected. For oral drugs that require threshold
concentrations for efficacy, patients should take these medicines at least 1 hour before.
Red = Hospital use only
Green = GP & Hospital use. Drugs not classified as Red, Amber or Amber 2 are classified as Green by default
Amber 1 = Drugs with shared care agreement
Amber 2 = Initiated by Hospital specialist only
Gateshead Health NHS Foundation Trust
Drug Formulary
Page 5 of 19
Date: 1.6.2012
Review Date: 1.6.2013
Treatment of hypoglycaemia

Glucagon 1mg syringe

Glucose 40% gel 25g
Dose
- Glucagon 1mg vial: subcutaneous, intramuscular or intravenous injection, adult and child over
25kg- 1 mg.
Prescribing notes

Following administration of glucagon, it is important to give supplementary carbohydrate to
restore liver glycogen and prevent secondary hypoglycaemia.

Although intravenous glucose is the more effective treatment where intravenous access is
readily available, intramuscular glucagon may be more appropriate.

Glucagon injection may be repeated once after 10 minutes if necessary, but intravenous
glucose is preferable. If there is no response, then hospital admission should be considered.
Diabetic equipment

Insulin syringes 100 units

Microfine + needles 5mm, 8mm, 12.7mm

Accu-check advantage II Test strips

Accu-check Aviva blood test strips

Diabur 5000 strips

Ketur strips

Keto-diabur 500 test strips

BD Optimus Lancer, Microfine + lancets, BD safe clip

Penfine needles Sizes 6mm, 12mm

Novofine needles sizes 6mm, 8mm, 12mm

Humapen Ergo

Accu-check Fastclix lancets
Choice of meter depends on experience and patient preference and capabilities e.g. visual acuity,
manual dexterity. Meters are not available on prescription. Patients may purchase any meter but
should do so only following expert advice from a suitably trained person. Strips may be prescribed
and can also be bought over-the-counter.
Prescribing notes

Home blood glucose monitoring in non-insulin treated Type 2 diabetes should routinely be
undertaken:
* where treatment change is indicated
Red = Hospital use only
Green = GP & Hospital use. Drugs not classified as Red, Amber or Amber 2 are classified as Green by default
Amber 1 = Drugs with shared care agreement
Amber 2 = Initiated by Hospital specialist only
Gateshead Health NHS Foundation Trust
Drug Formulary
Page 6 of 19
Date: 1.6.2012
Review Date: 1.6.2013
* to monitor a treatment change
* where hypoglycaemia is suspected
* where control is poor

In such cases, blood glucose monitoring should not require to be performed routinely on
more than 2 days in the week or more than twice in the day. The timing of the samples will
depend on the particular case but a fasting value is useful. Correct meter care and quality
control are essential when meters are used.

Patients must be aware of how to interpret the results.

Meters are obtainable from centres with expert advice from a suitably trained person; it is
impossible to recommend one specific meter since they are all similar in quality and cost.

Strips deteriorate rapidly if exposed to the atmosphere.

Correct meter care and quality control are essential when meters are used.

It is important to test for urinary ketones where there is a significant risk of ketoacidosis,
such as may occur with significant intercurrent illness.
Red = Hospital use only
Green = GP & Hospital use. Drugs not classified as Red, Amber or Amber 2 are classified as Green by default
Amber 1 = Drugs with shared care agreement
Amber 2 = Initiated by Hospital specialist only
Gateshead Health NHS Foundation Trust
Drug Formulary
Page 7 of 19
Date: 1.6.2012
Review Date: 1.6.2013
6.2 Thyroid and antithyroid drugs
Thyroid hormones

Levothyroxine (Thyroxine) sodium 25, 50, 100 micrograms tablets

Levothyroxine 25microgram/5ml oral solution

Liothyronine sodium 20 microgram tablets

Liothyronine sodium 20 microgram injection
Dose
- Levothyroxine tablets 25micrograms, 50micrograms, 100 micrograms: initially 100 micrograms
(50micrograms if elderly) daily, adjusted in steps of 50micrograms every 6 weeks until TSH is within
normal reference range (usually 100-150micrograms daily); where there is cardiac disease, initially
25micrograms daily or 50 micrograms on alternate days, adjusted in steps of 25micrograms every 3
weeks.
- Liothryonine tablets 20micrograms, injection 20micrograms: see BNF
Prescribing notes

Prior to treatment it is important to establish that TSH is elevated thus confirming primary
hypothyroidism. A normal or low TSH suggests pituitary or hypothalamic disease for which
specialist referral is necessary.

Thyroid stimulating hormone should be checked 6 weeks after starting thyroxine or after any
change in dose, then annually once stable.

Myxoedema coma is a rare medical emergency and, in a semi- comatose patient, the clue
might be a low plasma sodium. Treatment should be with specialists using liothyronine (L-triiodothyronine) by intravenous injection (20micrograms 8 hourly).
Antithyroid drugs

Carbimazole 5mg, 20mg tablets

Aqueous iodine oral solution (Lugols solution)

Propylthiouracil 50mg tablets
Dose
- Carbimazole tablets 5mg, 20mg: 20-60mg daily until euthyroid (usually 4-8 weeks), then
progressively reduced to a maintenance dose, typically 5-15mg, daily usually for 18 months.
- Lugols solution: see BNF
- Propylthiouracil tablets 50mg: see BNF
Prescribing notes

Carbimazole 20-40mg daily may be given with levothyroxine 50-150micrograms daily in a
blocking-replacement regimen, usually for 18 months.

Carbimazole has rarely been associated with bone marrow suppression and treatment should
be stopped promptly if there is clinical or laboratory evidence of neutropenia. Patients should
Red = Hospital use only
Green = GP & Hospital use. Drugs not classified as Red, Amber or Amber 2 are classified as Green by default
Amber 1 = Drugs with shared care agreement
Amber 2 = Initiated by Hospital specialist only
Gateshead Health NHS Foundation Trust
Drug Formulary
Page 8 of 19
Date: 1.6.2012
Review Date: 1.6.2013
be asked to report symptoms and signs suggestive of infection, especially sore throat. A
white blood cell count should be performed if there is any clinical evidence of infection.

Propylthiouracil may be an alternative for patients who suffer sensitivity reactions to
carbimazole.

Thyrotoxic crisis needs emergency specialist treatment including all, or combinations of,
medications such as intravenous fluids, propranolol (5mg), hydrocortisone sodium succinate
(100mg every 6 hours), potassium iodide, carbimazole and even amiodarone).

Beta blockade can be withdrawn once hyperthyroidism is controlled (2-6 weeks), and the
patient maintained on carbimazole.

Pregnant patients receiving carbimazole must be monitored and administered at the lowest
effective dose.
Red = Hospital use only
Green = GP & Hospital use. Drugs not classified as Red, Amber or Amber 2 are classified as Green by default
Amber 1 = Drugs with shared care agreement
Amber 2 = Initiated by Hospital specialist only
Gateshead Health NHS Foundation Trust
Drug Formulary
Page 9 of 19
Date: 1.6.2012
Review Date: 1.6.2013
6.3 Corticosteroids
Replacement therapy

Fludrocortisone 100 microgram tablets
Glucocorticoid therapy

Prednisolone 1mg, 5mg tablets

Prednisolone 5mg dispersible tablets

Prednisolone 2.5mg EC tablets

Prednisolone 5mg suppositories

Dexamethasone 500 microgram, 2mg tablets

Dexamethasone 2mg/5ml SF solution

Dexamethasone 4mg/ml injection

Hydrocortisone 10mg, 20mg tablets

Hydrocortisone 100mg injection (sodium succinate) (Solu-Cortef®)

Methylprednisolone sodium succinate 1g injection (Solu-Medrone®)

Methylprednisolone acetate 40mg/ml, 120mg/3ml depot injection (Depo-Medrone®)

Triamcinolone 40mg/ml injection (Kenalog®)

Betamethasone sodium phosphate 4mg/ml injection (Maternity only)
Dose
- Hydrocortisone tablets 10mg, 20mg
- Fludrocortisone tablets 100micrograms: 50-300micrograms daily.
- Prednisolone tablets 1mg, 5mg; e/c tablets 2.5mg;soluble tablets 5mg.
- Dexamethasone tablets 500micrograms, 2mg; injection 4mg/mL, 24mg/mL: orally, usual range
0.5-10mg daily. By intramuscular injection or slow intravenous injection or infusion, initially 0.520mg.
- Methylprednisolone sodium succinate (Solu-Medrone®) vials 1g: by slow intravenous
injection or infusion, initially 10-500mg.
- Methylprednisolone acetate (Depo-Medrone®) vials 40mg/mL, 80mg/2mL, 120mg/3mL:
deep intramuscular injection into gluteal muscle, 40-120mg, repeated after 2-3 weeks if required.
- Triamcinolone injection 40mg: see BNF
- Betamethasone injection 4mg/ml: see BNF
Prescribing notes

In Addison's disease (primary adrenal failure) hydrocortisone (glucocorticoid) and
fludrocortisone (mineralocorticoid) are given. In acute adrenocortical insufficiency,
intravenous hydrocortisone sodium succinate 100mg is given every 6-8 hours. The
extracellular fluid deficit (usually 3-4 litres) should be replaced by: sodium chloride
intravenous infusion 0.9% with glucose intravenous infusion 5%; 1litre is given during the
first hour, and the remainder over 12-24 hours.

In secondary adrenal failure (hypopituitarism), hydrocortisone is given alone, there being no
mineralocorticoid deficiency.
Red = Hospital use only
Green = GP & Hospital use. Drugs not classified as Red, Amber or Amber 2 are classified as Green by default
Amber 1 = Drugs with shared care agreement
Amber 2 = Initiated by Hospital specialist only
Gateshead Health NHS Foundation Trust
Drug Formulary
Page 10 of 19
Date: 1.6.2012
Review Date: 1.6.2013

Patients deficient in glucocorticoids do not respond adequately to stress and should be
advised to double the replacement dose of hydrocortisone for several days if significantly
unwell. More serious illnesses or gastro-intestinal disturbances necessitate prompt parenteral
hydrocortisone.

Patients receiving more than 7.5mg of prednisolone (or equivalent; see BNF section 6.3.2)
for longer than 3-6 months should receive osteoporosis prophylaxis).

Care should be taken in reducing pharmacological doses of glucocorticoids if the patient has
been treated for longer than 3 weeks to avoid cortisol insufficiency due to prolonged
suppression of the hypothalamic-pituitary-adrenal (HPA) axis

In terms of their anti-inflammatory properties, approximately 20mg hydrocortisone is
equivalent to 5mg prednisolone or 750micrograms dexamethasone. See BNF section 6.3.2.
Red = Hospital use only
Green = GP & Hospital use. Drugs not classified as Red, Amber or Amber 2 are classified as Green by default
Amber 1 = Drugs with shared care agreement
Amber 2 = Initiated by Hospital specialist only
Gateshead Health NHS Foundation Trust
Drug Formulary
Page 11 of 19
Date: 1.6.2012
Review Date: 1.6.2013
6.4 Sex hormones
Female sex hormones
Conjugated oestrogens with progestogen

Conjugated oestrogens 625 microgram plus norgestrel 150 microgram tablets (Prempak-C 0.625)

Conjugated oestrogens 1.25mg plus norgestrel 150 microgram tablets (Prempak-C 1.25)

Conjugated oestrogens 625 microgram plus medroxyprogesterone acetate 5mg tablets (Premique)
Conjugated oestrogens only Conjugated oestrogens with progestogen

Conjugated oestrogens 625 microgram and 1.25mg tablets (Premarin)
Estradiol only

Oestradiol valerate 1mg and 2mg tablets (Climaval)

Oestradiol patch releasing 25 micrograms per 24 hours (Estraderm MX)

Oestradiol patch releasing 50, 75 and 100 micrograms per 24 hours (Femseven)
Estradiol with progestogen

Oestradiol valerate 1mg plus norethisterone (Climagest 1mg)

Oestradiol valerate 2mg plus norethisterone (Climagest 2mg)

Oestradiol 2mg plus norethisterone 1mg tablets (Kliofem)

Oestradiol 1mg plus norethisterone 500mcg tablets (Kliovance)
Miscellaneous

Tibolone 2.5mg tablets
Progestogens

Medroxyprogesterone 5mg and 10mg tablets (Provera®)

Norethisterone 5mg tablets

Progesterone 400mg pessaries
Prescribing notes
(See MHRA Drug Safety Update Vol 1 Issue 2 Sept 2007)
Short-term treatment of menopausal symptoms

HRT should generally only be prescribed for menopausal symptoms and not for prevention of
osteoporosis or cardiovascular disease.

It is recommended that the lowest dose of HRT based on relieving menopausal symptoms
should be prescribed.
Red = Hospital use only
Green = GP & Hospital use. Drugs not classified as Red, Amber or Amber 2 are classified as Green by default
Amber 1 = Drugs with shared care agreement
Amber 2 = Initiated by Hospital specialist only
Gateshead Health NHS Foundation Trust
Drug Formulary
Page 12 of 19
Date: 1.6.2012
Review Date: 1.6.2013

Oral HRT regimens are well tolerated, cheaper than patches and should be considered as
first-line therapy in most women.

Transdermal regimens should be considered in women intolerant of or unable to take oral
HRT, or theoretically in those with some gastro-intestinal and liver problems. Transdermal
HRT carries less risk of venous thromboembolism and should be used preferentially in women
with cardiovascular risk factors.

There is significant individual variation in response to HRT, and it is often appropriate to try
two or three different preparations. Women should be encouraged to persevere with a new
preparation for 2-3 months as any side-effects experienced initially may settle with time.

Women should be reviewed three months after commencing therapy. The on-going need for
HRT should be reassessed at least annually. Blood pressure should be checked 6-12 monthly,
and the woman encouraged to attend cervical and breast screening programmes. Breast
awareness should be encouraged.

HRT is not a method of contraception.

Stopping HRT abruptly can cause some women to have hot flushes and it should therefore be
withdrawn gradually by decreasing dosages over 3-6 months.

HRT is contra-indicated in the presence of active venous thromboembolism, unexplained
vaginal bleeding, oestrogen dependent tumours (breast and endometrial cancer), current or
recent cardiovascular disease and acute porphyria. Women with severe menopausal
symptoms following breast or endometrial cancer may occasionally be prescribed HRT after
specialist consultation.
HRT and cardiovascular disease

There is no evidence that HRT protects against either ischaemic heart disease or stroke and it
should not be commenced for this indication. HRT may be associated with worsening of
cardiovascular outcome, particularly in women with pre-existing cardiovascular risk factors.
The decision to continue or stop HRT in women with CVD who have been receiving long-term
oestrogen therapy should be based on presence of acute menopausal symptoms. If a woman
develops an acute CVD event, e.g. heart attack or stroke, or is immobilised while receiving
HRT, the risk of thromboembolism is increased and consideration should be given to stopping
HRT.
HRT and breast cancer

Risk of breast cancer increases with increasing duration of HRT use (see below) and this
should be balanced against the benefits of taking long-term therapy. The risk is significantly
greater for combined HRT than for oestrogen only therapy. Tibolone also appears to have an
increased risk of breast cancer. Women with a significant family history should seek specialist
opinion prior to being prescribed HRT.

The additional risk of breast cancer begins to decline when HRT is stopped and by 5 years
reaches the same level as in women who have never taken HRT. The need for HRT should be
reassessed at least annually.

Women with premature menopause have an overall lower risk of breast cancer and in most
instances should receive HRT until the age of normal menopause and then should be
reassessed.
HRT and osteoporosis
Red = Hospital use only
Green = GP & Hospital use. Drugs not classified as Red, Amber or Amber 2 are classified as Green by default
Amber 1 = Drugs with shared care agreement
Amber 2 = Initiated by Hospital specialist only
Gateshead Health NHS Foundation Trust
Drug Formulary
Page 13 of 19
Date: 1.6.2012
Review Date: 1.6.2013

HRT prevents loss of bone density and reduces risk of osteoporotic fracture. However, in
2003, the Committee on Safety of Medicines in the UK stated that HRT should not be used as
first-line for prevention of osteoporosis as the risk:benefit ratio of HRT is unfavourable.
General notes

Continuous combined therapy (period-free HRT) should only be used by women who are at
least a year past the menopause or over 54 years of age. Both oestrogen and progestogen
are taken daily to give a period-free regimen. Erratic bleeding is common in the first few
months of use.

Women with irregular or heavy bleeding with HRT which persists for more than 3 months
should be referred to a gynaecology or menopause service.

Amenorrhoea with HRT is not a risk for endometrial cancer and does not require
investigation.

* Conjugated oestrogens are extracted from pregnant mares' urine and may not be
acceptable to some women.
Male sex hormones and antagonists

Testosterone undeconate 40mg capsules

Testosterone 250mg injection (Sustanon®)

Testosterone 100mg injection (Sustanon®)

Testosterone undecanoate 1000mg/4ml injection (Nebido®)

Testosterone 100mg implant

Testosterone 2% gel (Tostran®)

Cyproterone 50mg tablets

Finasteride 5mg tablets
Dose
- see BNF.
Prescribing notes

Intramuscular depot preparations of testosterone esters are preferred for replacement therapy. Gel
may be preferred if the patient find the injection painful.
Red = Hospital use only
Green = GP & Hospital use. Drugs not classified as Red, Amber or Amber 2 are classified as Green by default
Amber 1 = Drugs with shared care agreement
Amber 2 = Initiated by Hospital specialist only
Gateshead Health NHS Foundation Trust
Drug Formulary
Page 14 of 19
Date: 1.6.2012
Review Date: 1.6.2013
6.5 Hypothalamic and pituitary hormones and anti-oestrogens
Anti-oestrogens

Clomifene 50mg tablets
Dose
- see BNF
Anterior pituitary hormones

Tetracosactide/Tetracosactrin 250 micrograms injection (Synacthen®)

Tetracosactide/Tetracosactrin 1mg depot injection (Synacthen Depot®)

Chorionic gonadotrophin 5000 unit amp (Pregnyl®)

Menopur® 75 unit injection

Follitropin alfa (Gonal F®) injection
Dose
- see BNF
Hypothalamic hormones

Gonadorelin 100 microgram/ml injection

Protirelin 200 microgram/2ml injection
Dose
- see BNF
Posterior pituitary hormones and antagonists

Argipressin 20units/ml injection (vasopressin)

Desmopressin 100microgram and 200 microgram tablets (DDVAP®)

Desmopressin 4 microgram/ml injection (DDVAP®)

Desmopressin 10 microgram/dose nasal spray (Desmospray®)

Desmopressin 100 microgram/ml nasal solution (DDVAP®)

Terlipressin 1mg injection
Dose
- Desmopressin nasal spray 10micrograms/metered spray; intranasal solution 100micrograms/mL:
intranasally, diabetes insipidus, treatment, 10-40micrograms daily in 1-2 divided doses.
- Desmopressin tablets 100micrograms, 200micrograms: diabetes insipidus, treatment, initially
300micrograms daily in 3 divided doses; maintenance 300-600micrograms daily in 3 divided doses;
range 0.2-1.2mg daily.
Red = Hospital use only
Green = GP & Hospital use. Drugs not classified as Red, Amber or Amber 2 are classified as Green by default
Amber 1 = Drugs with shared care agreement
Amber 2 = Initiated by Hospital specialist only
Gateshead Health NHS Foundation Trust
Drug Formulary
Page 15 of 19
Date: 1.6.2012
Review Date: 1.6.2013
- Terlipressin injection 1mg vial: by intravenous injection, 2mg followed by 1 or 2mg every 4 to 6
hours until bleeding is controlled, for up to 72 hours.
Prescribing notes

A single dose of desmopressin is also used as part of a test following fluid deprivation in the
differential diagnosis of thirst and polyuria.

For nephrogenic diabetes insipidus, the usual treatment is a thiazide diuretic. Caution if due
to lithium; refer to endocrinologist.

Desmopressin injection 4micrograms/mL may be indicated in unconscious patients (dose 14micrograms daily by subcutaneous, intramuscular or intravenous injection).

Measurement of plasma sodium once or twice a year guards against excessive water intake
which would be reflected by a low plasma sodium.
Antidiuretic hormone antagonists

Demeclocycline 150mg capsules
Dose
- Demeclocycline capsules 150mg: initially 0.9-1.2g daily in divided doses; maintenance 600900mg daily.
Prescribing notes

Demeclocycline is indicated for chronic Syndrome of Inappropriate Secretion of Anti-Diuretic
Hormone (SIADH) where fluid deprivation is unsuccessful.

Higher doses of demeclocycline may be associated with a decline in glomerular filtration.
Creatinine should be monitored along with plasma sodium.
Red = Hospital use only
Green = GP & Hospital use. Drugs not classified as Red, Amber or Amber 2 are classified as Green by default
Amber 1 = Drugs with shared care agreement
Amber 2 = Initiated by Hospital specialist only
Gateshead Health NHS Foundation Trust
Drug Formulary
Page 16 of 19
Date: 1.6.2012
Review Date: 1.6.2013
6.6 Drugs affecting bone metabolism
Calcitonin

Calcitonin(salmon)/salcatonin 50 units/ml, 200units/ml injection

Calcitonin 200units/spray nasal spray
Bisphosphonates

Alendronic acid 10mg tablets

Alendronic acid 70mg once-a week tablets

Disodium etidronate 200mg tablets

Disodium etidronate 400mg tablets plus calcium carbonate 1.25mg tablets (Didronel PMO)

Disodium pamidronate 30mg and 90mg injection

Zoledronic acid 4mg injection

Zoledronic acid 5mg injection

Sodium clodronate 400mg capsule

Risedronate 5mg, 30mg tablets

Risedronate 35mg once-a-week tablets

Ibandronate 50mg tablets (Bondronat®)

Ibandronate 3mg/3ml syringe
Other

Strontium ranelate 2g sachets

Raloxifene 50mg tablets

Denosumab 60mg/ml injection
Dose
- see BNF
Prescribing notes

The aim of treatment is the prevention of fracture.

Treatment should be based on identification of risk factors for osteoporosis and use of bone
densitometry scanning, where available.

Before starting treatment, calcium, phosphate, alkaline phosphatase and renal function
should be checked.

Those with, or at risk of, osteoporosis should maintain an adequate intake of calcium and
vitamin D. If deficiency is suspected, this should be corrected by increasing dietary intake or
taking supplements.
Red = Hospital use only
Green = GP & Hospital use. Drugs not classified as Red, Amber or Amber 2 are classified as Green by default
Amber 1 = Drugs with shared care agreement
Amber 2 = Initiated by Hospital specialist only
Gateshead Health NHS Foundation Trust
Drug Formulary
Page 17 of 19
Date: 1.6.2012
Review Date: 1.6.2013

Standard calcium and vitamin D preparations may be ineffective in moderate to severe renal
disease; alfacalcidol may be a suitable alternative.

Long-term therapy is required to treat or prevent osteoporosis. Optimum duration is
unknown and there is limited information regarding the long-term safety and efficacy of
bisphosphonates.

Patients with identified risk factors for osteoporosis should be encouraged to perform weight
bearing exercise and strength training, give up smoking, and follow a healthy diet with
adequate calcium and vitamin D.

Treatment with oral contraceptives or HRT should be considered for early menopause until
around the age of 50 years. The CSM now advises that HRT should not be considered firstline therapy for the long-term prevention of osteoporosis in women who are over 50 years of
age and at an increased risk of fractures.

A review of the evidence suggests that Didronel PMO® is less effective than alendronate and
side-effects from the calcium preparation are common.

Teriparatide is for specialist use only, for severe osteoporosis and is available on a nonformulary basis.

Oral bisphosphonates should be avoided in anyone with a history of oesophageal stricture or
severe oesophagitis.

Bisphosphonates have complex administration instructions. GI side-effects are minimised by
following these instructions.

Alendronate is the 1st choice oral bisphosphonate.
Red = Hospital use only
Green = GP & Hospital use. Drugs not classified as Red, Amber or Amber 2 are classified as Green by default
Amber 1 = Drugs with shared care agreement
Amber 2 = Initiated by Hospital specialist only
Gateshead Health NHS Foundation Trust
Drug Formulary
Page 18 of 19
Date: 1.6.2012
Review Date: 1.6.2013
6.7 Other endocrine drugs
Bromocriptine and other dopamine receptor stimulants

Quinagolide 75microgram tablet and Starter Pack
Dose
- Quinagolide tablets 75micrograms: see BNF for dose adjustment.
Prescribing notes

For suppression of lactation, see chapter 7

For Parkinson's disease, see Chapter 4
Drugs affecting gonadotrophins

Danazol 100mg capsules

Buserelin 1mg/ml injection

Goserelin 3.6mg implant injection

Leuprorelin 3.75mg injection

Nafarelin 200 microgram/dose nasal spray
Dose
- see BNF
Red = Hospital use only
Green = GP & Hospital use. Drugs not classified as Red, Amber or Amber 2 are classified as Green by default
Amber 1 = Drugs with shared care agreement
Amber 2 = Initiated by Hospital specialist only
Gateshead Health NHS Foundation Trust
Drug Formulary
Page 19 of 19
Date: 1.6.2012
Review Date: 1.6.2013