Q. I would like to request a copy of the latest medicines formularies for Cornwall and the Isles of Scilly, as well as any prescribing guidelines for asthma, COPD or diabetes. Answer: Follow the link to the PCT website for the joint formulary: Attached are the following: Respiratory resource pack Formulary factsheet, Insulin for Type 2 Diabetes Formulary factsheet, Metformin Guidelines for initiation of insulin to previously insulin naïve Type 2 diabetes patients. The information supplied to you continues to be protected by the Copyright, Designs and Patents Act 1988. You are free to use it for your own purposes, including any non-commercial research you are doing and for the purposes of news reporting. Any other re-use, for example commercial publication, would require the permission of the copyright holder. Most documents supplied by Cornwall and Isles of Scilly Primary Care Trust will have been produced by local officials and will be our copyright. Information you receive which is not subject to our copyright continues to be protected by the copyright of the person, or organisation, from which the information originated. You must ensure that you gain their permission before reproducing any third party information. Chair : Andrew Williamson CBE  Chief Executive : Steve Moore
PEC Chair : Dr Shelagh McCormick
Working in Partnership to promote a healthy future for Cornwall and the Isles of Scilly Formulary Factsheet:

The purpose of this factsheet is to emphasise the importance of appropriate prescribing of
metformin in type 2 diabetes. As we know, in the UKPDS, significant improvements in
macrovascular outcomes leading to fewer deaths were reported for overweight patients
receiving metformin therapy for a median period of 10 years. The reduction in morbidity and
mortality was much greater than that reported for patients treated with sulphonylureas and
insulin despite there being no overall difference in glycaemic control. This emphasises the
need to optimise therapy with metformin, so that these benefits can be more widely realised.
The Bottom Line

Metformin is the first-choice hypoglycaemic drug in type 2 diabetes, with a sulfonylurea as an
alternative in certain circumstances. NICE states that if blood glucose control is inadequate on
monotherapy (HbA1c above 6.5% [48mmol/mol] or other higher agreed level); dual therapy
with metformin and a sulfonylurea is the preferred second-line therapy.
Initiating Metformin

Metformin should routinely be initiated at a dose of 500mg with breakfast for at least
2 weeks, then 500mg with breakfast and evening meal for at least 2 weeks, then
500mg with breakfast lunch and evening meal.

The benefits observed in the UKPDS were achieved at a relatively high dose of metformin. Whilst more than half
of the patients in the UKPDS received a daily dosage of 2550 mg/day, more than three quarters of patients
received at least 1700 mg/day.

Managing Side Effects

Slow and steady dose titration over several weeks will result in a good tolerance to
the drug and minimise the risk of gastrointestinal adverse effects.

The majority of adverse effects associated with metformin are gastrointestinal, and usually appear soon after
initiation. They can lead to discontinuation of therapy in up to 5% of patients. These adverse effects are usually
transient however, and tend to subside over several months of continued therapy.

The maximum daily dosage of metformin is 3 g (in divided doses), although in
practice, daily dosages above 2 g are rarely exceeded.

Evidence suggests that increasing the metformin dose beyond 1500–2000 mg/day does not markedly increase
the risk of gastrointestinal side effects or lactic acidosis, and fear of these side-effects should not prevent the
achievement of optimal dosage levels in patients with type 2 diabetes. It may not be practical however to use the
full dose range of metformin particularly if this is unlikely to achieve the glycaemic target. In the latter situation,
the dosage should revert to the lowest dose to achieve the maximum effect and consideration given to
combination therapy
Very weak evidence supports changing from standard-release metformin to
modified-release metformin if gastrointestinal adverse effects prevent an individual
continuing standard-release therapy.

However, it may also be considered appropriate to consider the use of metformin MR if the alternative would be
to consider the addition of other more expensive options.

Date of preparation: April 2012
Formulary Factsheet:

Renal Impairment

Metformin should be used with caution in renal impairment due to an increased risk of lactic
acidosis. Although this complication is rare (0.3% of patients prescribed metformin per
annum), NICE recommends that metformin prescribing should be reviewed if the eGFR is less
than 45 mins/minute/1.73m2 and to avoid altogether if the eGFR is less than 30
mins/minute/1.73m2. Patients with acute kidney injury, and/or who are dehydrated are likely to
experience a sudden deterioration in renal function. In these cases metformin may also need
to be withdrawn or discontinued. When renal function improves, it may be appropriate to
reinitiate the metformin and monitor closely.
Patients with swallowing difficulties
There is an oral powder version of metformin, currently available as 500mg or 1g sachets.
The contents of the sachet are mixed with 150mls of water and swallowed immediately. This
preparation is significantly less expensive than metformin 500mg/5ml oral solution. A 28 day
prescription of the sachets at 2g per day will cost £12.25 compared to £296 for the oral
Metformin Preparation Cost Comparison

Meformin - Costs of 2g per day dose

Cost per 28 Days
Metformin 500mg/5ml oral solution: £296 for 28 days

Respiratory Resource Pack
This pack has been put together with input from the
Respiratory QIPP Group and The Respiratory
Clinical Specialist Team
If you have any queries please contact the prescribing team
01726 627953
Version 1: September 2012
Review: September 2013
Respiratory Resource Pack
Asthma Prescribing Guidelines: Adults over 18 years Asthma Prescribing Guidelines: Adults over 18 years Guidance on stepping up and stepping down Pulmonary Rehabilitation Information Sheet Pulmonary Rehabilitation Referral Programme Version 1: September 2012
Review: September 2013
Respiratory Nurses Contact Details (by surgery) Version 1: September 2012
Review: September 2013
Formulary Factsheet:
Insulin for Type 2 Diabetes
The purpose of this fact sheet is to emphasise the importance of following NICE guidance with regard to the use of
insulin in type 2 diabetes, and to support the implementation of local insulin initiation guidelines.

A recent study has shown that the annual cost of analogue insulin increased across the NHS from £18 million in
2000 (12% of total insulin cost) to £305 million in 2009 (85% of total insulin cost). If only 50% of analogue insulin
dispensed in the UK between 2000 and 2009 had been for human insulin alternatives, the NHS would have saved
an estimated £312 million.
What does NICE recommend2?
Human NPH (isophane) insulin, used once or twice-daily according to need, is the preferred first choice insulin. It is
preferred based on cost effectiveness and its well-recognised safety profile. Insulin analogues (glargine, detemir)
should be considered only in specific circumstances, see below:
The Bottom Line
 For most people with type 2 diabetes, long-acting insulin analogues offer no significant advantage over human
NPH (isophane) insulin and are much more expensive.  In terms of HbA1c lowering, there is no difference between long-acting insulin analogues and human NPH  Whilst <7 year data from the ORIGIN study3 looks positive, the longer-term safety of the long-acting insulin analogues, insulin glargine and insulin detemir, is not known. Robust evidence that they improve patient-orientated outcomes and are cost effective is not available at the current time.
When are analogue insulins appropriate?
The main benefits of the long acting insulin analogues relate to lower rates of hypoglycaemia, and once daily use.
However, these potential benefits need to be balanced against their much higher costs and lack of long-term safety
and outcome data. It is more cost-effective to target the use of long acting insulin analogues to those people with
type 2 diabetes who would be most likely to benefit. NICE therefore recommends them as an option if:

 The patient needs assistance from a carer or health professional to inject insulin, and use of a long-acting insulin
analogue would reduce the frequency of injections from twice to once daily OR  The patient’s lifestyle is restricted by recurrent symptomatic hypoglycaemic episodes OR  The patient would otherwise need twice-daily NPH insulin injections in combination with oral glucose-lowering  The patient cannot use the device to inject NPH insulin  Patient with significant renal/liver pathology due to increased risk of hypoglycaemia (eGFR<30 or established
When is it appropriate to switch from analogue to NPH insulin?
By initiating new type-2 patients on NPH insulins first line rather than the analogues, and reviewing patients with sub-
optimal (HbA1C>9%) control with a view to switching to NPH insulin, prescribers will regain experience with this type
of insulin. Mass switching to NPH insulin is not recommended at present and switching should only be considered on
an individual patient basis. Specialist input should be sought if required. Going forward however it may be that the
50% aspiration identified in the current Prescribing Strategy can be achieved through wider switching programmes.
This will result in significant savings to the healthcare economy.
What are the safety issues? (inc. nocturnal hypoglycaemic attacks)
Compared with human NPH insulin, long acting insulin analogues result in a statistically significantly lower incidence
of any hypoglycaemia and a statistically significantly lower incidence of nocturnal hypoglycaemia. However, there is
no statistically significant reduction in the incidence of severe hypoglycaemia.

Formulary Factsheet:
Insulin for Type 2 Diabetes
What NPH Isophane insulin could be prescribed?

Prefilled devices
5x3ml Insuman
Basal Solostar
5x3ml Insulatard
Innolet device
is administered
in the morning
Humulin I
5x3ml Humulin I
Kwikpen £21.70

Switching to NPH insulin
When switching a patient from a long acting analogue to an NPH insulin it would be advisable to reduce the number
of daily units by 10% then adjust according to requirements. Although patient preference will guide the device of
choice, Insuman Basal may be the most cost-effective option and is the first line formulary choice within the NPH
insulin group. The Solostar Prefilled device is the same as the Lantus pre-filled pen which may make the transition
easier for some patients. The local diabetic specialist nurses have the greatest experience with Insuman Basal and
endorse its use first line if an NPH insulin is required.
Biphasic insulins (Specialist input required)
Biphasic insulins (e.g. Humulin M3, Insuman Combi etc) have a place in the management of patients who have
difficulty with, or prefer not to use multiple injection regimens. They may also be useful in particular where HbA1c is
elevated above 9%. Biphasic preparations of insulin analogues (e.g. Humalog Mix25) may be considered over pre-
mixed human insulin preparations however when:
 Immediate injection before a meal is preferred, or
 Blood glucose levels rise markedly after meals


1 Evaluation of the incremental cost to the National Health Service of prescribing analogue insulin, BMJ, Sept 11 2 NICE. The management of type 2 diabetes. Clinical guideline 87. May 2009 NPC document “Key therapeutic topics– Medicines management options for local implementation” at Long-acting and intermediate-acting insulin analogues e-learning 3 Basal Insulin and Cardiovascular and Other Outcomes in Dysglycemia

Source: http://www.cornwallandislesofscilly.nhs.uk/DocumentsLibrary/CornwallAndIslesOfScillyPCT/WebDocuments/Internet/GettingInformation/DisclosureLog/3633036330.pdf

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