Endocrine System - BNF Chapter 6

DGRefHelp - NHS Dumfries & Galloway
NHS Dumfries and Galloway

1. Anti-diuretic hormone disorders

1.0 Posterior pituitary hormones and antagonists ✓ Specialist Use Only

1.1 Diabetes insipidus ✓ Specialist Use Only

1.2 Syndrome of inappropriate ADH secretion ✓ Specialist Use Only

2. Corticosteroid responsive conditions

For inpatients refer to the D&G clinical handbook>endocrine> ‘Hyperglyceamia & Steroids’ for inpatient management for all patients on high dose steroids

Primary care management – under discussion

National Patient Safety Alert Card

Addisons Disease link to nhs steroid card

2.1 Cushing's syndrome and disease

Refer to specialist services

3. Diabetes mellitus and hypoglycaemia

3.1 Diabetes mellitus treatment

Prescribing notes
Oral hypoglycaemic agents which cause <5mmol/mol reduction in HbA1c after 6 months should be discontinued and alternative tried. For local guidance see DGRefHelp/Diabetes

Biguanides

  • Metformin ✓ First Choice - maximum recommended dose is 2g daily
  • Metformin MR – a trial of up to 6 months could be considered in patients with severe GI side effects who would otherwise discontinue immediate release. Dose is usually once daily with main meal of the day.
Prescribing notes
Metformin may cause gastro-intestinal adverse effects; it should be started at low dose and taken with or after meals, and the dose gradually increased if tolerated

Hypoglycaemia is not a problem with metformin monotherapy Sick day rules apply to metformin. Supply the patient with appropriate advice

Be aware of the possibility of Vitamin B12 deficiency associated with treatment with Metformin

Combination tablets containing metformin + a DPP4i or an SGLT2i may offer a lower tablet burden and lower cost option for patients suitable for the fixed doses

SGLT2 inhibitors

In patients with type 2 diabetes and established cardiovascular disease, SGLT2 inhibitors with proven cardiovascular benefit (currently empagliflozin, dapagliflozin and canagliflozin) should be considered (SIGN 154).

Prescribing notes
There is a risk of euglycaemic ketoacidosis with SGLT2 inhibitors; provide clear guidance to stop treatment if intercurrent dehydrating illness – advise on sick day rules

Omit on the morning of surgery then restart when drinking and eating again Drug Safety Update MHRA March 2020 SGLT2 inhibitors monitor ketones in blood during treatment interruption for surgical procedures or acute serious medical illness

The glucose lowering efficacy of dapagliflozin and empagliflozin is dependent on renal function, and is reduced in patients with eGFR < 45ml/min. If eGFR falls below 45 ml/min, additional glucose lowering treatment should be considered in patients with type 2 diabetes mellitus.

Patients on SGLT2 inhibitors should be given advice on genitourinary infections and should be used with caution in patients with a history of recurrent genito-urinary tract infection.

Avoid if active foot disease or low carbohydrate diet

SGLT2 treatment should be stopped for surgical procedures or acute serious medical illness - MHRA advice

Sulfonylureas

Prescribing notes
Sulfonylureas should be taken before meals.

Patients should be informed that sulfonylureas can cause hypoglycaemia.

DVLA regulations on testing should discussed

Dipeptidylpeptidase-4 inhibitors (DPP4i)

  • Sitagliptin ✓ First Choice
  • Linagliptin -requires no dosage adjustment in renal failure and can be used in end stage renal failure

Patients should be counselled to report any signs of acute pancreatitis 

Glitazones

Prescribing notes
Pioglitazone is contra-indicated in patients with heart failure, active bladder cancer or a history of bladder cancer

Use with caution in patients with other cardiovascular diseases and in the elderly

Advise patient of risk of osteoporosis and bladder neoplasia Investigate macroscopic haematuria).

Incretin mimetics

Patients should be reviewed at 6 months and only continue therapy in those with a ≥5 mmol/mol reduction in HbAlc and/or ≥3% reduction in body weight.

Prescribing notes
Oral semaglutide can be initiated in primary care based on SMC restrictions (www.scottishmedicines.org.uk)

Oral semaglutide is taken on an empty stomach with a small glass of water avoiding food, drink and other oral medicines for 30mins. Adherence to these instructions is important for efficacy

Ensure HbA1c and weight reviewed at 6 months If glycaemic targets have not been met on oral semaglutide an injectable GLP-1 agonist is likely to be a more effective alternative.

GLP-1 agonists are associated with gastro-intestinal side-effects; use with caution if previous pancreatitis

Semaglutide can worsen diabetic retinopathy, caution in pre-existing retinopathy

Patients should be counselled to report any signs of acute pancreatitis

Insulins

Prescribing notes
Insulin should be initiated on specialist advice only

Choice depends on the needs of the individual patient, taking into consideration 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

Insulins are not interchangeable.

When prescribing insulin on a discharge or out-patient prescription, the word unit must be typed/ written in full.

For sustainability penfill cartridges should be considered 1st line

Short acting Insulins

  • Humalog® cartridges 3ml ✓ First Choice
  • Humalog® Kwikpen pre-filled pen ✓ First Choice
  • Humalog® 10ml vial ✓ First Choice
  • Admelog Sanofi® cartridges 3ml▼ ✓ First Choice(formerly Insulin lispro)
  • Admelog Sanofi® vials 10ml▼ ✓ First Choice
  • Admelog Sanofi® pre-filled pen▼ ✓ First Choice
  • Novorapid® penfill cartridges 3ml ✓ First Choice
  • Novorapid® pre-filled pen ✓ First Choice
  • Novorapid® 10ml vials ✓ First Choice
  • Humulin S® 3ml cartridges
  • Apidra® Solostar pre-filled pen
  • Apidra® 10ml vial

Ultra short acting insulin

  • Fiasp ®Penfill catrridge 3ml▼
  • Fiasp ®FlexTouch pre-filled pen▼
  • Fiasp ® vial 10ml▼

Intermediate and long-acting insulins

Insulin Analogues – for restricted use as per SMC

  • Abasaglar® cartridge 3ml
  • Abasaglar® Kwikpen pre-filled pen
  • Levemir® penfill cartridge 3ml
  • Levemir® Flexpen pre-filled pen
  • Lantus® injection cartridge 3ml
  • Lantus® Solostar pre-filled disposable pen
  • Tresiba ® Penfill 100 units/mL solution for injection in cartridge
  • Tresiba ®FlexTouch 100 units/mL solution for injection in pre-filled pen

Biphasic insulins

3.1b Diabetes mellitus diagnosis and monitoring

Blood monitoring

Self blood glucose monitoring in Diabetes should be undertaken only:

  • when insulin is prescribed
  • to monitor for hypoglycaemia due to treatment with sulphonylureas

Meters cannot be prescribed; strips to be read only with the appropriate meter. Please see table.

Blood testing for ketones should only be undertaken on specialist advice (Supply 10/prescription, pregnant women may need more)

Meter Patient Group Compatible Glucose Strips Compatible Ketone Strips
CareSens Dual Type 1 CareSens Pro KetoSens

GlucoRx Q

Accu-check Instant

 Type 2

GlucoRx Q

Instant

 -
Glucose Nexus Voice Visually Impaired Glucose Nexus  
Freesyle Libre 2 Plus Only on advice of specialist diabetes team Freestyle Libre 2 plus sensor (1 sensor lasts 15 days - 25 sensors per year per patient on NHS) CareSens meter and ketoSens strips
Deacon One Plus Only on advice of specialist diabetes team. Second line for patients who have experienced difficulties with Libre (e.g. adhesion) Freestyle Libre 2 plus sensor (1 sensor lasts 10 days - 37 sensors per year per patient on NHS) CareSens meter and ketoSens strips
Jazz Wavesense Gestational diabetes Wavesense Jazz strips -

Urine testing for ketones

Hypodermic equipment

Injection devices

Reusable pens are available to prescribe in different colours to aid patients distinguish between their differing types of Insulin

  • Novopen 6 re-useable pen 3ml 1-60units for use with Novo Penfill cartridges
  • NovoPen Echo Plus re-usable pen 3ml 0.5-30 units for use with Novo penfill cartridges
  • Autopen 24® HumaPen® Savvio re-useable pen 3ml 1- 60units for use with Humulin and Humalog cartridges
  • AllStar PRO® re-usable pen 1- 80units for use with Lantus and Apidra catrtridges
  • Junior STAR®

Lancets

Droplet and Caresens Lancets are compatible with most finger-pricking devices.

  • Droplet lancets
  • CareSens Lancets
  • Unistik 3 (for visually impaired/dexterity problems)
  • FastClix Lancets drum (only compatible with FastClix finger pricking device – provided with each Accuchek Instant meter)

N.B Health professionals must only use single use devices: Sterilance Lite II – for use by health professionals only – do not prescribe – PECOS 143276

Needles

  • BD Viva® (4mm) ✓ First Choice
  • BD Autoshield Duo® – for use by health professionals only (do not prescribe- PECOS 189649)

Sharps Containers

Sharps bins should be provided for patients

  • SharpSafe® container 1 litre
  • SharpSafe® container 4 litre (Libre sensor patients only)

3.2 Hypoglycaemia

Treatment for hypoglycaemia must not routinely be prescribed

  • Fruit juice/sugared drinks or soft jelly sweet ✓ First Choice

Choice of treatment if appropriate depends on the clinical situation and includes:

  • Rapilose® Gel (glucose oral gel) ✓ First Choice
  • Lift Glucose Juice Shot ® for renal patients (pay & report)
  • Glucagon injection (GlucaGen® hypokit) – reserved for insulin-treated patients at high risk of hypoglycaemic attack who have a relative, carer or health professional who is able to reconstitute and administer correctly when required

3.2b Chronic Hypoglycaemia

Refer to specialist services

4. Disorders of bone metabolism

4.1 Osteoporosis

For further please refer to the following reference sources and local protocols

Fracture risk assessment

Management has shifted from diagnosing osteoporosis by bone density definition (lumbar spine or hip bone density 2.5 standard deviations or more below the young adult mean value for women, reported as T score <-2.5 by DEXA scan) to assessing and reducing fracture risk.

A DEXA scan is recommended as part of the fracture risk assessment if already identified as “increased risk” – see Referral Criteria for DEXA on RefHelp and FRAX or Qfracture risk assessment calculators.

If multiple vertebral collapses (2 or more) exclude myeloma or metastatic disease and commence treatment to reduce fracture risk regardless of bone density (DEXA not required however can be useful)

Safety considerations

Bisphosphonates are contraindicated where eGFR < 30ml/min for risedronate and ibandronic acid and eGFR < 35ml/min for alendronic acid

MHRA warning regarding osteonecrosis of jaw with bisphosphonates https://www.gov.uk/drug-safety-update/bisphosphonates-osteonecrosis-of-the-jaw

MHRA warning for neck of femur fractures https://www.gov.uk/drug-safety-update/bisphosphonates-atypical-femoral-fractures

Prevention and treatment of postmenopausal osteoporosis

Early menopause or under 60 years with no contraindications

  • HRT see 6.8.1 ✓ First Choice

Calcium & Vitamin D Supplements

  • Dietary sources ✓ First Choice
  • Accrete D3 film coated tablet (1 tablet twice daily) ✓ First Choice
  • TheiCal-D3 chewable (1 tablet daily, dissolves on tongue for those with swallowing difficulties)
  • Adcal D3 caplet (2 tablets twice daily)

Treatment of osteoporosis

Early menopause or under 60 years with no contraindications

  • HRT see 6.8.1 ✓ First Choice

Post menopausal osteoporosis

+ Calcium and Vitamin D3 supplement ✓ First Choice

Specialist initiation only

Corticosteroid-induced osteoporosis (treatment and prevention)

Male osteoporosis

Specialist referral should be considered

  • Alendronic acid 70mg (once weekly) please note licensed dose of alendronic acid in men is 10mg once daily, but it is common practice to use 70mg once weekly + Calcium and Vitamin D3 supplement

Treatment of Vitamin D deficiency

See DG RefHelp>Osteoporosis> Vitamin D

5. Dopamine responsive conditions

Treatment of hyperprolactinaemia

  • Quinagolide in light of recent MHRA advice this should be drug of choice unless not tolerated/effective
  • Cabergoline no longer first line therapy due to possibility of pulmonary fibrosis/cardiac valvolopathy
  • Bromocriptine recommended for women planning a pregnancy

6. Gonadotrophin responsive conditions

6 Gonadotrophin responsive conditions

  • Nafarelin ✓ Specialist Use Only

Acromegaly somatostatin analogues

  • Octreotide – Olatuton preferred brand ✓ Specialist Initiation Only
  • Lanreotide ✓ Specialist Initiation Only

6.1 Hereditary angioedema

Refer to specialist services

7. Hypothalamic and anterior pituitary hormone related disorders

7.1 Adrenocortical function testing

Refer to specialist services

7.2 Assessment of pituitary function

Refer to specialist services

7.3 Gonadotrophin replacement therapy

Refer to specialist services

7.4 Growth hormone disorders

Refer to specialist services

8. Sex hormone responsive conditions

8.1 Female sex hormone responsive conditions

Prescribing notes
• For women requiring both oestrogen and progestogen aim to give as a single preparation where available to minimise patient error and encourage equal absorption of both components

• For women deemed low-risk of thromboembolism utilise oral tablet HRT

• Consider transdermal HRT for women with: GI disorder affecting oral absorption; previous or family history of VTE; BMI>30; migraine headache; current use of hepatic inducing enzyme medication; gallbladder disease

• Initiate prescribing using the lowest available dose, titrating no quicker than 3 monthly to the lowest effective dose, continuing for the shortest duration to manage symptoms.

• Consider switching from sequential combined HRT to continuous combined HRT in women over 50 years old after a period of 12-18 months on sequential combined HRT, however women younger than 50 years old may require to be on sequential HRT for 2-3 years to reach amenorrhoea; sequential combined HRT should not be used for longer than 5 year duration

• HRT-Guide-160516.pdf BMS flowchart

HRT dose: Menopause matters

Oestrogen-only HRT

For women who have had a hysterectomy; or receiving progestogen separately i.e. Mirena coil inserted within 5 years, or taking micronised progesterone, or medroxyprogesterone in a dose proportionate to oestrogen

Oestrogen-only HRT – Oral Tablets

Dose Brand Contents
Low Elleste Solo ✓ First Choice Estradiol hemihydrate 1mg
Zumenon 1mg Estradiol valerate 1mg
Progynova 1mg Estradiol valerate 1mg
Medium Elleste Solo ✓ First Choice Estradiol hemihydrate 2mg
Zumenon Estradiol valerate 2mg
Progynova Estradiol valerate 2mg

Oestrogen-only HRT – Transdermal Patches

Dose Brand Contents
Low Estraderm MX ✓ First Choice Estradiol 25mcg
Evorel Estradiol 25mcg
Estradot* Estradiol 25mcg, 37.5mcg
Medium Estraderm MX ✓ First Choice Estradiol 50mcg
Evorel Estradiol 50mcg
Estradot* Estradiol 50mcg
High Estraderm MX ✓ First Choice Estradiol 75mcg; 100mcg
Evorel Estradiol 75mcg; 100mcg
Estradot* Estradiol 75mcg; 100mcg

*note the Estradot patches are the smallest in size, are often the brand women report stick best, but are also most often associated with stock shortages

Oestrogen-only HRT – Transdermal Gel/Spray

Note: All formulations contain ethanol

Brand Strength Form
Oestrogel ✓ First Choice 0.75mg per 1.25g pump Gel
Lenzetto 1.53mg per spray Spray
Sandrena 0.5mg per sachet Gel
Sandrena 1mg per sachet Gel

Sequential Combined HRT

Peri-menopausal women with a uterus, i.e. less than 1 year since last menses.

Sequential Combined HRT – Oral Tablets

Dose Brand Contents
Low Elleste Duet 1mg ✓ First Choice Estradiol 1mg + norethisterone 1mg
Femoston 1/10mg Estradiol 1mg + dydrogesterone 10mg
Medium Elleste Duet 2mg ✓ First Choice Estradiol 2mg + norethisterone 1mg
Femoston 2/10mg Estradiol 2mg + dydrogesterone 10mg

Sequential Combined HRT – Transdermal Patch

Dose Brand Contents
Medium Evorel Sequi ✓ First Choice Estradiol 50mcg; Estradiol 50mcg + norethisterone

Combined patches are only available in medium dose strength.

Local menopause service would suggest starting treatment using half of an Evorel Sequi patch twice weekly to achieve a low dose regimen. This is an unlicensed dose but supported by local and national specialists. The cut half of the patch should be kept in a refrigerator.

Prescribing note
Evorel Sequi contains two different types of patches in the pack, with the regimen of two weeks of Evorel 50mcg (estradiol only) patches, to be followed by two weeks of Evorel Sequi (estradiol and norethisterone) patches. It is important to appropriately counsel patients on the safe and effective use of this product when prescribing.

Continuous combined HRT

For post-menopausal women, with a uterus, who have not experienced menses for 1 year+ or perimenopausal women who are amenorhoeic due to their POP/implant

Continuous Combined HRT – Oral Tablets

Dose Brand Contents
Ultra-Low Femoston-conti 0.5mg/2.5mg ✓ First Choice Estradiol 0.5mg + dydrogesterone 2.5mg
Low Kliovance ✓ First Choice Estradiol 1mg + norethisterone 0.5mg
Femoston-conti 1mg+5mg Estradiol 1mg + dydrogesterone 5mg
Bijuve Estradiol 1mg + progesterone 100mg
Medium Kliofem ✓ First Choice Estradiol 2mg + norethisterone 1mg
Elleste Duet Conti Estradiol 2mg + norethisterone 1mg

Continuous Combined HRT - Transdermal patch

  • Evorel Conti - estradiol 50mcg / norethisterone 170mcg ✓ First Choice

Separate Oestrogen and Progestogen Regimens

When oestrogen and progestogen are administered separately, in order to protect against endometrial hyperplasia the dose of progestogen should be proportional to the required oestrogen dose, i.e. high dose oestrogen-containing regimens should have high dose progestogen component.

The levonorgestrel 52mg IUS system, i.e. Mirena, can be used for all licensed doses of oestrogen and current practice would be to use this for up to 5 years for endometrial protection. 14-BMS-TfC-Progestogens-and-endometrial-protection-APR2023-A.pdf

ORAL PROGESTOGEN

Micronised progestogen should be taken at night due to side effect of sleepiness. Absorption is improved by taking with some food.

Before increasing dose of oestrogen, first worth considering the following:

  • Expectations—are the symptoms likely to be hormone related, or are life stresses more relevant
  • Address any diet and lifestyle factors which may be contributing to menopausal symptoms if appropriate, such as smoking, alcohol, caffeine, high carbohydrate, sugary diet, lack of exercise.
  • Addition of Cognitive Behaviour Therapy may help for flushes, anxiety, low mood, irritability, sleep disturbance https://www.womens-health-concern.org/wp-content/uploads/2023/02/02-WHC-FACTSHEET-CBT-WOMEN-FEB-2023-A.pdf
  • If brain fog is a prominent symptom, the following leaflet may be helpful, explaining that brain fog is common, may or may not respond to HRT and does resolve https://www.imsociety.org/wp-content/uploads/2022/09/ENGLISH-WMD-Leaflet.pdf
  • If using patches: are they adhering, any skin irritation, consider site application—buttocks provide best absorption
  • If using gel ensure applying to thighs and letting soak in for 10-15minutes prior to dressing
Type of HRT regime Oestrogen Progestogen Regimen
Ultra-low to medium dose sequential Up to 50mcg patch /
2 pumps Oestrogel /
2 sprays Lenzetto		 Micronised progesterone 100mg ✓ First Choice 200mg nightly with food on days 15–28
Medroxyprogesterone tablets 10mg daily on days 15–28
High dose sequential Up to 75mcg patch /
3 pumps Oestrogel /
3 sprays Lenzetto		 Micronised progesterone 100mg ✓ First Choice 300mg nightly with food on days 15–28
Medroxyprogesterone tablets 10mg daily on days 15–28
Ultra-low to medium dose continuous combined Up to 50mcg patch /
2 pumps Oestrogel		 Micronised progesterone 100mg ✓ First Choice 100mg nightly with food
Medroxyprogesterone acetate 2.5mg daily
High dose continuous combined Up to 75mcg patch /
3 pumps Oestrogel		 Micronised progesterone 100mg ✓ First Choice 200mg nightly with food
Medroxyprogesterone acetate 5mg daily

Discuss with Menopause team if ultra-high dose oestrogen being considered

Dysmenorrhoea

Irregular uterine bleeding – contraception not required

Irregular uterine bleeing – contraception required

Endometriosis

Uterine Fibroids – treatment of moderate to severe uterine fibroids is by Specialist advice only

8.2 Male sex hormone responsive conditions

Testosterone for hypogonadism due to testosterone deficiency in adult men Ensure FBC and PSA checked annually once stable

Testosterone Replacement Options

Brand Form / Pack Size Typical Dose Strength
TESTAVAN® 85.5g pump Apply 23mg (1 pump) daily.
Increased in steps of 23mg to a max of 69mg (3 pumps) daily.
1 pump actuation = 1.15g (1.25ml) gel containing 23mg testosterone		 20mg testosterone in 1ml gel
TESTOGEL® 88g pump Apply 40.5mg (2 pumps) daily.
Increased in steps of 20.25mg to a max of 81mg (4 pumps) daily.
1 pump actuation = 1.25g gel containing 20.25mg testosterone		 16.2mg testosterone in 1g gel
TESTOGEL® 30 x 5g sachets Apply 50mg (5ml) daily.
Increased in steps of 25mg to a max of 100mg (10ml) daily.		 50mg testosterone in 5ml gel
TOSTRAN® 60g gel Apply 60mg (3g) daily.
Increase to a max of 80mg (4g) daily.		 20mg testosterone in 1g gel
NEBIDO 1 x 4ml vial
✓ Specialist Initiation Only		 1g (4ml) by very slow deep IM injection into gluteal muscle every 10–14 weeks.
(First injection interval can be 6 weeks.)		 250mg testosterone per 1ml solution

Male sex hormone antagonism

Refer to specialist services

9. Thyroid disorders

9.1 Hyperthyroidism

Antithyroid drugs

To be initiated on specialist advice

Beta-blockers

9.2 Hypothyroidism

MHRA Dryg Safety Update 2021: levothyroxine new prescribing advice for patients whoexperience symptoms on switching between different levothyroxine products

Hypoparathyroidism

Hyperparathyroidism

Editorial Information

Last reviewed: 25/04/2025

Next review date: 30/04/2027

Author(s): Formulary subgroup of ADTC.

Version: 1.0

Approved By: ADTC