Antidiabetic Drugs

NHSL Medicines Guidance
NHS Lanarkshire

General Notes

Fixed dose combination oral therapy could be considered for those tolerant on the individual medicines for at least 6 months and a clinical benefit has been demonstrated. Fixed dose combination oral therapy can be useful to reduce tablet burden and improve compliance with treatment.

Biguanides

Preferred list (P)

METFORMIN

  • Recommended maximum daily dose 2g daily.

 

Total list (T)

METFORMIN modified-release tablets

  • Restriction: For use in patients who are intolerant of standard-release metformin.

Sulfonylureas (SU)

Preferred list (P)

GLICLAZIDE

Thiazolidinediones

Preferred list (P)

PIOGLITAZONE

 

Dipeptidylpeptidase-4 Inhibitors (DPP-4 Inhibitors)

Preferred list (P)

SITAGLIPTIN

  • See British National Formulary for dose adjustments when prescribing in renal impairment.

Sodium Glucose Co-Transporter 2 Inhibitors (SGLT2 Inhibitors)

Preferred list (P)

EMPAGLIFLOZIN (Jardiance®)

CANAGLIFLOZIN (Invokana®)

DAPAGLIFLOZIN (Forxiga®)

Prescribing Notes:

See NICE Technology appraisal guidance (TA390) for restrictions on use of canagliflozin, dapagliflozin and empagliflozin as monotherapies for treating type 2 diabetes.

Further information and guidance on prescribing the above medications for patients with type 2 diabetes mellitus (T2DM) in the presence of co-morbidities can be found in the NHS Lanarkshire Guidelines Management of patients with T2DM and CV disease, Heart Failure or Diabetic Kidney Disease.

Rare but serious, sometimes life-threatening and fatal cases of diabetic ketoacidosis have been reported in patients on SGLT2 inhibitor treatment. These medications should be stopped in intercurrent illness where there is a risk of dehydration (acute serious medical conditions) or when major surgical procedures are required. Treatment may be restarted when the patient’s condition has stabilised.

NHS Lanarkshire also has guidance on the use of Sodium Glucose Co-Transporter 2 Inhibitors in 

Glucagon-Like Peptide-1 Receptor Agonists (INJECTABLE)

Specialist initiation (S1)

SEMAGLUTIDE (Ozempic®)

  • Administration: once weekly
  • SMC restriction: In addition to other oral anti-diabetic medicines, or as an add-on to basal insulin, as an alternative glucagon-like peptide-1 receptor agonist option.
  • As per BNF, Semaglutide must be prescribed and dispensed by brand name. Different brands of Semaglutide have different licensed clinical indications and thus this medicine should not be prescribed generically. 
  • Each pre-filled disposable device contains four doses, which is a four week supply.

DULAGLUTIDE (Trulicity®)

  • Administration: once weekly
  • SMC restriction: as part of a triple therapy in patients with inadequate glycaemic control on two oral anti-diabetic drugs, as an alternative glucagon-like peptide 1 (GLP-1) agonist option.
  • Supplied as single-use pre-filled pen. May be beneficial in healthcare professional administration; device is pre-loaded and needle automatically retracts after administration. 
  • Prescribe by brand name.
  • Each pre-filled disposable device contains one weekly dose of Trulicity®. 

TIRZEPATIDE (Mounjaro®)

  • Administration: once weekly
  • See NHS Lanarkshire guidance "Use of Tirzepatide (Mounjaro®)" for further guidance and eligibility criteria.
  • SMC restriction: in addition to other oral anti-diabetic medicines as an option when glucagon-like peptide-1 (GLP-1) receptor agonists would be considered. 
  • Prescribe by brand name.
  • Each pre-filled disposable device contains four doses, which is a four week supply.

Prescribing Notes: 

Glucagon-Like Peptide-1 Receptor Agonists (ORAL)

Preferred list (P)

SEMAGLUTIDE (Rybelsus®)

  • Indication: type 2 diabetes mellitus
  • SMC restriction: In addition to other oral anti-diabetic medicines, or as an add-on to basal insulin, as an alternative glucagon-like peptide-1 receptor agonist option.
  • NOTE: Due to the high pharmacokinetic variability of oral semaglutide, the effect of switching between oral and subcutaneous semaglutide cannot be easily predicted. Please refer to SPC for more information.

Warrning: risk of medication error due to introduction of new formulation with increased bioavailability

See MHRA Drug Safety Update (December 2025) for more information. 

Rybelsus® tablets are being replaced with a new formulation with increased bioavailability, which is bioequivalent to the initial formulation, as described below. For further information, see Direct Healthcare Professional Communication.

Initial formulation
(one oval tablet)		 Bioequivalent to New formulation
(one round tablet)
3 mg (starting dose) = 1.5 mg (starting dose)
7 mg (maintenance dose) = 4 mg (maintenance dose)
14 mg (maintenance dose) = 9 mg (maintenance dose)

Key points for Prescribers and Pharmacists

  • The new formulation has the same efficacy, safety, and method of administration as the previous one.
  • Patients currently taking Rybelsus® should be informed and advised about the change in formulation and dose when their prescription is updated.
  • Once available, patients newly starting Rybelsus® should be prescribed the new formulation only.
  • Community Pharmacists: always verify that the correct strength and formulation (oval vs. round tablet) are dispensed to prevent dosing errors.
  • Rybelsus® should always be dosed as one tablet per day. Patients should not take two tablets to get the effect of a higher dose. 
  • A Patient Transition Guide produced by the manufacturer of Rybelsus® is available here. 

Combination: Insulin Degludec & Glucagon-Like Peptide-1 Receptor Agonists

Specialist initiation (S1)

INSULIN DEGLUDEC WITH LIRAGLUTIDE (Xultophy®)

  • A fixed combination therapy of insulin degludec + liraglutide.
  • Restrictions: for use in patients who are uncontrolled on basal insulin analogues (glycosylated haemoglobin [HbA1c] >59mmol/mol [7.5%]) and for whom a GLP-1 receptor agonist is appropriate as an add-on intensification therapy to basal insulin to obtain glucose control.

 

NHSL Joint Adult Formulary Key

To indicate the category of a formulary medicine, updated sections adopt the following key:

Preferred list (P): First-line formulary choices.

Total list (T): Alternative choices when preferred list options not effective/not tolerated, or not indicated.

Specialist initiation (S1): Specialist initiation, or on the advice of a Consultant or Specialist Practitioner in this therapeutic area. Continuation in primary care is acceptable.

Specialist use only (S2): Supply via hospital, Homecare Service or a hospital based prescription (HBP) for dispensing by community pharmacy. Not prescribed in primary care setting.

Editorial Information

Last reviewed: 31/01/2022

Next review date: 31/12/2026

Author(s): NHSL.

Version: Please refer to the introduction section for an explanation of the review dates above.

Approved By: ADTC

Reviewer name(s): ADTC.