North East and North Cumbria Formulary


	North East and North Cumbria ICS Formulary

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Formulary Chapter 6: Endocrine system - Full Chapter

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NTAG Endocrine System Recommendations

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06.03.02

Glucocorticoid therapy

Prednisolone

First Choice

The lowest cost formulation should be used when clinically appropriate. Formulations approved include:
- 1mg, 5mg tablets;
- 5mg soluble tablets;
- 1mg in 1ml oral solution (Prednisolone Dompé®);
- 5mg suppositories.

Hydrocortisone sodium phosphate (Efcortesol^®)

Formulary

100mg/ml solution for injection
As an additional option to hydrocortisone sodium succinate for patients who are steroid dependent (pituitary or adrenal cause and occasionally non-endocrine reasons for long term steroid use) to manage sick day rules to avoid an Addisonian crisis.
Paraesthesia and pain may follow intravenous injection.

Dexamethasone

Alternatives

500microgram & 2mg tablets
500microgram soluble tablets
2mg in 5ml oral solution and 5mg in 5ml oral solution is also approved. unlicensed
20mg/5ml oral solution
Approved for use in patients requiring high dose to reduce pill burden

MHRA Alert (Oct 2014): Dexamethasone 4 mg/ml injection (Organon Laboratories Limited): reformulation with changes in name, concentration, storage conditions, and presentation

Methylprednisolone sodium succinate 2mg, 4mg, and 16mg (tablets)

Alternatives

Dexamethasone 3.3mg in 1ml and 6.6mg in 2ml
(injection )

Alternatives

Note: there are two different strength preparations of dexamethasone injection available in the UK (3.8mg/ml and 3.3mg/ml) where traditionaly a 4mg/ml preparation was available and prescribed as such. To avoid confusion the 3.3mg/ml strength is the preparation of choice in the acute Trusts. Where previously a 4mg dose would have prescribed it is appropriate to prescribe a 3.3mg dose (or multiples thereof). This is because the range of doses given in clinical practice varies widely and subsequent doses tend to be adjusted to reflect clinical response. If 4mg is required please ensure that the appropriate volume of 3.3mg/ml is (e.g. 1.2ml) prescribed (or mulitples thereof).

Hydrocortisone

Alternatives

10mg and 20mg tablets
5mg, 10mg and 20mg dispersible tablets
2.5mg buccal tablets
5mg/5ml and 10mg/5ml oral solution (Colonis®)
In patients who are unable to swallow or have swallowing difficulties the most cost effective product should be used
0.5mg, 1mg, 2mg & 5mg granules (in capsules for opening)
- Approved for treatment of adrenal insufficiency in infants, children and adolescents
- Patients should be transitioned onto tablets once they are able to take them

MHRA Drug Safety Update (Feb 2021): Alkindi (hydrocortisone granules): risk of acute adrenal insufficiency in children when switching from hydrocortisone tablet formulations to granules

Methylprednisolone Acetate 40mgin 1ml and 120mg in 3ml (depot)
(injection)

Alternatives

Methylprednisolone sodium succinate 40mg, 125mg, 500mg & 1000mg (injection)

Alternatives

MHRA Drug Safety Alert (Oct 2017): Methylprednisolone injectable medicine containing lactose (Solu-Medrone 40 mg): do not use in patients with cows’ milk allergy

NICE NG220: Multiple sclerosis in adults: management

Triamcinolone acetonide 40 mg in 1ml
(Intramuscular/intra-articular injection)

Alternatives

Betamethasone 4mg in 1ml
(injection)

Alternatives

MHRA Drug Safety Update (Aug 2017): Corticosteroids: rare risk of central serous chorioretinopathy with local as well as systemic administration

NICE NG243 : Adrenal insufficiency: identification and management

06.03.02

Disadvantages of corticosteroids

06.03.02

Use of corticosteroids

06.03.02

Pregnancy and breastfeeding

06.03.02

Administration

06.03.02

Withdrawal of corticosteroids

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Key

	Notes
	Section Title (top level)
	Section Title (sub level)
	First Choice item
	Non Formulary section
	Restricted Drug
	Unlicensed
	Display tracking information
	Link to adult BNF
	Link to children's BNF
	Link to SPCs

	Cytotoxic Drug
	Controlled Drug
	High Cost Medicine
	NHS England
	Homecare
	CCG

Traffic Light Status Information

Status	Description
	Drugs for hospital use only. The responsibility for initiation and monitoring treatment should rest with an appropriate hospital clinician and the drug should be supplied through the hospital throughout the duration of treatment. In some very exceptional circumstances (e.g. due to distance from the hospital, storage, supply or mobility/transport problems) it may be appropriate for the GP to be asked to prescribe a Red drug. This should be negotiated on an individual patient basis and should only be done with the GP’s prior informed agreement where the roles of the GP and hospital services are clearly defined and agreed. The GP should not feel under pressure to prescribe in these circumstances. For all RED drugs automatically added to the formulary in response to a positive NICE TA: Prescribers need to ensure that local Trust new drug governance procedures and pharmacy processes are followed before any prescribing.
	Drugs initiated by hospital specialist, but where continuing treatment by GPs may be appropriate under a shared care arrangement. The specialist should send the GP a copy of the shared care agreement to sign. The GP should sign the shared care agreement, or indicate they do not want to be part of such an agreement, and return a copy back to the specialist. Shared care guidelines are available or are being developed for most of the drugs listed as Amber. If no shared care guideline is available, the hospital specialist should provide the patient’s GP with sufficient information and support to allow treatment to be continued and managed safely in primary care.
	Drugs normally recommended or initiated by a specialist (hospital or GP with an extended role https://www.rcgp.org.uk/gpwer), but can be safely maintained in primary care with very little or no monitoring required. In some cases there may be a further restriction for use outlined - these will be defined in each case. Provision of additional information, or an information leaflet, may be appropriate in some cases to facilitate continuing treatment by GPs.
	Drugs where prescribing by GPs is appropriate. Can be initiated and prescribed in all care settings, and if appropriate, discontinued without recourse to secondary care.
	NOT APPROVED: Drugs that have been considered by NTAG or the NENC ICB Medicines Subcommittee (or other approved body) and are not approved for prescribing within the North East and North Cumbria.
	UNDER REVIEW: drugs whose current formulary status or RAG status is currently under review.
	NOT REVIEWED: Drugs that haven not been reviewed yet. This usually means that an application is in progress. These drugs are not normally considered appropriate for prescribing in the North East and North Cumbria until such time that a decision is taken on their formulary status.