TRIPASS XR تري باس

 

Endocrine system

6

Note: The following recommendations provide general

guidance for the management of diabetes during surgery.

Local protocols and guidelines should be followed where

they exist.

Use of insulin during surgery

Elective surgery—minor procedures in patients with good

glycaemic control

g Patients usually treated with insulin who have good

glycaemic control (HbA1c less than 69 mmol/mol or 8.5 %)

and are undergoing minor procedures, can be managed during

the operative period by adjustment of their usual insulin

regimen, which should be adjusted depending on the type of

insulin usually prescribed, following detailed local protocols

(which should also include intravenous fluid management,

monitoring and control of electrolytes and avoidance of

hyperchloraemic metabolic acidosis). On the day before the

surgery, the patient’s usual insulin should be given as

normal, other than once daily long-acting insulin analogues,

which should be given at a dose reduced by 20 %. l

Elective surgery—major procedures or poor glycaemic control

g Patients usually treated with insulin, who are either

undergoing major procedures (surgery requiring a long

fasting period of more than one missed meal) or whose

diabetes is poorly controlled, will usually require a variable

rate intravenous insulin infusion (continued until the

patient is eating/drinking and stabilised on their previous

glucose-lowering medication).

The aim is to achieve and maintain glucose concentration

within the usual target range (6–10 mmol/litre; but up to

12 mmol/litre is acceptable) by infusing a constant rate of

glucose-containing fluid as a substrate, while also infusing

insulin at a variable rate. Detailed local protocols should be

consulted. In general, the following steps should be

followed:

. on the day before surgery, once daily long-acting insulin

analogues should be given at 80 % of the usual dose;

otherwise the patient’s usual insulin should be given as

normal;

. on the day of surgery and throughout the intra-operative

period, once daily long-acting insulin analogues should be

continued at 80 % of the usual dose; all other insulin

should be stopped until the patient is eating and drinking

again after surgery;

. on the day of surgery, start an intravenous substrate

infusion of potassium chloride with glucose and sodium

chloride p. 1039 (based on serum electrolytes which must

be measured frequently), and infuse at a rate appropriate

to the patient’s fluid requirements. To prevent

hypoglycaemia, this infusion must not be stopped while

the insulin infusion is running;

. a variable rate intravenous insulin infusion of soluble

human insulin p. 712 in sodium chloride 0.9 % p. 1040

(made either according to locally agreed protocols or using

prefilled syringes) should be given via a syringe pump at an

initial infusion rate determined by bedside capillary bloodglucose measurement. Hourly blood-glucose measurement

should be taken to ensure that the intravenous insulin

infusion rate is correct for at least the first 12 hours; the

insulin infusion rate should be adjusted according to local

protocol to maintain blood-glucose concentrations within

the usual target range (6–10 mmol/litre; up to

12 mmol/litre is acceptable);

. intravenous glucose 20 % p. 1041 should be given if bloodglucose drops below 6 mmol/litre, and blood-glucose

checked every hour, to prevent a drop below 4 mmol/litre.

If blood-glucose drops below 4 mmol/litre, intravenous

glucose 20 % should be adjusted and blood-glucose

checked every 15 minutes, until blood-glucose is above

6 mmol/litre (testing can then revert to hourly). If bloodglucose rises above 12 mmol/litre, check ketones and

consider other signs of diabetic ketoacidosis (see Diabetic

ketoacidosis p. 689).

Conversion back to a subcutaneous insulin should not

begin until the patient can eat and drink without nausea or

vomiting. Once the patient’s previous insulin regimen is restarted, the usual insulin dose may require adjustment, as

insulin requirements can change due to post-operative

stress, infection or altered food intake.

Previous subcutaneous basal-bolus regimens, should be

restarted when the first postoperative meal-time insulin

dose is due (e.g. with breakfast or lunch); doses may need

adjustment due to postoperative stress, infection or altered

food intake. The variable rate intravenous insulin infusion

and intravenous fluids should be continued until

30–60 minutes after the first meal-time short-acting insulin

dose. If the patient was previously on a long-acting insulin

analogue, this should have been continued throughout the

operative period at 80 % of the normal dose, and should now

just continue at that same dose until the patient leaves

hospital; only the short-acting insulin needs to be restarted

as above.

Previous subcutaneous twice-daily mixed insulin

regimens, should be restarted before breakfast or an

evening meal (not at any other time). The variable rate

intravenous insulin infusion should be maintained for

30–60 minutes after the first subcutaneous insulin dose has

been given.

Patients who were previously managed with a

continuous subcutaneous insulin infusion should be

referred to a specialist team. The subcutaneous infusion

should be restarted at the normal basal rate, not at bedtime,

and the insulin infusion continued until the next meal bolus

has been given.

Patients not previously prescribed insulin, who are to

start a subcutaneous insulin regimen post-surgery, should

have an insulin dose calculated with advice from a specialist

diabetes team, considering the patient’s sensitivity to

insulin, degree of glycaemic control, weight, age, and the

average hourly insulin dose used in the peri-operative

period. l

Emergency surgery

g Patients with diabetes (type 1 and 2) requiring

emergency surgery, should always have their blood-glucose,

blood or urinary ketone concentration, serum electrolytes

and serum bicarbonate checked before surgery. If ketones

are high or bicarbonate is low, blood gases should also be

checked. If ketoacidosis is present, recommendations for

Diabetic ketoacidosis p. 689 should be followed immediately,

and surgery delayed if possible. If there is no acidosis,

intravenous fluids and an insulin infusion should be started

and managed as for major elective surgery (above). l

Use of antidiabetic drugs during surgery

g Manipulation of antidiabetic drug may not be

appropriate for all surgery or for all patients; particularly

when fasting time is more than one missed meal, in patients

with poor glycaemic control, and when there is risk of renal

injury. In these cases, a variable rate intravenous insulin

p. 712 infusion should be used as for major elective surgery

(above), and usual antidiabetic medication adjusted in the

peri-operative period. Insulin is almost always required in

medical and surgical emergencies.

When insulin is required and given during surgery,

acarbose p. 692, meglitinides, sulfonylureas, pioglitazone

p. 710, dipeptidyl peptidase-4 inhibitors (gliptins) and

sodium glucose co-transporter 2 inhibitors should be

stopped once the insulin infusion is commenced and not

restarted until the patient is eating and drinking normally.

Glucagon-like peptide-1 receptor agonists can be continued

as normal during the insulin infusion.

If elective minor surgical procedures only require a shortfasting period (just one missed meal), it may be possible to

adjust antidiabetic drugs to avoid a switch to a variable rate

intravenous insulin infusion; normal drug treatment can

continue.

690 Diabetes mellitus and hypoglycaemia BNF 78

Endocrine system

6

In suitable cases, acarbose, nateglinide p. 701 and

repaglinide p. 702 can be continued with just the dose

omitted on the morning of surgery if fasting (the morning

dose may be given if the patient is not fasting and surgery is

in the afternoon).

Pioglitazone, dipeptidylpeptidase-4 inhibitors

(gliptins) and glucagon-like peptide-1 receptor agonists

can be taken as normal during the whole peri-operative

period.

Sodium glucose co-transporter 2 inhibitors should be

omitted on the day of surgery and not restarted until the

patient is stable; their use during periods of dehydration and

acute illness is associated with an increased risk of

developing diabetic ketoacidosis.

Sulfonylureas are associated with hypoglycaemia in the

fasted state and therefore should always be omitted on the

day of surgery until the patient is eating and drinking again.

Capillary blood-glucose should be checked hourly. If

hyperglycaemia occurs, an appropriate dose of subcutaneous

rapid-acting insulin may be given. A second dose may be

given 2 hours later, and a variable rate intravenous insulin

infusion considered if hyperglycaemia persists.

Metformin hydrochloride p. 692 is renally excreted; renal

impairment may lead to accumulation and lactic acidosis

during surgery. If only one meal will be missed during

surgery, and the patient has an eGFR greater than

60 mL/minute/1.73m2 and a low risk of acute kidney injury

(and the procedure does not involve administration of

contrast media), it may be possible to continue metformin

hydrochloride throughout the peri-operative period—just

the lunchtime dose should be omitted if the usual dose is

prescribed three times a day.

If the patient will miss more than one meal or there is

significant risk of the patient developing acute kidney injury,

metformin hydrochloride should be stopped when the preoperative fast begins. A variable rate intravenous insulin

infusion should be started if the metformin hydrochloride

dose is more than once daily. Otherwise insulin should only

be started if blood-glucose concentration is greater than

12 mmol/litre on two consecutive occasions. Metformin

should not be recommenced until the patient is eating and

drinking again, and normal renal function has been assured.

There is no need to stop metformin hydrochloride after

contrast medium in patients missing only one meal or who

have an eGFR greater than 60 mL/minute/1.73m2

. If contrast

medium is to be used, and eGFR is less than

60 mL/minute/1.73m2

, metformin should be omitted on the

day of the procedure and for the following 48 hours. l

Use of antidiabetic drugs during medical illness

Manufacturers of some antidiabetic drugs recommend that

they may need to be replaced temporarily with insulin during

intercurrent illness when the drug is unlikely to control

hyperglycaemia (such as myocardial infarction, coma, severe

infection, trauma and other medical emergencies). Consult

individual product literature.

Sodium glucose co-transporter 2 inhibitors are associated

with increased risk of developing diabetic ketoacidosis

during periods of dehydration, stress, surgery, trauma, acute

medical illness or any other catabolic state, and should be

used with caution during these times. The MHRA has advised

(2016) that these drugs should be temporarily stopped in

patients who are hospitalised for acute serious illness until

the patient is medically stable.

Diabetes, pregnancy and

breast-feeding 01-Aug-2017

Description of condition

Diabetes in pregnancy is associated with increased risks to

the woman (such as pre-eclampsia and rapidly worsening

retinopathy), and to the developing fetus, compared with

pregnancy in non-diabetic women. Effective blood-glucose

control before conception and throughout pregnancy

reduces (but does not eliminate) the risk of adverse

outcomes such as miscarriage, congenital malformation,

stillbirth, and neonatal death.

Management of pre-existing diabetes

g Women with pre-existing diabetes who are planning on

becoming pregnant should aim to keep their HbA1c

concentration below 48 mmol/mol (6.5%) if possible without

causing problematic hypoglycaemia. Any reduction towards

this target is likely to reduce the risk of congenital

malformations in the newborn.

Women with pre-existing diabetes who are planning to

become pregnant should be advised to take folic acid at the

dose for women who are at high-risk of conceiving a child

with a neural tube defect, see folic acid p. 1025. h

Overview

Oral antidiabetic drugs

g All oral antidiabetic drugs, except metformin

hydrochloride p. 692, should be discontinued before

pregnancy (or as soon as an unplanned pregnancy is

identified) and substituted with insulin therapy. Women

with diabetes may be treated with metformin hydrochloride

p. 692 [unlicensed in type 1 diabetes] as an adjunct or

alternative to insulin in the preconception period and during

pregnancy, when the likely benefits from improved bloodglucose control outweigh the potential for harm. Metformin

hydrochloride p. 692 can be continued, or glibenclamide

p. 709 resumed, immediately after birth and during breastfeeding for those with pre-existing Type 2 diabetes p. 686.

All other antidiabetic drugs should be avoided while breastfeeding. h

Insulin

Limited evidence suggests that the rapid-acting insulin

analogues (insulin aspart p. 713 and insulin lispro p. 714) can

be associated with fewer episodes of hypoglycaemia, a

reduction in postprandial glucose excursions and an

improvement in overall glycaemic control compared with

regular human insulin.

g Isophane insulin p. 716 is the first-choice for longacting insulin during pregnancy, however in women who

have good blood-glucose control before pregnancy with the

long-acting insulin analogues (insulin detemir p. 717 or

insulin glargine p. 718), it may be appropriate to continue

using them throughout pregnancy.

Continuous subcutaneous insulin infusion p. 712 (insulin

pump therapy) may be appropriate for pregnant women who

have difficulty achieving glycaemic control with multiple

daily injections of insulin p. 712 without significant disabling

hypoglycaemia.

All women treated with insulin p. 712 during pregnancy

should be aware of the risks of hypoglycaemia, particularly in

the first trimester, and should be advised to always carry a

fast-acting form of glucose, such as dextrose tablets or a

glucose-containing drink. Pregnant women with Type 1

diabetes p. 684 should also be prescribed glucagon p. 724 for

use if needed.

Women with pre-existing diabetes treated with insulin

p. 712 during pregnancy are at increased risk of

hypoglycaemia in the postnatal period and should reduce

their insulin immediately after birth. Blood-glucose levels

should be monitored carefully to establish the appropriate

dose. h

Medication for diabetic complications

g Angiotensin-converting enzyme inhibitors and

angiotensin II receptor antagonists should be discontinued

and replaced with an alternative antihypertensive suitable

for use in pregnancy before conception or as soon as

pregnancy is confirmed (see Hypertension in pregnancy under

BNF 78 Diabetes mellitus 691

Endocrine system

6

Hypertension p. 140). Statins should not be prescribed

during pregnancy and should be discontinued before a

planned pregnancy. h

Gestational diabetes

g Women with gestational diabetes who have a fasting

plasma glucose below 7 mmol/litre at diagnosis, should first

attempt a change in diet and exercise alone in order to

reduce blood-glucose. If blood-glucose targets are not met

within 1 to 2 weeks, metformin hydrochloride below may be

prescribed [unlicensed use]. Insulin p. 712 may be prescribed

if metformin is contra-indicated or not acceptable, and may

also be added to treatment if metformin is not effective

alone.

Women who have a fasting plasma glucose above

7 mmol/litre at diagnosis should be treated with insulin

p. 712 immediately, with or without metformin

hydrochloride below, in addition to a change in diet and

exercise.

Women who have a fasting plasma glucose between 6 and

6.9 mmol/litre alongside complications such as macrosomia

or hydramnios should be considered for immediate insulin

p. 712 treatment, with or without metformin hydrochloride

below.

Glibenclamide p. 709 [unlicensed use] may be considered

for women from 11 weeks gestation (after organogenesis)

who cannot tolerate metformin, or for those in whom

metformin is not effective and do not wish to have insulin

therapy.

Women with gestational diabetes should discontinue

hypoglycaemic treatment immediately after giving birth. h

Useful Resources

Management of diabetes. Scottish Intercollegiate Guidelines

Network. Clinical guideline 116. March 2010 (updated

November 2017).

www.sign.ac.uk/assets/sign116.pdf

Diabetes in pregnancy: management from preconception

to the postnatal period. National Institute for Health and

Care Excellence. Clinical guideline NG3. February 2015.

www.nice.org.uk/guidance/ng3

BLOOD GLUCOSE LOWERING DRUGS › ALPHA

GLUCOSIDASE INHIBITORS

Acarbose 10-Sep-2018

l DRUG ACTION Acarbose, an inhibitor of intestinal alpha

glucosidases, delays the digestion and absorption of starch

and sucrose; it has a small but significant effect in

lowering blood glucose.

l INDICATIONS AND DOSE

Diabetes mellitus inadequately controlled by diet or by

diet with oral antidiabetic drugs

▶ BY MOUTH

▶ Adult: Initially 50 mg daily, then increased to 50 mg

3 times a day for 6–8 weeks, then increased if necessary

to 100 mg 3 times a day (max. per dose 200 mg 3 times

a day)

l CONTRA-INDICATIONS Hernia . inflammatory bowel disease . predisposition to partial intestinal obstruction . previous

abdominal surgery

l CAUTIONS May enhance hypoglycaemic effects of insulin

and sulfonylureas (hypoglycaemic episodes may be treated

with oral glucose but not with sucrose)

l INTERACTIONS → Appendix 1: acarbose

l SIDE-EFFECTS

▶ Common or very common Diarrhoea (may need to reduce

dose). gastrointestinal discomfort. gastrointestinal

disorders

▶ Uncommon Nausea . vomiting

▶ Rare or very rare Hepatic disorders . oedema

▶ Frequency not known Acute generalised exanthematous

pustulosis (AGEP).thrombocytopenia

SIDE-EFFECTS, FURTHER INFORMATION Antacids

containing magnesium and aluminium salts unlikely to be

beneficial for treating side effects.

l PREGNANCY Avoid.

l BREAST FEEDING Avoid.

l HEPATIC IMPAIRMENT Manufacturer advises avoid in

severe impairment.

l RENAL IMPAIRMENT Avoid if eGFR less than

25 mL/minute/1.73 m2

.

l MONITORING REQUIREMENTS Monitor liver function.

l DIRECTIONS FOR ADMINISTRATION Tablets should be

chewed with first mouthful of food or swallowed whole

with a little liquid immediately before food.

l PATIENT AND CARER ADVICE Antacids unlikely to be

beneficial for treating side-effects. To counteract possible

hypoglycaemia, patients receiving insulin or a

sulfonylurea as well as acarbose need to carry glucose (not

sucrose—acarbose interferes with sucrose absorption).

Patients should be given advice on how to administer

acarbose tablets.

l MEDICINAL FORMS There can be variation in the licensing of

different medicines containing the same drug.

Tablet

▶ Acarbose (Non-proprietary)

Acarbose 50 mg Acarbose 50mg tablets | 90 tablet P £15.00 DT

= £11.51

Acarbose 100 mg Acarbose 100mg tablets | 90 tablet P £27.00

DT = £19.03

BLOOD GLUCOSE LOWERING DRUGS ›

BIGUANIDES

Metformin hydrochloride 06-Jun-2017

l DRUG ACTION Metformin exerts its effect mainly by

decreasing gluconeogenesis and by increasing peripheral

utilisation of glucose; since it acts only in the presence of

endogenous insulin it is effective only if there are some

residual functioning pancreatic islet cells.

l INDICATIONS AND DOSE

Type 2 diabetes mellitus [monotherapy or in combination

with other antidiabetic drugs (including insulin)]

▶ BY MOUTH USING IMMEDIATE-RELEASE MEDICINES

▶ Child 10–17 years (specialist use only): Initially 500 mg

once daily, dose to be adjusted according to response at

intervals of at least 1 week, maximum daily dose to be

given in 2–3 divided doses; maximum 2 g per day

▶ Adult: Initially 500 mg once daily for at least 1 week,

dose to be taken with breakfast, then 500 mg twice

daily for at least 1 week, dose to be taken with breakfast

and evening meal, then 500 mg 3 times a day, dose to

be taken with breakfast, lunch and evening meal;

maximum 2 g per day

▶ BY MOUTH USING MODIFIED-RELEASE MEDICINES

▶ Adult: Initially 500 mg once daily, then increased if

necessary up to 2 g once daily, dose increased

gradually, every 10–15 days, dose to be taken with

evening meal, alternatively increased to 1 g twice daily,

dose to be taken with meals, alternative dose only to be

used if control not achieved with once daily dose

regimen. If control still not achieved then change to

standard release tablets

692 Diabetes mellitus and hypoglycaemia BNF 78

Endocrine system

6

Type 2 diabetes mellitus [reduction in risk or delay of

onset]

▶ BY MOUTH USING MODIFIED-RELEASE MEDICINES

▶ Adult 18–74 years: Initially 500 mg once daily, then

increased if necessary up to 2 g once daily, dose

increased gradually, every 10–15 days, dose to be taken

with evening meal, for further information on risk

factors—consult product literature

Polycystic ovary syndrome

▶ BY MOUTH USING IMMEDIATE-RELEASE MEDICINES

▶ Adult: Initially 500 mg once daily for 1 week, dose to be

taken with breakfast, then 500 mg twice daily for

1 week, dose to be taken with breakfast and evening

meal, then 1.5–1.7 g daily in 2–3 divided doses

l UNLICENSED USE

▶ In adults g Based on clinical experience of increased

side-effects, maximum dose for metformin immediaterelease medicines in BNF Publications differs from product

licence. lNot licensed for polycystic ovary syndrome.

l CONTRA-INDICATIONS Acute metabolic acidosis (including

lactic acidosis and diabetic ketoacidosis)

l CAUTIONS Risk factors for lactic acidosis

CAUTIONS, FURTHER INFORMATION

▶ Risk factors for lactic acidosis Manufacturer advises caution

in chronic stable heart failure (monitor cardiac function),

and concomitant use of drugs that can acutely impair renal

function; interrupt treatment if dehydration occurs, and

avoid in conditions that can acutely worsen renal function,

or cause tissue hypoxia.

l INTERACTIONS → Appendix 1: metformin

l SIDE-EFFECTS

▶ Common or very common Abdominal pain . appetite

decreased . diarrhoea (usually transient). gastrointestinal

disorder. nausea .taste altered . vomiting

▶ Rare or very rare Hepatitis . lactic acidosis (discontinue). skin reactions . vitamin B12 absorption decreased

SIDE-EFFECTS, FURTHER INFORMATION Gastro-intestinal

side-effects are initially common with metformin, and may

persist in some patients, particularly when very high doses

are given. A slow increase in dose may improve

tolerability.

l PREGNANCY Can be used in pregnancy for both preexisting and gestational diabetes. Women with gestational

diabetes should discontinue treatment after giving birth.

l BREAST FEEDING May be used during breast-feeding in

women with pre-existing diabetes.

l HEPATIC IMPAIRMENT Withdraw if tissue hypoxia likely.

l RENAL IMPAIRMENT

▶ In adults Manufacturer advises avoid if eGFR is less than

30 mL/minute/1.73 m2

.

▶ In children Manufacturer advises avoid if estimated

glomerular filtration rate is less than

30 mL/minute/1.73 m2

.

Dose adjustments ▶ In children Manufacturer advises

consider dose reduction in moderate impairment.

▶ In adults Manufacturer advises reduce dose in moderate

impairment—consult product literature.

l MONITORING REQUIREMENTS Determine renal function

before treatment and at least annually (at least twice a

year in patients with additional risk factors for renal

impairment, or if deterioration suspected).

l PRESCRIBING AND DISPENSING INFORMATION

▶ In adults Patients taking up to 2 g daily of the standardrelease metformin may start with the same daily dose of

metformin modified release; not suitable if dose of

standard-release tablets more than 2 g daily.

l PATIENT AND CARER ADVICE Manufacturer advises that

patients and their carers should be informed of the risk of

lactic acidosis and told to seek immediate medical

attention if symptoms such as dyspnoea, muscle cramps,

abdominal pain, hypothermia, or asthenia occur.

Medicines for Children leaflet: Metformin for diabetes

www.medicinesforchildren.org.uk/metformin-diabetes

l NATIONAL FUNDING/ACCESS DECISIONS

GLUCOPHAGE ® SR

Scottish Medicines Consortium (SMC) decisions

The Scottish Medicines Consortium has advised (September

2009) that Glucophage ® SR is accepted for restricted use

within NHS Scotland for the treatment of type 2 diabetes

mellitus in adult patients who are intolerant of standardrelease metformin, and in whom the prolonged-release

tablet allows the use of a dose of metformin not previously

tolerated, or in patients for whom a once daily preparation

offers a clinically significant benefit.

l MEDICINAL FORMS There can be variation in the licensing of

different medicines containing the same drug. Forms available

from special-order manufacturers include: capsule, oral

suspension, oral solution

Modified-release tablet

CAUTIONARY AND ADVISORY LABELS 21, 25

▶ Metformin hydrochloride (Non-proprietary)

Metformin hydrochloride 500 mg Metformin 500mg modifiedrelease tablets | 28 tablet P £3.20 | 56 tablet P £6.40 DT =

£4.00

▶ Bolamyn SR (Teva UK Ltd)

Metformin hydrochloride 500 mg Bolamyn SR 500mg tablets | 28 tablet P £3.20 | 56 tablet P £6.40 DT = £4.00

Metformin hydrochloride 1 gram Bolamyn SR 1000mg tablets | 28 tablet P £5.06 | 56 tablet P £10.13 DT = £6.40

▶ Glucient SR (Consilient Health Ltd)

Metformin hydrochloride 500 mg Glucient SR 500mg tablets | 28 tablet P £2.51 | 56 tablet P £5.03 DT = £4.00

Metformin hydrochloride 750 mg Glucient SR 750mg tablets |

28 tablet P £3.20

Metformin hydrochloride 1 gram Glucient SR 1000mg tablets | 28 tablet P £4.26 | 56 tablet P £8.52 DT = £6.40

▶ Glucophage SR (Merck Serono Ltd)

Metformin hydrochloride 500 mg Glucophage SR 500mg tablets | 28 tablet P £1.99 | 56 tablet P £4.00 DT = £4.00

Metformin hydrochloride 750 mg Glucophage SR 750mg tablets | 28 tablet P £3.20 | 56 tablet P £6.40 DT = £6.40

Metformin hydrochloride 1 gram Glucophage SR 1000mg tablets |

28 tablet P £3.20 | 56 tablet P £6.40 DT = £6.40

▶ Meijumet (Medreich Plc)

Metformin hydrochloride 500 mg Meijumet 500mg modifiedrelease tablets | 28 tablet P £2.66 | 56 tablet P £5.32 DT =

£4.00

Metformin hydrochloride 750 mg Meijumet 750mg modifiedrelease tablets | 28 tablet P £3.20 | 56 tablet P £6.40 DT =

£6.40

Metformin hydrochloride 1 gram Meijumet 1000mg modifiedrelease tablets | 28 tablet P £4.26 | 56 tablet P £8.52 DT =

£6.40

▶ Metabet SR (Actavis UK Ltd, Morningside Healthcare Ltd)

Metformin hydrochloride 500 mg Metabet SR 500mg tablets | 28 tablet P £1.99–£2.61 | 56 tablet P £5.22–£5.32 DT = £4.00

Metformin hydrochloride 1 gram Metabet SR 1000mg tablets | 28 tablet P £4.53 | 56 tablet P £9.06 DT = £6.40

▶ Metuxtan SR (Accord Healthcare Ltd)

Metformin hydrochloride 500 mg Metuxtan SR 500mg tablets |

28 tablet P £1.99 | 56 tablet P £5.32 DT = £4.00

▶ Sukkarto SR (Morningside Healthcare Ltd)

Metformin hydrochloride 500 mg Sukkarto SR 500mg tablets | 56 tablet P £2.38 DT = £4.00

Metformin hydrochloride 1 gram Sukkarto SR 1000mg tablets | 56 tablet P £3.82 DT = £6.40

▶ Yaltormin SR (Wockhardt UK Ltd)

Metformin hydrochloride 500 mg Yaltormin SR 500mg tablets | 28 tablet P £1.20 | 56 tablet P £2.39 DT = £4.00

Metformin hydrochloride 750 mg Yaltormin SR 750mg tablets |

28 tablet P £1.44 | 56 tablet P £2.88 DT = £6.40

Metformin hydrochloride 1 gram Yaltormin SR 1000mg tablets | 28 tablet P £1.92 | 56 tablet P £3.83 DT = £6.40

BNF 78 Diabetes mellitus 693

Endocrine system

6

Tablet

CAUTIONARY AND ADVISORY LABELS 21

▶ Metformin hydrochloride (Non-proprietary)

Metformin hydrochloride 500 mg Metformin 500mg tablets | 28 tablet P £1.55 DT = £0.99 | 84 tablet P £2.16–£2.97 | 500 tablet P £15.00–£17.68

Metformin hydrochloride 850 mg Metformin 850mg tablets | 56 tablet P £2.56 DT = £1.56 | 300 tablet P £7.34–£8.36

▶ Glucophage (Merck Serono Ltd)

Metformin hydrochloride 500 mg Glucophage 500mg tablets | 84 tablet P £2.88

Metformin hydrochloride 850 mg Glucophage 850mg tablets | 56 tablet P £3.20 DT = £1.56

Oral solution

CAUTIONARY AND ADVISORY LABELS 21

▶ Metformin hydrochloride (Non-proprietary)

Metformin hydrochloride 100 mg per 1 ml Metformin 500mg/5ml

oral solution sugar free sugar-free | 100 ml P £4.55–£10.50

sugar-free | 150 ml P £60.00 DT = £6.83

Metformin hydrochloride 170 mg per 1 ml Metformin 850mg/5ml

oral solution sugar free sugar-free | 150 ml P £19.95 DT = £19.95

Metformin hydrochloride 200 mg per 1 ml Metformin 1g/5ml oral

solution sugar free sugar-free | 150 ml P £23.48–£24.00 DT =

£24.00

Combinations available: Alogliptin with metformin, below . Canagliflozin with metformin, p. 704 . Dapagliflozin with

metformin, p. 705 . Empagliflozin with metformin, p. 707 . Linagliptin with metformin, p. 695 . Pioglitazone with

metformin, p. 711 . Saxagliptin with metformin, p. 696 . Sitagliptin with metformin, p. 697 . Vildagliptin with

metformin, p. 698

BLOOD GLUCOSE LOWERING DRUGS ›

DIPEPTIDYLPEPTIDASE-4 INHIBITORS (GLIPTINS)

Alogliptin 11-Sep-2018

l DRUG ACTION Inhibits dipeptidylpeptidase-4 to increase

insulin secretion and lower glucagon secretion.

l INDICATIONS AND DOSE

Type 2 diabetes mellitus in combination with other

antidiabetic drugs (including insulin) if existing

treatment fails to achieve adequate glycaemic control

▶ BY MOUTH

▶ Adult: 25 mg once daily, for further information on use

with other antidiabetic drugs—consult product

literature

DOSE ADJUSTMENTS DUE TO INTERACTIONS

▶ Dose of concomitant sulfonylurea or insulin may need

to be reduced.

▶ Caution with use in combination with both metformin

and pioglitazone—risk of hypoglycaemia (dose of

metformin or pioglitazone may need to be reduced).

l CONTRA-INDICATIONS Ketoacidosis

l CAUTIONS History of pancreatitis . not recommended in

moderate to severe heart failure (limited experience)

l INTERACTIONS → Appendix 1: alogliptin

l SIDE-EFFECTS

▶ Common or very common Abdominal pain . gastrooesophageal reflux disease . headache . increased

risk of infection . skin reactions

▶ Frequency not known Angioedema . hepatic function

abnormal . pancreatitis acute . Stevens-Johnson syndrome

SIDE-EFFECTS, FURTHER INFORMATION Discontinue if

symptoms of acute pancreatitis occur such as persistent,

severe abdominal pain.

l ALLERGY AND CROSS-SENSITIVITY Contra-indicated if

history of serious hypersensitivity to dipeptidylpeptidase4 inhibitors.

l PREGNANCY Manufacturer advises avoid—no information

available.

l BREAST FEEDING Avoid—present in milk in animal studies.

l HEPATIC IMPAIRMENT Manufacturer advises avoid in

severe impairment—no information available.

l RENAL IMPAIRMENT Use with caution if eGFR less than

30 mL/minute/1.73 m2

.