Medication Supply Issues

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Testosterone gel/sachet

The GLP1-RA Problem:

There is an ongoing national shortage of glucagon like peptde-1 receptor agonists (GLP-1 RAs) used in the management of Type 2 Diabetes (T2DM). This situation is not expected to resolve until mid2024. Supplies of some GLP-1 RA preparations may be intermittent or exhausted within this timeframe. Although other GLP-1 RA therapies may be available, it is possible there will be insufficient additional capacity to accommodate switching everyone with T2DM currently prescribed an affected GLP-1 RA to an alternative brand.

 The following advice has been issued from DHSC for the period:

What are the medications involved: 
Semagutide (Ozempic)
Exenatide (Bydureon)
Dulaglutide (Trulicity)
Liraglutide (Victoza)

• Avoid initiating people with Type 2 Diabetes on GLP-1 RAs for the duration of the GLP-1 RA national shortage.
• Review the need for prescribing a GLP-1 RA agent and stop treatment if no longer required due to not achieving desired clinical effects as per NICE NG28.
• Avoid switching between brands of GLP-1 RAs, including between injectable and oral forms.
• Where a higher-dose preparation of GLP-1 RA is not available, do not substitute by doubling up a lower-dose preparation.
• Proactively identify patients established on the affected preparation and consider prioritising for review based on the criteria below.
• Where an alternative glucose-lowering therapy needs to be considered, use the principles of shared decision making as per NICE guidelines in conjunction with the Supporting information below.
• Support people with Type 2 Diabetes to access structured education and weight management programmes where available.
• Order stocks sensibly in line with demand during this time, limiting prescribing to minimise risk to the supply chain whilst acknowledging the needs of the patient.
• Offer lifestyle advice
• Review patients on GLP-1RA and stop if not achieving effects or not diagnosed.

The solution - At our practice we are doing the following:

• Do not initiate any new patients on GLP-Is
• Run an audit of patients on GLP-1s and review these
• Identify patients who are taking this for weight and deal with these separately
  • Weight management Eligible people with T2DM who would like support with weight management should be signposted to available weight management programmes
    • https://www.gov.uk/government/publications/adult-weight-management-a-guide-to-brief-interventions
    • https://www.england.nhs.uk/digital-weight-management/
    • https://assets.publishing.service.gov.uk/government/uploads/system/uploads/attachment_data/file/737905/Tier2_adult_weight_management_services__guide.pdf
    • https://www.england.nhs.uk/diabetes/treatment-care/diabetes-remission/
    • https://www.nhs.uk/better-health/lose-weight/
  • Identify patients who have
    • HbA1c greater than 86mmol/mol in the previous 3 to 6 months.
    • HbA1c greater than 86mmol/mol prior to starting the GLP-1 RA.
    • HbA1c not recorded in the previous 6 months.
    • Urine albumin:creatinine ratio (uACR) greater than 30mg/mmol.
    • Self-monitoring of blood glucose readings (or Continuous Glucose Monitoring, where available) persistently above individualised target range.
    • Prioritise these patients for review.
  • Review patients as per MSN Annex 1: Criteria for prioritised review
    • if on insulin optimise insulin therapy
    • if on medication optimise meds

We have been informed that the following will be able to deal with the expected increased demand:

• Intermediate - HumulinI KwikPen
• Basal Toujou U300 Solostar pen
• Mixed Insulin Humulin M3 Kwik pen

 This is the leaflet we are sharing with our patients: 

Tresiba® (insulin degludec) FlexTouch® 100units/ml solution for injection 3ml pre-filled pens will be inshortage with an anticipated re-supply date of January 2024. 

• Do NOT initiate new patients with Tresiba® FlexTouch 100 units/ml pre-filled pens.
• Switch patients to Tresiba® PENFILL 3ml cartridges and prescribe a compatible reusable pen device (NovoPen® 6 or NovoPen Echo Plus®) OR
• Switch from Tresiba 100 units FlexTouch pre-filled PEN to Tresiba 200 units FlexTouch pre-filled PEN -  DO NOT advise the patient to half the dose - the Tresiba® 200 units FlexTouch® pre-filled pen dials the dose in 2 unit increments instead of 1 unit increments. Note, the dose window shows the number of insulin units to be delivered and so no dose conversion is needed regardless of the strength of the Tresiba® FlexTouch pre-filled pen.

• Clinicians in primary and secondary care should refer to UKHSA guidance on the management of scabies cases and outbreaks in long-term care facilities and other closed settings including the appropriate infection prevention and control measures with advice on cleaning of clothing and bedding.
• Where scabies has been diagnosed and where individuals have been confirmed as contactsb , UKHSA has advised that existing stock of permethrin 5% cream should be reserved for these patients.
• If licensed permethrin 5% cream is unavailable, prescribe unlicensed permethrin 5 % cream.
• Where permethrin 5% cream is unavailable, consider prescribing unlicensed special-order benzyl benzoate 25% emulsion if locally available.
• If both alternatives are unavailable, consider prescribing unlicensed ivermectin 3mg tablets. Ivermectin tablets are now a licensed product, although sources like the BNF, CKS, and UKHSA guidance have yet to update to reflect this, and still describe oral ivermectin as an unlicensed product.

Lead Presscribing Pharmacist and GP partner at WellBN