Chapter 6: Endocrine system

Indicated to control symptoms of hyperglycaemia (metformin is first line in DMT2)

Safety

NOTE: It takes years for the benefit (mostly microvascular risk) of tight HbA1C control to accrue. Establish individual HbA1C targets balancing any benefits vs hypoglycaemia risk. See NNT Table

Adherence/Patient centeredness

CAUTION: Risk of lactic acidosis. Avoid if eGFR < 30 ml/min. Stop when at risk of dehydration

Safety

CAUTION: Hypoglycaemia: Active metabolites can accumulate when renal function is impaired

Safety

Avoid in patients with heart failure

Safety

Rarely indicated for long term use. Consider dose reduction/withdrawal where possible

Need

• Consider need for treatment in light of risk factors for osteoporotic fractures: previous osteoporotic fragility fracture, parental history of hip fracture, alcohol intake ≥ 4 units/d, rheumatoid arthritis, oral steroids, BMI<22kg/m²), ankylosing spondylitis, Crohn’s disease, prolonged immobility, untreated menopause. See NNT table

Safety

• Check patient’s ability and willingness to take bisphosphonates (and calcium) as instructed
• If the patient has been taking a bisphosphonate for osteoporosis for at least 3 years, discuss the option of discontinuing. There is no consistent evidence of benefit or harm of continued use after at least 3 years therapy.See NICE Guidance. Continue calcium and vitamin D supplements.
  • There are no current guidelines for bisphosphonate holidays/discontinuation in the UK. SeeNICE Multimorbidity Guidance
  • There is no evidence to guide monitoring after discontinuation of bisphosphonate therapy
  • Women who stop alendronate after 5 years rather than continuing for 10 years show moderate decline in bone mineral density and a gradual rise in biochemical markers but no high fracture risk except clinically asymptomatic fractures.
  • Women at high fracture risk may benefit from continuing alendronate beyond 5 years but this should be a considered decision rather than automatic continuation

Adherence/Patient centeredness