NHS Greater Glasgow & Clyde Area Drug and Therapeutics Committee
Greater Glasgow and Clyde Medicines
Medicines Update Primary Care

Postscript Primary Care (Aug '13)

Formulary Update - Topical NSAIDS

Piroxicam (Feldene®) 0.5% gel for use as a topical non-steroidal anti-inflammatory drug replaced Movelat® in the Preferred List of the NHSGGC Adult Formulary in June 2013 and is now the first line choice. Movelat® products and ketoprofen 2.5% gel are included in the Total Formulary as second line options.

Ketoconazole Oral Formulation

The MHRA have recently advised that oral ketoconazole should no longer be prescribed for fungal infections.  This is because the incidence and severity of liver damage is higher than with other available antifungal medicines.  This does not apply to topical formulations of ketoconazole.

Nitrofurantoin Contraindication

The MHRA have recently published a reminder to prescribers that nitrofurantoin is contraindicated in patients with creatinine clearance less than 60ml/min. This followed reports of a number of suspected adverse reactions in patients with renal impairment.  Nitrofurantoin or trimethoprim are the recommended drugs for empiric treatment of uncomplicated lower urinary tract infections in females and males in the NHSGGC Adult Infection Management Guideline.  Prescribers should be aware of a patient’s renal function before prescribing, particularly in the elderly.

Diabetes and Driving

This article draws on the guidance produced by Diabetes UK and that issued by the Association of British Clinical Diabetologists (ABCD).

Licence groups
Group 1  includes motorcars and motorcycle
Group 2  includes large lorries and buses
For patients with diabetes the risk of hypoglycaemia is the main danger to safe driving.  Recent changes to DVLA regulations have significant implications for patients with diabetes who drive and for those responsible for their care.  Changes in monitoring practice, stricter regulations regarding hypoglycaemic episodes and the ability for Group 2 drivers on insulin treatment to obtain licences are some of the changes which have been implemented.

What are the DVLA blood glucose monitoring requirements for people with non-insulin treated diabetes driving cars or motorcycles (group 1)?
For patients taking hypoglycaemic agents which can result in hypoglycaemia (sulfonylureas and glinides), the DVLA state in their 'At a Glance Guide’ that it may be appropriate to monitor blood glucose regularly and at times relevant to driving but does not state that it is a requirement to test on every occasion prior to driving.

The Association of British Clinical Diabetologists has stated that the frequency of hypoglycaemia is greatest during the first three months after starting such therapy and it would be sensible to encourage blood glucose testing during this period and in patients who experience frequent hypoglycaemia or who have impaired hypoglycaemic awareness. A medication review should also be undertaken in order to reduce the risk of hypoglycaemia. For group 1 drivers, the Secretary of State for Transport’s Honorary Medical Advisory Panel has advised that the frequency of blood glucose monitoring should depend on the clinical context.1

What are the DVLA blood glucose monitoring requirements for people with non-insulin treated diabetes driving buses or lorries (group2)?
For group 2 drivers who take sulfonylureas or glinides there is a clear requirement to monitor their blood glucose at least twice daily and at times relevant to driving.  There must be evidence of adequate control which would normally take the form of a report from the driver's doctor.  For group 2 drivers on metformin, gliptins or GLP-1 analogues there is no requirement to monitor blood glucose.  However it would seem sensible to encourage regular monitoring in this group.

What are the DVLA blood glucose monitoring requirements for group 1 drivers on insulin?
DVLA regulations state that group 1 drivers must undertake “appropriate blood glucose monitoring”.  No definition of appropriate monitoring is given.  However in letters sent by the DVLA to both group 1 and group 2 drivers on insulin therapy, the following advice is given:

  • You must always carry your glucose meter and blood glucose strips with you. 
  • You must check your blood glucose before driving and every 2 hours whilst you are driving.
  • If your blood glucose is 5.00mmol/l or less, take a snack. 
  • If your blood glucose is less than 4.00mmol/l or you feel hypoglycaemic, do not drive.

Although not stated in their advice, it is sensible to always keep quick-acting carbohydrate (Lucozade®, GlucoTabs® etc) in the car for emergency use. 

What are the DVLA blood glucose monitoring requirements for group 2 drivers on insulin therapy?
From November 2011, people with insulin-treated diabetes have been able to apply for a group 2 licence to drive lorries and buses.  Such drivers must show strict adherence to blood glucose monitoring. They are required to monitor their blood glucose at least twice daily (even on days when they are not driving) and at times relevant to driving.  A glucose meter with a memory function is required.  At the annual examination by an independent consultant diabetologist, three months of blood glucose readings must be available.
What are the DVLA requirements around episodes of hypoglycaemia?
For group 1 drivers who are managed by insulin, sulfonylureas or glinides, not more than one episode of hypoglycaemia requiring the assistance of another person must have occurred in the preceding 12 months.  This would include episodes of nocturnal hypoglycaemia. The requirement of assistance would include admission to A&E, treatment from paramedics or from a partner or friend who has to administer glucose or glucagon because the patient cannot do it themselves. Group 1 drivers with two or more episodes of hypoglycaemia requiring assistance from another person at any time must inform the DVLA and be advised not to drive.

For group 2 drivers similarly treated, no episode of hypoglycaemia requiring the assistance of another must have occurred in the preceding 12 months. If one such episode has occurred the patient should be advised not to drive and notify the DVLA.

What about hypoglycaemia unawareness?
The DVLA guidance states that group 1 drivers should have "awareness of hypoglycaemia" while group 2 drivers should have "full awareness of hypoglycaemia".  Impaired awareness of hypoglycaemia is defined as 'inability to detect the onset of hypoglycaemia because of a total absence of warning'.  Group 1 drivers must stop driving if impaired hypoglycaemic awareness occurs.  However, their licences may be regained if awareness is regained.  This option does not appear to be available to group 2 drivers. 

The DVLA regulations impose new rules for the monitoring and management of drivers with diabetes and it is therefore important that those responsible for the care of patients with diabetes have a full understanding of these rules.

1. Gallen I. et al. Driving and Hypoglycaemia: Questions and Answers. Practical Diabetes. 2012; 29(1):13-14.