1

New Medicines Committee Briefing November 2013

Topical corticosteroids are to be reviewed for use within:

Consultant submitting application: Dr Nicholas Craven (Consultant Dermatologist)

Clinical Director supporting application: Mr Gareth Rowland

Dr Craven has requested that the whole skin section of the formulation be reviewed. As part of

this process, the topical corticosteroid section is being reviewed. Dr Craven has requested that

fluocinolone acetonide 0.0025% cream, fluocinolone acetonide 0.00625% cream and ointment,

fluocinolone acetonide 0.025% cream, gel and ointment, fluocinolone acetonide 0.025% with

clioquinol 3% cream and ointment, fluocinolone acetonide 0.025% with neomycin 0.5% cream

and ointment, Haelan® tape, Trimovate® cream, Diprosalic® ointment and Nerisone Forte® oily

cream and ointment be included in the North Staffordshire Joint Formulary while the following

corticosteroids: hydrocortisone 0.5% cream and ointment 30g, hydrocortisone 1% cream and

ointment 50g, hydrocortisone 2.5% cream and ointment, Canesten HC® cream 15g, Daktacort®

cream 15g, Fucidin H® cream 60g, Betnovate® scalp application, Fucibet® cream 60g, and

Clarelux® Foam Scalp Application) be removed from the Joint Formulary.

Dr Craven states that Haelan® tape would be used in the following conditions: nodular prurigo,

lichen simplex, fissured dermatitis, stubborn plaques of psoriasis, chronic discoid lupus

erythematosus and granuloma annulare, plus any other stubborn localised steroid-responsive

dermatoses. The super-potent topical steroids such as Dermovate® and Nerisone Forte® are used

when the affected areas are more extensive. He also stated that the Synalar® products will be

used in patients allergic to hydrocortisone, clobetasone butyrate and betamethasone esters and

that Synalar gel is standard treatment for steroid-responsive dermatoses in the scalp.

Topical Corticosteroids

Primary Care

Secondary Care

Formulary application:

2

He noted that these are well-established products which should be available in any dermatological

formulary. A healthy selection of topical corticosteroids ranging from mild to very potent, with or

without antimicrobials, are essential as there is wide inter-patient variability in response to

treatments.

Corticosteroids are synthetic analogues of the natural hormones that are produced by the adrenal

cortex. Like the natural hormones, synthetic corticosteroids can have glucocorticoid and/or

mineralocorticoid properties. Corticosteroids can be administered systemically (orally and

parenterally) or locally (topically to the skin, nose, and eyes; by inhalation; rectally and by intra-

articular injection). Local corticosteroids are predominantly glucocorticoids with anti-

inflammatory, immunosuppressive, anti-proliferative (anti-mitotic) and vasoconstrictive effects.

Topical corticosteroids exert these effects on the skin to treat various inflammatory skin

conditions (other than those arising from an infection), such as eczema, contact dermatitis, insect

stings, psoriasis, lichen planus, discoid lupus erythematosus and alopecia areata. Topical

corticosteroids are also available as compound preparations containing antibacterials, antifungals

and salicylic acid for use in inflammatory skin conditions associated with bacterial and fungal

infection according to the sensitivity of the infecting organism and hyperkeratosis respectively.

They may also be used in conjunction with other topical agents eg coal tar or dithranol.

Corticosteroids are not curative.1,2

Topical corticosteroids are available in four potencies: Mild, moderately potent, potent and very

potent. The potency is determined by the amount of vasoconstriction produced as well as the

formulation (ointments are more potent than creams), occlusion, the salt of the steroid, the

presence of other ingredients and fluorination. The occlusion involves the covering of the

treatment area is by a thin polythene film which enhances effectiveness as well as local and

systemic toxicity. The salt of the steroid do influence the potency as dipropionate and butyrate

salts are stronger than valerate salts. The presence of other ingredients such as salicylic acid or

urea and fluorination increases potency (fluorinated corticosteroids e.g. Dermovate®, Haelan®,

Metosyn® and Cutivate® have increased potency).1

There are no published systematic reviews comparing the effectiveness of different topical

corticosteroids. Choice of agent is made according to patient need.3 The British Association of

Dermatologists states that patients who fail to respond to one topical agent may respond to

another and it is worthwhile rotating different types of topical agents.4 They also noted there is

lack of evidence supporting twice-daily application of topical corticosteroids to be more effective

than once daily application. The choice of topical corticosteroid depends on the condition being

treated and its stage, the area of the body that is affected, and the age of the person. Mild forms

of dermatitis may only require a mild corticosteroid whereas psoriasis may require a more potent

steroid with the most potent treatments reserved for recalcitrant dermatoses.

The least potent steroid that relieves the symptoms should be prescribed, and at an appropriate

quantity. Patients should be advised to spread thinly over the affected area and use the fingertip

unit as a measuring guide.2 Where long-term topical corticosteroids are required, gradual

Relevance in therapy:

3

withdrawal of the steroid may be needed to prevent rebound exacerbation of the condition. Use

of emollient helps in reduction of use of steroids and where emollient is required, the

corticosteroid should be applied 30 minutes after the emollient to ensure full absorption of the

emollient. Areas where the skin is thin or flexural e.g. face, scrotum, groin, axillae and

submammary area, usually require a weak or moderately-potent corticosteroid whereas areas

where the skin is thick e.g. palms of the hands, soles of feet, scalp, or lichenified skin due to

constant scratching, typically require more potent preparations.1

Pregnancy: Mildly potent, moderately potent and potent corticosteroids, if used correctly, are

suitable for use during pregnancy. Some evidence suggested that very potent corticosteroids

might be associated with low birth weight and will need specialist advice.1

Breastfeeding: Mildly potent, moderately potent and potent corticosteroids are considered

suitable for use during breastfeeding. If applied to the breasts, the steroid should be washed off

before breastfeeding to prevent the infant ingesting it.1

Cautions: Steroids are not recommended to be applied to the face for prolonged periods or for

prolonged use in children. Potent and very potent corticosteroids are recommended to be used

under specialist supervision. The use of potent or very potent corticosteroids in psoriasis can

result in rebound relapse, development of pustular psoriasis, and local and systemic toxicity..1,2

Contraindications: Primary infections of the skin caused by bacteria, fungi or viruses, in acne, and

rosacea. Potent corticosteroids are contraindicated in plaque psoriasis.1,2

Side-effects: Long-term continuous topical steroid therapy, especially with the potent and very

potent preparations can produce atrophic skin changes such as thinning of the skin, irreversible

striae and telangiectasia, and even adrenal suppression and Cushing’s syndrome. Contact

dermatitis, irritation at site of application, spread and worsening of untreated infection, perioral

dermatitis, acne/worsening of acne or rosacea, reversible depigmentation and hypertrichosis are

other local side-effects reported.1,2

Tolerance may occur in response to continued use of any topical steroid and is related to duration

of use rather than potency. The British Association of Dermatologists therefore recommends that

No more than 100g of a moderately potent or higher potency preparation should be applied

per month.

Use of very potent preparations should be under dermatological supervision.

Use of fingertip unit as a measure to help patients know how much ointment or cream to

apply.

No topical corticosteroid should be used regularly for more than four weeks without critical

review.

Potent corticosteroids should not be used regularly for more than 7 days.

No unsupervised repeat prescriptions should be made. Patients should be reviewed every 3

months.4

4

Table 1: Practical guidance to formulation choice of topical steroids based on the condition being treated, patient’s preference, its severity and location. 1,5

Formulation Formulation advantages Formulation disadvantages Body areas Selection of products available

(not an exhaustive list)

Solutions

A low viscosity, alcohol- or water-

based liquids. Easy to apply and non-

greasy.

Very drying if alcohol is the base, and

can sting sore skin.

Scalp Betnovate®

Betacap®

Dermovate®

Scalp Application

Cream

A mixture of water suspended in oil,

thicker than lotions- good

moisturising qualities, absorb rapidly

into skin and cosmetically acceptable.

Useful for exudating (weepy) and

moist areas.

Contains preservatives in formulation,

which may cause irritation/allergic

reactions. Lesser occlusive effect than

ointments.

Face, limbs, trunks

Flexures and genitals

Palms and soles

Cutivate® cream

Elocon® cream

Haelan® cream

Nerisone® cream

Gel

Less greasy and occlusive. Has a jelly-

like consistency, beneficial for

exudative inflammation and does not

cause hair matting.

Lesser occlusive effect than creams and

ointments.

Face, Limbs, Trunk

Flexures and genitals

Palms and soles

Scalp and hairy

areas

Synalar® gel

Lotions

Less greasy and occlusive. Penetrate

well on hairy areas and leave little

residue.

Contain alcohol, which has a drying

effect.

Scalp and hairy

areas

Diprosone® lotion

Locoid Crelo® lotion

Elocon® scalp lotion

Betnovate® lotion

5

Formulation Formulation advantages Formulation disadvantages Body areas Selection of products available

(not an exhaustive list)

Ointment

Paraffin-based, providing an occlusive

emollient effect, which improved

steroid absorption (this formulation

slightly increases potency). Most

useful for very dry skin and

hyperkeratotic areas.

Ointments are not suitable for hairy

areas, flexures and genitals, as they

may cause maceration and folliculitis.

Greasy nature means they are not

cosmetically acceptable. Paraffin-based

products are flammable.

Face

Limbs

Trunk

Palms and soles

Betnovate® ointment

Dermovate® ointment

Haelan® ointment

Modrasone® ointment

Mousse (foam) Effectively delivers steroids to the

scalp. Non-greasy.

Can only be used on the scalp. Scalp Bettamousse® foam

Clarelux® foam

Shampoo

Effectively delivers steroids to the

scalp. Needs to be applied to a dry

scalp and rinsed off 15 minutes.

Can only be used on the scalp. May be

confusing for patients as this shampoo

formulation is not used for washing

hair.

Scalp Etrivex® shampoo

Tape

Flexible and effective delivery method

for targeted application under

occlusion. Helps protect easily

damaged areas of skin (areas

constantly scratched), areas of very

thick skin, and areas difficult to treat

with other formulations (fingers).

Not suitable for flexures, as occlusion

increases potency (Haelan® tape does

not increase potency). May not stick to

weepy areas. Courses limited to five

days for children.

Limbs

Trunk

Palms and soles

Haelan® tape

6

Hypersensitivity Reactions to Corticosteroids:6

Contact allergy is occasionally a complication of topical corticosteroid treatment and can be

confirmed by appropriate patch testing. Patients generally present with a chronic dermatitis that is

not exacerbated by, but fails to respond to corticosteroid therapy. In general, corticosteroid-

sensitive patients react to several corticosteroids; this may be due to multiple sensitizations after

the use of various different preparations, or due to a true cross-reactivity mechanism. In 1989,

based on corticosteroid patch test results and their chemical structure, Coopman et al. concluded

that cross reactions between corticosteroids occurred primarily within 4 groups:

A: hydrocortisone type

B: triamcinolone acetone type

C: betamethasone type

D: hydrocortisone-17-byturate type

Group D was later subdivided into groups D1 and D2. The corticosteroids in each group have

similar chemical structure, a fact which might explain the existence of a high cross-reactivity

between the corticosteroids in each group (table 2). However, cases of cross reaction have also

been reported between corticosteroids from group D2 and groups A and B, with Group D1

exhibiting quite low cross-reactivity with the other groups. Coopman’s classification has proved

useful in the evaluation of reactions induced by topically administered corticosteroids, although it

is not accepted by all.

Table 2: Coopman classification of topical corticosteroids by the function of their allergenicity6

7

In 1994, Wilkinson et al7 published a study that was contradicting Coopman et al’s classification

table as they found many of their patients with multiple positive patch-test reactions to

corticosteroids did not fit easily into the above four categories. Coopman and others have

subsequently stated that not all of the cross-reactions that they see, fit into corticosteroid classes

A to D. Wilkinson et al looked at the positive patch-test reactions to other corticosteroids in 96

patients who were allergic to hydrocortisone, to establish which substitutions were important in

determining concomitant reactions. These patients were patch tested with tixocortol pivalate (1%

petrolatum) as this compound is both a sensitive and specific marker for hypersensitivity to

hydrocortisone. Patients positive on patch testing to tixocortol pivalate were then patch tested to

a battery of corticosteroids, using Finn chambers® on Scanpor® tape, left on the skin of the back for

48 hours. The patch tests were read at 2 and 4 days and patients were asked to return for a

further reading if they developed a reaction after 4 days. Reactions were scored as recommended

by the International Contact Dermatitis Research Group, and were considered positive when a

palpable erythematous (+) reaction or greater was present with the frequency of positive

reactions to other corticosteroids being expressed as a percentage.

Results: It was found that the two commonest corticosteroid allergies occurring in patients

hypersensitive to hydrocortisone were to hydrocortisone-17-butyrate and budesonide (Table 3).

On the contrary, these three corticosteroids lie in different classes according to Coopman et al.

(i.e. Class A: hydrocortisone, Class B: Budesonide, Class D: hydrocortisone-17-butyrate). The effect

of the C6 and C9 substitution had greater statistical significance than that of the C16 and C17

substitutions as shown by the P-values after correction for other grouping (C6 and C9 P<0.0001; C16

and C17 P=0.005). The authors concluded that patients sensitised to topical hydrocortisone are

most likely to concomitantly react to other non-C6 and –C9 substituted corticosteroids. They added

that where facilities are not available to patch test to other corticosteroids (1% in ethanol), an

alternative topical agent should be chosen based primarily on the C6 and C9 substitution, followed

by the C16 and C17 substitution.

Table 3: Other positive patch test reactions in 96 patients allergic to hydrocortisone

Corticosteroid % positive n

Hydrocortisone-17-butyrate 43.8 96

Budesonide 28.1 96

Methylprednisolone acetate 13.3 83

Alclometasone dipropionate 10.8 65

Flurandrenolone 7.23 83

Fluocortolone 3.61 83

Betamethasone valerate 5.21 96

Clobetasol butyrate 5.21 96

Clobetasol propionate 4.2 96

8

Triamcinolone acetonide 3.6 83

Desoxymethasone 2.4 83

Beclomethasone

dipropionate 2.4 83

Betamethasone

dipropionate 1.9 52

Halcinonide 1.2 83

Fluocinonide 3.6 83

Diflucortolone valerate 1.2 83

Fluocinolone acetonide 1.2 83

The North Staffordshire Joint Formulary currently lists the following agents:

13.3 TOPICAL CORTICOSTEROIDS NICE TA81

Corticosteroid only preparations

Mild potency

Hydrocortisone (0.5%, 1%,

2.5%)

Moderate potency

Betamethasone valerate

0.025% (Betnovate-RD®)

Clobetasone butyrate

0.05% (Eumovate®)

Potent

Betamethasone valerate

0.1% (Betnovate®)

Hydrocortisone butyrate

0.1% (Locoid®)

Very potent

Clobetasol propionate

0.05% (Dermovate®)

Topical corticosteroids with antimicrobials

Mild potency

Canesten HC®

Daktacort®

Fucidin H®

Current formulary status::

9

Vioform-Hydrocortisone®

Moderate potency

Trimovate®

Potent

Betnovate-C®

FuciBET®

Very potent

Dermovate-NN®

Scalp applications

Potent

Betamethasone valerate

0.1% scalp application

Diprosalic®

(betamethasone 0.05%,

salicylic acid 3%) scalp

application

Very potent

Dermovate®

(clobetasol propionate

0.05%) scalp application

10

Drug Strength (w/w) Brand Formulation Recommended Pack Size and

Primary Care Price*

Mild

Fluocinolone acetonide 0.0025% Synalar 1 in 10 dilution® Cream 50g (£4.58)

Hydrocortisone 0.5% Generic Cream / Ointment 15g (£1.42 / £3.39)

Hydrocortisone 1% Generic Cream / Ointment 15g (£1.12/£1.27)

Mild with Antimicrobial Hydrocortisone / Clotrimazole 1% / 1% Canesten HC® Cream 30g (£2.42)

Hydrocortisone / Miconazole 1% / 2% Daktacort® Cream / Ointment 30g (£2.48 / £2.50)

Hydrocortisone acetate / Fusidic acid 1% / 2% Fucidin H® Cream 30g (£5.02)

Moderate

Fluocinolone acetonide 0.00625% Synalar 1 in 4 dilution® Cream / Ointment 50g (£4.84)

Fludroxycortide 4 µg / cm2 Haelan® tape Polythene Adhesive Film 7.5 cm x 50cm (£9.27),

7.5 cm x 200 cm (£24.95)

Betamethasone valerate 0.025% Betnovate-RD® Cream / Ointment 100g (£3.15)

Clobetasone butyrate 0.05% Eumovate® Cream / Ointment 30g (£1.86), 100g (£5.44)

Moderate with Antimicrobial Clobetasone butyrate / Oxytetracycline

/ Nystatin 0.05% / 3% /

100,000 units/g Trimovate® Cream 30g (£3.29)**

Potent

Fluocinolone acetonide 0.025% Synalar® Cream / Ointment 30g (£4.14), 100g (£11.75)

Hydrocortisone butyrate 0.1% Locoid® Cream / Ointment 30g (£1.60), 100g (£4.93)

Betamethasone valerate 0.1% Betnovate® Cream 30g (£2.73), 100g (£9.10)

Betamethasone valerate 0.1% Betnovate® ointment 30g (£3.16), 100g (£10.53)

RECOMMENDED CORTICOSTEROIDS

11

*Primary care costs were obtained Drug Tariff December 2013.8

**Costs unavailable in the Drug Tariff. Costs obtained from the C&D.9

***Prices have been taken from the British National Formulary (BNF) 66 September 2013.10

Drug Strength (w/w) Brand Formulation Recommended Pack Size and Primary Care Price*

Potent With Antimicrobial Betamethasone valerate / Clioquinol 0.1% / 3% Generic Cream / Ointment 30g (£9.48)

Betamethasone valerate / Fusidic Acid 0.1% / 2% Fucibet® Cream 30g (£5.32), 60g (£10.63)

Fluocinolone acetonide / Clioquinol 0.025% / 3% Synalar C® Cream / Ointment 15g (£2.66)**

Fluocinolone acetonide / Neomycin 0.025% / 0.5% Synalar N® Cream / Ointment 30g (£4.36)**

Potent With Salicylic Acid

Betamethasone dipropionate / Salicylic Acid

0.05% / 3% Diprosalic® Ointment 30g (£3.18), 100g (£9.14)

Potent Scalp Application

Betamethasone valerate 0.1% Betacap® Scalp Application 100ml (£3.75)

Betamethasone dipropionate / Salicylic acid

0.05% / 2% Diprosalic® Scalp Application 100ml (£10.10)

Fluocinolone acetonide 0.025% Synalar® Gel 30g (£5.56), 60g (£10.02)

Very Potent

Clobetasol propionate 0.05% Dermovate® Cream / Ointment 30g (£2.69), 100g (£7.90)

Diflucortolone valerate 0.3% Nerisone Forte® Oily Cream /Ointment 15g (£2.09)

Very Potent Scalp Application

Clobetasol propionate 0.05% Dermovate® Scalp Application 30ml (£3.07), 100ml (£10.42)

Very Potent with Antimicrobial Clobetasol propionate / Neomycin

sulphate / Nystatin 0.05% / 0.5% / 100,000

units/g Generic Cream / Ointment 30g (£64.00)***

Table updated by Monjur Ali (Clinical Pharmacist) – February 2014.

12

Expenditure in Primary and Secondary Care for a 12-month period (June 2012 - May 2013):

Product UHNS STOKE CCG NORTH STAFF CCG

Haelan® Tape £142.49 £2,575.16 £2,131.05

Trimovate® cream £1,335.67 £14,387.83 £11,532.92

Diprosalic® ointment £197.10 £7,939.59 £5,197.16

Nerisone Forte® oily cream £2.20 £3.90 £9.67

Nerisone Forte® ointment £0.00 £3.89 £3.87

Fluocinolone acetonide 0.0025%

(Synalar 1 in 10 dilution®) cream £17.87 £343.50 £415.14

Hydrocortisone 0.5% cream £100.85 £4,728.99 £2,931.30

Hydrocortisone 0.5% ointment £48.30 £2,183.44 £1,041.39

Hydrocortisone 1% cream £332.19 £18,602.12 £14,969.59

Hydrocortisone 1% ointment £75.38 £5,799.51 £3,632.77

Hydrocortisone 2.5% cream £0.00 £5,020.17 £4,301.19

Hydrocortisone 2.5% ointment £0.00 £3,638.92 £2,173.13

Canesten HC® cream £155.36 £3,060.76 £2,524.74

Daktacort® cream £380.77 £7,255.88 £4,739.01

Daktacort® ointment £40.60 £1,501.36 £635.57

Fucidin H® cream £726.12 £12,689.87 £7,449.48

Synalar 1 in 4 dilution® (fluocinolone

acetonide 0.00625%) cream / ointment £4.63 £527.90 £1,047.72

Betnovate-RD® (betamethasone valerate

0.025%) cream / ointment £410.03 £14,184.51 £8,737.66

Eumovate® (clobetasone butyrate) cream /

ointment £1,112.05 £5,471.59 £5,877.75

Fluocinolone Acetonide (Synalar®) 0.025%

cream/ointment £75.40 £2,663.10 £1,287.01

Synalar® Gel (fluocinolone acetonide 0.025%) £152.65 £2,391.21 £1,102.45

Cost analysis:

13

Product UHNS STOKE CCG NORTH STAFF CCG

Hydrocortisone butyrate (Locoid®) 0.1%

cream /ointment £12.59 £462.99 £384.44

Betamethasone valerate (Betnovate®) 0.1%

cream £555.78 £22,159.58 £18,830.25

Betnovate® 0.1% ointment £615.26 £12,145.12 £7,708.04

Betacap® (betamethasone valerate 0.1%)

scalp application £146.58 £563.15 £267.46

Betnovate® (betamethasone valerate 0.1%)

scalp application £33.30 £10,226.11 £8,721.89

Diprosalic® scalp application (betamethasone

dipropionate 0.05% + salicylic acid 2%) £214.02 £4,562.93 £3,135.35

Betamethasone valerate 0.1% + Clioquinol

3% cream/ointment £1503.76 £1,529.98 £889.60

Fucibet® cream £959.03 £20,128.90 £12,569.69

Synalar C® (fluocinolone acetonide 0.025% +

clioquinol 3%) cream/ointment £3.04 £327.36 £231.49

Synalar N® (fluocinolone acetonide 0.025% +

neomycin 0.5%) cream/ointment £4.93 £197.72 £181.45

Clobetasol propionate 0.05% (Dermovate®)

cream / ointment £2,079.24 £11,093.65 £7,416.87

Clarelux® Foam (=scalp application)

(clobetasol propionate 0.05%)

£527.56

(inc Dermovate® and

Etrivex® brands)

£347.49 £10.23

Clobetasol propionate 0.05% + neomycin

sulfate 0.5% + nystatin 100,000 units/g cream £3,033.57 £8,851.84 £4,370.14

Clobetasol propionate 0.05% + neomycin

sulfate 0.5% + nystatin 100,000 units/g

ointment

£0.00 £650.00 £177.18

Expenditure for UHNS reflects items dispensed via UHNS dispensary (i.e. inpatients,) Lloyds

pharmacy &FPHP10 prescriptions

14

References

1 NICE CKS. Corticosteroids-topical (skin), nose and eyes. Available at:

http://cks.nice.org.uk/corticosteroids-topical-skin-nose-and-eyes. <accessed 1st Aug 2013>

2 British National Formulary (BNF) 65 March 2013. Available at: http://www.bnf.org

3 MeReC.Using topical corticosteroids in general practice. MeReC Bulletin 1999; 10(6):21-24.

Available at :

http://www.npc.co.uk/merec/therap/skin/resources/merec_bulletin_vol10_no06.pdf

4 British Association of Dermatologists. Topical Corticosteroids. Avaiable at:

http://www.bad.org.uk/site/1117/Default.aspx. <accessed 25th July 2013>

5 Topical Corticosteroids. Available at:

http://www.topicalsteroids.co.uk/how_to_use_topical_corticosteroids/topical_steroid_formulat

ion.htm#Formulation_selection_for_body_area_. <accessed 25th July 2013>

6 Canto G. et. Al. Hypersensitivity Reactions to Corticosteroids. Curr Opin Allergy Clin Immunol

2010;10(4):273-279. Available at: http://www.medscape.com. <accessed 27th July 2013>

7 Wilkinson SM, Hollis S, Beck MH. Reactions to other corticosteroids in patients with allergic

contact dermatitis from hydrocortisone. British Journal of Dermatology 1995;132:766-771.

8 NHS Electronic Drug Tariff, February 2014. Available from

http://www.ppa.org.uk/ppa/edt_intro.htm <accessed 03/02/14>

9 Chemist & Druggist. Product List. January 2014. C & D.

10 British National Formulary September 2013. Available at http://www.bnf.org/bnf/index.htm

<accessed on 04/02/14>

Produced by Susheela Sumelingam Rotational Specialist Pharmacist University Hospital of North Staffordshire Telephone: 01782 674542 e-mail: Susheela.Sumelingam@uhns.nhs.uk Produced for use within the NHS. Not to be reproduced for commercial purposes.