Practice Guidelines
ANTIBIOTICS
ANTIEMETICS
ASTHMA
ASTHMA_MAMC
BRONCHODILATOR
CANCER_PAIN
CARDIAC_VALVULAR
CARPAL_TUNNEL
CATARACT
CHOLESTEROL_DRUGS_MAMC
CHRONIC_PAIN
COMPLEX_REGIONAL
CONGESTIVE_HEART
CONJUNCTIVITIS
CONSTIPATION
COPD_MAMC
DEPRESSION_MAMC
DIABETES_MELLITUS
DIABETIC_FOOT
DYSPEPSIA
ELDERS_WITH_GENETIC
FIBROMYALGIA
GASTROESOPHAGEAL_REFLUX_MAMC
H_PYLORI_MAMC
HYPERTENSION
HYPERTENSION_MAMC
IMMUNIZATION
KNEE_MAMC
LOW_BACK_PAIN_MAMC
LOW_VISION
METFORMIN_MAMC
MUSCULOSKELETAL_CONDITIONS
MYOCARDIAL_ISC
NONSTEROIDALS_MAMC
OCCULT_BLOOD
OSTEOARTHRITIS_OF_THE_KNEE
OSTEOPOROSIS
OSTEOPOROSIS_MAMC
PEPTIC_ULCER
PHARYNGITIS
PLANTAR_FASCIITIS_MAMC
PROSTATIC_CANCER
RHEUMATOID_ARTHRITIS
RHINITIS
RHINITIS_MAMC
SINUSITIS
STREPTOCOCCAL_PHARYNGITIS
SUBSTANCE_ABUSE
SYNCOPE
THYROID_DISEASE_HYPER_HYPO
VISION_EVALUATION
{1} ADULT EYE EVALUATION - 22 Feb 2000 (PRIVATE) 334 Lines
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------------------------------------------------------------------------
Brief Summary
TITLE:
Comprehensive adult eye evaluation.
SOURCE(S):
San Francisco (CA): AAO; 1996. 13 p [30 references]
ADAPTATION:
Not applicable: The guideline was not adapted from another
source.
RELEASE DATE:
1996 Sep
MAJOR RECOMMENDATIONS:
Evaluation Process
A comprehensive eye evaluation includes history,
examination,
diagnosis and initiation of management. Included within
each are
a series of items particularly relevant to the detection,
diagnosis and choice of appropriate therapy for ocular,
visual
and systemic disease. The items listed are basic areas of
evaluation or investigation and are not meant to exclude
additional elements when appropriate. For example, because
history taking is an interactive process, additional
questions
and evaluation may be suggested by the patient's responses.
History
In general, a thorough history includes the following
items,
although the exact composition varies with the patient's
particular problems and needs.
* Demographic data: includes name, date of birth, gender
and
race.
* The identity of the patient's other pertinent health care
providers.
* Chief complaint and history of present illness (including
a
review of systems relevant to eye conditions).
* Present status of visual function: includes a review of
the
patient's assessment of his/her visual status, visual
needs,
any recent or current ocular symptoms, and use of
eyeglasses
or contact lenses (type, wearing habits).
* Past history (ocular): prior eye disease (e.g.,
amblyopia),
injuries, diagnoses, surgery or other treatments and
medications.
* Past history (systemic): allergies or adverse reactions
to
medications, medication use, pertinent medical conditions
and previous surgery.
* Family history: poor vision (and cause, if known) and
other
pertinent familial ocular and systemic disease.
* Medications: ophthalmic and systemic medications
currently
used.
* Social history: occupation, smoking history, alcohol use,
for example.
Examination
The comprehensive examination consists of an evaluation of
the
physiologic function and the anatomic status of the eye,
visual
system and its related structures. In general, this will
include,
but not necessarily be limited to, the following elements:
* Visual acuity with present correction (the power of the
present correction recorded) at distance and at near.
* Measurement of best corrected visual acuity (with
refraction
when indicated).
* Ocular alignment and motility.
* Pupillary function.
* Intraocular pressure measurement.
* Visual fields by confrontation when indicated.
* External examination: lids, lashes and lacrimal
apparatus,
orbit and pertinent facial features.
* Slit-lamp examination: eyelid margins and lashes, tear
film,
conjunctiva, sclera, cornea, anterior chamber and
assessment
of peripheral anterior chamber depth, iris, lens and
anterior vitreous.
* Examination of the fundus: vitreous, retina (including
posterior pole and periphery), vasculature and optic nerve.
Examination of anterior segment structures routinely
involves
gross and biomicroscopic evaluation prior to and after
dilation.
Evaluation of structures situated posterior to the iris may
require a dilated pupil. Optimal examination of the
peripheral
retina requires the use of an indirect ophthalmoscope and
sometimes a Goldmann three-mirror lens.
Based on the patient's history and findings, additional
tests or
evaluations might be indicated to evaluate further a
particular
structure or function. Components that are not routinely
part of
the comprehensive eye evaluation include:
* Gonioscopy
* Visual fields by perimetry
* Color-vision testing
* Microbiology and cytology
* Amsler grid
* Functional evaluation of the lacrimal system
* Fluorescein angiography
* Radiologic testing
* Electrophysiological testing
* Stereophotography and/or analysis of the optic disc
Diagnosis and Management
The ophthalmologist evaluates and integrates the findings
of the
comprehensive ophthalmologic examination with all aspects
of the
patient's health status and social situation in determining
an
appropriate course of action. The evaluation results may be
considered in one of three general categories: patients
with no
risk factors, patients with risk factors and patients with
conditions requiring intervention.
Category I: Patients With No Risk Factors
When the comprehensive evaluation is normal or involves
only
optical abnormalities requiring spectacle correction, the
ophthalmologist reviews the findings with the patient and
advises
him/her of the appropriate interval for re-examination.
Although
this group of patients is considered low risk, periodic
examination is indicated to detect asymptomatic or
unrecognized
ocular disease, the incidence of which increases with age.
All
patients are advised to return promptly if ocular symptoms
or
related problems develop.
Interim Evaluation
Appropriate interim evaluations, such as screenings,
refractions
or less extensive evaluations, are indicated when
addressing
episodic problems and complaints (such as vision changes or
ocular irritation) and for refraction or patient
reassurance. The
extent of the interim evaluation will be determined by the
patient's condition and complaints and by the
ophthalmologist's
medical judgment.
Comprehensive Eye Evaluation
There is no evidence in the literature regarding the
optimal
frequency of examination of patients with no eye symptoms
or
signs. However, the clinical rationale for examining these
patients at the recommended intervals is as follows. The
most
prevalent eye conditions that may be asymptomatic are
glaucoma,
diabetic retinopathy and age-related macular degeneration.
These
conditions increase in incidence with age, particularly in
elderly patients. Periodic evaluations provide an
opportunity to
detect disease at an early stage. At the time of each
comprehensive eye evaluation, the ophthalmologist will
reassess
the patient to determine the appropriate follow-up
interval.
After an initial comprehensive eye evaluation, in the
absence of
symptoms or other indications, patients should generally be
scheduled for a comprehensive examination within the period
indicated in Table 2, which takes into account the
relationship
between age and the risk of asymptomatic or undiagnosed
disease.
Table 2
Comprehensive Eye Evaluations for Patients With No Risk
Factors
--------------------------------------------------------------------
Age Frequency of Evaluation
65 or older Every 1-2 years
40-64 Every 2-4 years
20-39 At least once during period
NOTE: interim eye evaluations may be performed during these
periods
as well.
Category II: Patients With Risk Factors
A patient is considered to be at risk when the evaluation
reveals
signs that are suggestive of a potentially abnormal
condition or
when risk factors for developing ocular disease are
identified,
but the patient does not yet require intervention. These
situations require closer follow-up to monitor the
patient's
ocular health and to detect early signs of disease.
The ophthalmologist determines an appropriate follow-up
interval
for each patient based on the signs and/or the risk
factors, the
incidence of disease and rapidity of progression. For
example,
the earlier onset, higher incidence and more rapid
progression of
glaucoma in individuals of African descent require frequent
examinations. Patients with conditions and risk factors
listed in
Table 3 would benefit from a comprehensive eye evaluation
at the
suggested intervals.
Table 3
Comprehensive Eye Evaluations for Patients With Risk
Factors
--------------------------------------------------------------------
Condition/Risk Factor Frequency of Evaluation
Diabetes without retinopathy
Onset after age 30 Once a year
Onset before age 30 5 years after onset and yearly
thereafter
Pregnancy Prior to conception or early in
the first trimester; every 3
months thereafter
Risk factors for glaucoma (individuals of African descent,
family
history of glaucoma)
Age 65 or older Every 1-2 years
Age 40 - 64 Every 2-4 years
Age 20 - 39 Every 3-5 years
Category III: Conditions Requiring Intervention
The response of the ophthalmologist depends on the nature
of the
abnormal findings. For a patient with ophthalmic
abnormalities,
the ophthalmologist prescribes glasses, contact lenses or
other
optical devices; treats with medications; arranges for
additional
evaluation and testing, and follow-up as appropriate; and
performs nonsurgical procedures or surgical procedures
including
laser surgery when indicated. For a patient with
nonophthalmic
abnormalities, the ophthalmologist will arrange for further
evaluation and/or referral, as appropriate.
The ophthalmologist must discuss with the patient the
importance
of the findings and the need for further evaluation,
testing
and/or treatment. He/she should share the findings with the
patient's primary care physician or other specialist when
appropriate.
The vast majority of patients with abnormal signs and
symptoms
can be diagnosed and treatment can be initiated after a
comprehensive ophthalmologic evaluation. Additional details
of
that evaluation and recommendations for appropriate
treatment and
follow-up will necessarily vary with the abnormalities and
diseases identified.
Provider
A comprehensive eye evaluation is best performed by an
ophthalmologist, a doctor of medicine or osteopathy trained
to
distinguish normal from abnormal states accurately and
efficiently. An ophthalmologist has a thorough
understanding of
pathology and disease processes, systemic disorders with
ocular
manifestations, as well as skills and experience in medical
decision making. The ophthalmologist's knowledge of medical
and
surgical management options allows him/her to provide
patients
with the most complete information about conditions and
prognoses. While it is the ophthalmologist's responsibility
to
perform the comprehensive eye evaluation, certain aspects
of data
collection may be conducted by trained individuals under
the
supervision of an ophthalmologist.
CLINICAL ALGORITHM(S):
None provided
DEVELOPER(S):
American Academy of Ophthalmology - Medical Specialty
Society
COMMITTEE:
Preferred Practice Patterns Committee
GROUP COMPOSITION:
Names of Committee Members: Arlo C. Terry, MD, Chair; J.
Bronwyn
Bateman, MD, Joseph Caprioli, MD, Sid Mandelbaum, MD, Alice
Y.
Matoba, MD, Stephen A. Obstbaum, MD, Oliver D. Schein, MD,
Charles P. Wilkinson, MD.
ENDORSER(S):
Not stated
GUIDELINE STATUS:
This is the current release of the guideline.
This document is valid for 5 years from the "approved
by"
date
unless superseded by an earlier version. All Preferred
Practice
Patterns are reviewed by their parent panel annually or
earlier
if developments warrant.
GUIDELINE AVAILABILITY:
Print and CD-ROM copies: Available from the American
Academy of
Ophthalmology (AAO), P.O. Box 7424, San Francisco, CA
94120-7424.
COMPANION DOCUMENTS:
None available
PATIENT RESOURCES:
Not stated
NGC STATUS:
This summary was completed by ECRI on June 30, 1998. The
information was verified by the guideline developer on
December
1, 1998.
COPYRIGHT STATEMENT:
This NGC summary is based on the original guideline, which
is
subject to the guideline developer's copyright
restrictions.
Information about the content, ordering, and copyright
permissions can be obtained by calling the American Academy
of
Ophthalmology at (415) 561-8500.
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Date Modified: Thursday, June 03, 1999
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{60} ALL PRACTICE GUIDELINES - 22 Feb 2000 (PRIVATE) 107
Lines
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PRACTICE GUIDELINES FOR MIKE MARSHALL
Mike: The following 57 Practice Guidelines should cover ANY
reason for forward
Telephone Consults to the Patient's Own Assigned Provider!
They are all in you IN Box in CHCS Mailman. They involved 4
hours of work on
the WWW and CHCS, so give them a good try!
I can automate some of this for you from your DESKTOP if
you would like!
SWS
925 Subj: ADULT EYE EVALUATION (22 Feb 2000)
Tue, 22 Feb 2000 09:31:35 334 Lines
926 Subj: ALTERED MENTAL (22 Feb 2000) Tue, 22 Feb 2000
09:31:40 442 Lines
927 Subj: ANTIBIOTICS (MAMC) (22 Feb 2000) Tue, 22 Feb 2000
09:31:46 336
Lines
928 Subj: ANTIEMETICS (22 Feb 2000) Tue, 22 Feb 2000
09:31:51 481 Lines
929 Subj: ASTHMA (22 Feb 2000) Tue, 22 Feb 2000 09:31:57
1411 Lines
930 Subj: ASTHMA (MAMC) (22 Feb 2000) Tue, 22 Feb 2000
09:32:04 202 Lines
931 Subj: BRONCHODILATOR (22 Feb 2000) Tue, 22 Feb 2000
09:32:11 385 Lines
932 Subj: CANCER PAIN (22 Feb 2000) Tue, 22 Feb 2000
09:32:15 569 Lines
933 Subj: CARDIAC VALVULAR DISEASE (22 Feb 2000)
Tue, 22 Feb 2000 09:32:22 1162 Lines
934 Subj: CARPAL TUNNEL (22 Feb 2000) Tue, 22 Feb 2000
09:32:26 328 Lines
935 Subj: CATARACT (22 Feb 2000) Tue, 22 Feb 2000 09:32:30
377 Lines
936 Subj: CHOLESTEROL DRUGS (MAMC) (22 Feb 2000)
Tue, 22 Feb 2000 09:32:33 338 Lines
937 Subj: CHRONIC PAIN (22 Feb 2000) Tue, 22 Feb 2000
09:32:38 561 Lines
938 Subj: COMPLEX REGIONAL PAIN (22 Feb 2000)
Tue, 22 Feb 2000 09:32:43 294 Lines
939 Subj: CONGESTIVE HEART FAILURE (22 Feb 2000)
Tue, 22 Feb 2000 09:32:48 567 Lines
940 Subj: CONJUNCTIVITIS (22 Feb 2000) Tue, 22 Feb 2000
09:32:53 460 Lines
941 Subj: CONSTIPATION (22 Feb 2000) Tue, 22 Feb 2000
09:32:59 208 Lines
942 Subj: COPD (MAMC) (22 Feb 2000) Tue, 22 Feb 2000
09:33:05 65 Lines
943 Subj: DEPRESSION (MAMC) (22 Feb 2000) Tue, 22 Feb 2000
09:33:09 151 Lines
944 Subj: DIABETES MELLITUS (22 Feb 2000) Tue, 22 Feb 2000
09:33:13 204 Lines
945 Subj: DIABETIC FOOT CARE (22 Feb 2000) Tue, 22 Feb 2000
09:33:17 217
Lines
946 Subj: DYSPEPSIA (22 Feb 2000) Tue, 22 Feb 2000 09:33:21
165 Lines
947 Subj: ELDERS WITH GENETIC CONDITIONS (22 Feb 2000)
Tue, 22 Feb 2000 09:33:31 272 Lines
948 Subj: FIBROMYALGIA (22 Feb 2000) Tue, 22 Feb 2000
09:33:33 256 Lines
949 Subj: GASTROESOPHAGEAL REFLUX (MAMC) (22 Feb 2000)
Tue, 22 Feb 2000 09:33:36 189 Lines
950 Subj: H PYLORI (MAMC) (22 Feb 2000) Tue, 22 Feb 2000
09:33:40 60 Lines
951 Subj: HYPERTENSION (22 Feb 2000) Tue, 22 Feb 2000
09:33:44 644 Lines
952 Subj: HYPERTENSION (MAMC) (22 Feb 2000)
Tue, 22 Feb 2000 09:33:47 222 Lines
953 Subj: IMMUNIZATION (22 Feb 2000) Tue, 22 Feb 2000
09:33:51 256 Lines
954 Subj: KNEE (MAMC) (22 Feb 2000) Tue, 22 Feb 2000
09:33:56 103 Lines
955 Subj: LOW BACK PAIN (MAMC) (22 Feb 2000)
Tue, 22 Feb 2000 09:34:01 124 Lines
956 Subj: LOW VISION (22 Feb 2000) Tue, 22 Feb 2000
09:34:04 176 Lines
957 Subj: METFORMIN (MAMC) (22 Feb 2000) Tue, 22 Feb 2000
09:34:08 96 Lines
958 Subj: MUSCULOSKELETAL CONDITIONS (22 Feb 2000)
Tue, 22 Feb 2000 09:34:13 375 Lines
959 Subj: MYOCARDIAL ISCHEMIA (22 Feb 2000)
Tue, 22 Feb 2000 09:34:17 224 Lines
960 Subj: NONSTEROIDALS (MAMC) (22 Feb 2000)
Tue, 22 Feb 2000 09:34:19 105 Lines
961 Subj: OCCULT BLOOD IN THE STOOL (22 Feb 2000)
Tue, 22 Feb 2000 09:34:24 178 Lines
962 Subj: OSTEOARTHRITIS OF THE KNEE (22 Feb 2000)
Tue, 22 Feb 2000 09:34:28 158 Lines
963 Subj: OSTEOPOROSIS (22 Feb 2000) Tue, 22 Feb 2000
09:34:31 246 Lines
964 Subj: OSTEOPOROSIS (MAMC) (22 Feb 2000) Tue, 22 Feb
2000 09:34:36 84
Lines
965 Subj: PEPTIC ULCER (22 Feb 2000) Tue, 22 Feb 2000
09:34:40 128 Lines
966 Subj: PHARYNGITIS (22 Feb 2000) Tue, 22 Feb 2000
09:34:45 157 Lines
967 Subj: PLANTAR FASCIITIS (MAMC) (22 Feb 2000)
Tue, 22 Feb 2000 09:34:49 253 Lines
968 Subj: PROSTATIC CANCER (22 Feb 2000) Tue, 22 Feb 2000
09:34:52 218 Lines
969 Subj: RHEUMATOID ARTHRITIS (22 Feb 2000)
Tue, 22 Feb 2000 09:35:01 450 Lines
970 Subj: RHINITIS (22 Feb 2000) Tue, 22 Feb 2000 09:35:05
394 Lines
971 Subj: RHINITIS (MAMC) (22 Feb 2000) Tue, 22 Feb 2000
09:35:08 71 Lines
972 Subj: SINUSITIS (22 Feb 2000) Tue, 22 Feb 2000 09:35:13
120 Lines
973 Subj: SINUSITIS (MAMC) (22 Feb 2000) Tue, 22 Feb 2000
09:35:16 334 Lines
974 Subj: SSRI (MAMC) (22 Feb 2000) Tue, 22 Feb 2000
09:35:19 96 Lines
975 Subj: STREPTOCOCCAL PHARYNGITIS (22 Feb 2000)
Tue, 22 Feb 2000 09:35:23 350 Lines
976 Subj: SUBSTANCE ABUSE (22 Feb 2000) Tue, 22 Feb 2000
09:35:26 191 Lines
977 Subj: SYNCOPE (22 Feb 2000) Tue, 22 Feb 2000 09:35:31
159 Lines
978 Subj: THYROID DISEASE (HYPER/HYPO) (22 Feb 2000)
Tue, 22 Feb 2000 09:35:35 420 Lines
979 Subj: URINARY INCONTINENCE (22 Feb 2000)
Tue, 22 Feb 2000 09:35:39 621 Lines
980 Subj: VENOUS THROMBOEMBOLISM (22 Feb 2000)
Tue, 22 Feb 2000 09:35:43 172 Lines
981 Subj: VIAGRA (MAMC) (22 Feb 2000) Tue, 22 Feb 2000
09:35:46 76 Lines
982 Subj: VISION EVALUATION (22 Feb 2000) Tue, 22 Feb 2000
09:35:50 215 Lines
GOOD LUCK, MIKE, AND LET ME KNOW WHAT I CAN DO TO MAKE THIS
EASIER.
I BELIEVE THAT YOU SHOULD DISCONTINUE REFILLS COMPLETELY AS
TOO DANGEROUS FOR
THE SWEATSHOP TO DO THOROUGHLY.
SWS
[PAGE]
@1323
{2} ALTERED MENTAL - 22 Feb 2000 (PRIVATE) 442 Lines
----------------------------------------------------------------------------
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------------------------------------------------------------------------
Brief Summary
TITLE:
Altered mental states.
SOURCE(S):
Columbia (MD): The American Medical Directors Association
(AMDA);
1998. 20 [17 references]
ADAPTATION:
Not applicable: Guideline was not adapted from another
source.
RELEASE DATE:
1998
MAJOR RECOMMENDATIONS:
The steps involved in addressing altered mental states were
summarized by NGC:
I. Recognition
Step 1
1. Determine if the individual has a history of altered
mental states (AMS)
* Review the individual's physical, functional,
cognitive, and behavioral history. Document
pertinent information (onset, duration, frequency,
course, causes or precipitating factors,
aggravating/ameliorating factors) about any recent
alterations in mental state to help understand and
clarify the current situation. Relevant history
might include confusion, disorientation,
hallucinations, delusions, suspiciousness or
paranoia. These symptoms may be constant or
periodic, and stable or fluctuating. Changes in
nutritional status, eating habits, and physical
function may help identify causes or complications
of impaired mood or cognition.
* For new admissions or re-admissions, review
available transfer information -including any
recent hospital discharge summaries - and other
referral data-and the patient's medical, surgical,
family, and social history. Also look for related
diagnoses in the physician's admission history and
physical or a pertinent consultation report. Check
current orders for treatments and medications that
address behavioral, cognitive, or mood impairments
(e.g., anti-depressants, antipsychotics, etc.).
Seek information about the baseline mental status
and prior diagnostic work-up and management.
Step 2
1. Assess the current signs and symptoms of AMS
* Assess the patient's current physical functional
or psychosocial status
2. Document the AMS or disturbed behaviors
* Assessment categories should include level of
consciousness, cognition, mood, behavior, and
general function. Use objective and valid measures
and well-defined terms to describe and measure
mental status and behaviors.
* Record the results of any assessments in the
appropriate location in the medical record
* Quality rather than quantity of documentation is
important. Recording information that assists in
recognizing and managing problems should be
emphasized.
Step 3
1. Determine if the patient is at high risk for developing
AMS
* The physician, nursing and social services staff
should collaborate to identify risks and formulate
a plan to anticipate, monitor, and evaluate
occurrence or progression (e.g., examine lungs and
obtain a urinalysis if the patient becomes
confused and febrile).
* Significant alterations in mental state or
behavior may require urgent physician input.
Examples of such situations are given in the
guideline document.
II. Diagnosis
* Diagnostic efforts should focus on correctly
identifying the causes of AMS
* Examples of conditions or situations that may affect
mental status include
o Medications/non-compliance with regimen
o Fluid or electrolyte imbalance
o Infections
o Hypo- or hyperglycemia
o Recent hospitalization
o Recent surgery under general anesthesia
o Recent change in living situation or environment
o Recent fall or other trauma
o Significant pain
o Alcohol or drug abuse
o Hypo- or hyperthyroidism
o Nutritional deficiency
o Recent stroke or seizure
o Primary metastatic brain tumors or other
malignancies
o Cardiac arrhythmia/myocardial infarction
* Always review the patient's medications, as these are a
common source of AMS
Step 4
1. Define the duration and course of symptoms
* Define the course (progression, fluctuation, and
times of occurrence) and duration (length of time
present) of symptoms
Step 5
1. Determine if a medical work-up is medically necessary,
useful, and appropriate
* The physician must decide if a work-up could be
medically useful (i.e., whether testing and
examination may better define the patient's
current status or the correct cause of his or her
problems) and if such information might help guide
management. The physician then should consult with
the patient (if possible), the patient's surrogate
or family, and appropriate staff to determine if a
work-up is appropriate, i.e., whether the
potential benefits of any interventions determined
by the work-up results outweigh any risks or
expense cause by the work-up itself. A work-up may
not be indicated if an individual has a terminal
or end-stage condition, if the results of the
work-up would not change the management of course,
if the individual would refuse treatment, in case
of advance directives requesting such
restrictions, or if the burden or risk of a
work-up is greater than the benefit of the
treatment.
* An appropriate work-up for AMS may include a
history (usually obtained indirectly from the
family, staff, and the medical record), physical
examination (including a mental status
examination), and pertinent diagnostic tests
* Possible diagnostic tests to assess causes of AMS
o Electrolytes, BUN, glucose, creatinine, serum
osmolality/urine sodium (to identify fluid/
electrolyte imbalance)
o Urinalysis and/or urine culture (if urinary
tract infection is suspected)
o TSH/free T4 (to identify possible thyroid
dysfunction)
o Complete blood count (CBC) (if infection,
inflammatory processes, bleeding, or anemia
are suspected)
o Chest x-ray/Oxygen saturation (if pneumonia
or pulmonary embolism are suspected)
o EKG/rhythm strip (if a cardiac arrhythmia or
other heart dysfunction is suspected)
o Albumin (if undernutrition is suspected)
o Serum drug levels, when appropriate
* Whenever possible, this work-up should take place
in the facility. Hospitalization should be
avoided, since it in itself is a risk factor for
delirium in the elderly
* As part of any work-up, review the patient's
medication regimen and determine whether or not it
recently has been changed. Even if the regimen has
been stable and has not caused adverse reactions
in the past, it may contribute to or cause
symptoms of newly developed conditions.
Step 6
1. Determine if delirium is present
* Delirium is a state of acute confusion,
inattention, and altered level of consciousness
(LOC), usually abrupt in onset (over several hours
to several days).
* Typical symptoms of delirium may include anxiety,
disorientation, tremors, hallucinations,
delusions, and incoherence. In patients with
dementia, delirium may present as a subtle shift
or a marked decline in the usual level of activity
or responsiveness. Delirium is commonly related to
acute illnesses, heart or lung disease,
infections, poor nutrition, endocrine disorders,
medications (including over-the-counter and
prescription medications) or alcohol use.
* Some iatrogenic risk factors associated with
delirium include:
o Medications, especially neuroleptics and
sedatives/hypnotics
o Surgery under general anesthesia
o Presence of an indwelling urinary catheter
o Use of physical restraints
* If delirium is identified or suspected (regardless
of whether the Delirium Resident Assessment
Protocol (RAP) is triggered), a physician should
be involved as soon as possible so that medical
causes may be identified and managed promptly.
Step 7
1. Identify the presence of depression
* Signs and symptoms of depression
o Depressed mood most of the day, almost every
day
o Irritable mood
o Diminished interest/pleasure in most
activities, most of the time
o Weight loss accompanied by poor appetite
o Insomnia/hypersomnia nearly every day
o Psychomotor agitation/retardation
o Fatigue or loss of energy, worse than
baseline
o Feelings of worthlessness, hopelessness, or
helplessness
o Guilt
o Change in ability to think or concentrate
o Recurrent thoughts of death or suicide
o Social isolation
Step 8
1. Identify other causes of AMS
* Other common medical/neurological causes of AMS
o Hyper- or hypothyroidism
o Nutritional deficiencies (Vitamin B12 folate,
thiamine, iron, and protein-calorie
malnutrition)
o Multiple small strokes (vascular dementia)
o Central neurodegenerative disorders
(Alzheimer's Disease, Parkinson's Disease,
etc.)
III. Treatment
Step 9
1. Determine if interventions are useful and appropriate
* It is important to review any advance directive or
other specific written or verbal instructions from
patient or surrogate. Useful, appropriate
treatment should address the underlying medical
problem and improve or stabilize the patient's
functioning and quality of life, consistent with
his or her wishes and values
Step 10
1. Generate an interdisciplinary care plan
* The care plan should address risk assessment and
prevention, cause identification and treatment,
management of the underlying causes, areas for
staff support, patient and family education,
prevention and handling of existing complicating
conditions, changes in other components of the
existing treatment regimen, monitoring, and other
aspects of the patient's care. Team work and
communication are important.
* Changes in the current care plan should be based
on skilled assessment and identification of
supporting evidence.
Step 11
1. Initiate the appropriate interventions
* It is essential to weigh the potential effects of
the treatment, including the relative burdens and
benefits, on the patient. It also is important to
document reasons for not treating an identified
cause of AMS
* If a patient is already taking psychoactive
medications, this should always be considered as a
possible cause of AMS and reduced or discontinued
when possible.
* Specific considerations in treatment should
include functional and social impact, ethical
issues, and indirect complications.
* Impact on personal and social functioning should
be evaluated. A patient with AMS may require
additional Activities of Daily Living support.
* Identify and address ethical issues relevant to
the individual with AMS and disturbed behavior.
These include defining decision making capacity,
identifying situation that require informal and
formal direct or substitute decision making, and
defining possible limitations on medical
interventions such as artificial nutrition or
hydration, or cardiopulmonary resuscitation (CPR)
* Decisions about the scope and nature of any
interventions should arise from appropriate
discussions with the patient or family members, as
appropriate, and documented adequately in the
medical record. Such decisions may need to be
modified if the patient's decision-making capacity
improves after treating a cause of AMS.
* Prevent and manage complications and problems
associated with AMS such as impaired mobility and
urinary incontinence.
* Prevent and manage indirect consequences of AMS
such as aspiration pneumonia in a tube-fed
patient, decreased food intake in patients whose
alertness and cognition have been affected by
antihypertensive medications, or falls in patients
with poor balance who are taking psychoactive and
cardiac medications.
Step 12
1. Educate patients, families and staff regarding the
conditions and proposed treatments
* The physician and other members of the
interdisciplinary team should present families and
staff with a clear picture of the patient's
situation. This information should be updated as
new findings or condition changes develop.
IV. Monitoring
Step 13
1. Monitor and adjust treatment as indicated
* Document the patient's course carefully, and
relate symptoms to various causes and
interventions.
* Documentation should be frequent enough to track
the patient's progress and should help communicate
critical information to other members of the
interdisciplinary team.
Step 14
1. Is the individual stable or improving?
* Examples of situations when current diagnosis and
treatment should be reconsidered:
o Persistent reduced or widely fluctuating
level of consciousness
o Progressive decline in function or worsening
of behavior
o Failure to return to baseline function or
behavior
o Significant physical or functional
consequences
o Flare-ups of other chronic conditions or
acute illnesses
* If the patient is stable or improving, continue
appropriate management. The physician should
periodically reevaluate and discuss the patient's
condition and risk factors with the nursing staff.
* If the patient declines or remains stable but does
not return to his or her previous baseline, it may
be important to reconsider the diagnosis or
management plan.
CLINICAL ALGORITHM(S):
A clinical algorithm is provided that summarizes the steps
involved in addressing altered mental states, including
recognition, diagnosis, management, and monitoring the
condition.
DEVELOPER(S):
American Health Care Association - Professional Association
American Medical Directors Association (AMDA) -
Professional
Association
COMMITTEE:
Steering Committee
GROUP COMPOSITION:
Members: Sarah Greene Burger; Thomas J. Cali, PharmD; Laura
Fain,
RN; Janet George, RN; Janet M. Harrington, MSN; Carolyn
Harris,
RN; Keith Knapp; Steven Levenson, MD, CMD; Geri Mendelson,
RN,
M.Ed., MA; Reg Warren, PhD; Christine Williams, M.Ed.
ENDORSER(S):
Not stated
GUIDELINE STATUS:
This is the current release of the guideline.
An update is not in progress at this time. Planned revision
cycles will occur every three years.
GUIDELINE AVAILABILITY:
Print copies: Available from the American Medical Directors
Association, 10480 Little Patuxent Pkwy, Suite 760,
Columbia, MD
21044. Telephone: (800) 876-2632 or (410) 740-9743; Fax
(410)
740-4572. Web site: http://www.amda.com/
COMPANION DOCUMENTS:
The following companion documents are available:
* Guideline implementation: clinical practice guidelines.
Columbia, MD: American Medical Directors Association, 1998,
28 p.
* Dementia. Columbia, MD: American Medical Directors
Association; 1998. 32 p.
Print copies: Available from the American Medical Directors
Association, 10480 Little Patuxent Pkwy, Suite 760,
Columbia, MD
21044. Telephone: (800) 876-2632 or (410) 740-9743; Fax
(410)
740-4572. Web site: www.amda.com.
The guideline developers recommend that the guideline
should be
used in conjunction with the "Nursing Facility Minimum Data
Set
and Resident Assessment Instrument" (MDS/RAI), as well as
with
appropriate "Resident Assessment Protocols" (RAPs).
These tools are available from the U.S. Health Care
Financing
Administration (HCFA), 7500 Security Boulevard, Baltimore,
Maryland 21244; Telephone: (410) 786-3000; Web site:
http://www.hcfa.gov/
PATIENT RESOURCES:
Not stated
NGC STATUS:
This summary was completed by ECRI on July 12, 1999. The
information was verified by the American Medical Directors
Association as of August 8, 1999.
COPYRIGHT STATEMENT:
This NGC summary is based on the original guideline, which
is
copyrighted by the American Medical Directors Association
(AMDA)
and the American Health Care Association. Written
permission from
AMDA must be obtained to duplicate or disseminate
information
from the original guideline. For more information, contact
AMDA
at (410) 740-9743.
Return to top
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Date Modified: Tuesday, August 24, 1999
[PAGE]
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{41} ANTIBIOTICS (MAMC) - 22 Feb 2000 (PRIVATE) 336 Lines
----------------------------------------------------------------------------
Oral Antibiotic Department of Pharmacy
[Mamclogo.gif (11446 bytes)]
Oral Antibiotic Prescribing Guidelines
------------------------------------------------------------------------
The following prescribing guidelines have been endorsed by
the Madigan Army
Medical Center Pharmacy and Therapeutics Committee. These
guidelines
serve as an education tool for accepted antibiotics. While
general
prescribing guidelines can be written, not every patient
will fit these
guidelines. When faced with a therapeutic dilemma, the
Infectious Disease
Service provides timely consults. The costs are available
to authorized
parties upon written request.
------------------------------------------------------------------------
COMMUNITY ACQUIRED PNEUMONIA (Adult)
Common Pathogens 1st line 2nd line 3rd line agents
agents agents
Typical
Erythromycin
Streptococcus 500mg QID x Azithromycin
pneumoniae 10 days 500mg x 1,
then
Haemophilus ($) (typical
influenza or atypical) 250mg QD x 4
days ($$$)**
Enterobacteriaceae Doxycycline Amoxicillin/Clavulanic
(avoid in Cefpodoxime Acid
Staphyloccus pregnancy) 200mg BID x
aureus 14 days 875mg Q12 hr x 10 days
100mg BID x
Anaerobic bacteria 14 days ($)* ($$$$$)*** ($$$$$)
Atypical Amoxicillin Ofloxacin
(typical) 400mg Q 12hr
Mycoplasma x
pneumoniae 500mg TID x
10 days ($) 10 days ($$$)
Legionella
* Avoid if Strep pneumoniae suspected - better for atypical
pathogens
** Most cost effective second choice for patients who are
erythromycin
failures
Only 6 x 250mg tabs dispensed per Rx; unless diagnosis of
Legionella
*** Good choice if Strep pneumoniae or H. Influenza is
suspected and
patient is macrolide intolerant
STREP PHARYNGITIS
Common Pathogens Agent of Choice
*Penicillin VK *Erythromycin (if PCN allergic)
250 - 500 mg QID x 10 days ($) 250mg QID x 10 days
($)
Group A *Peds: <30 lbs 125mg BID-TID *Peds: EES 40mg/kg/day
Streptoccocci + TID-QID
>30 lbs 250mg BID-TID
If patient doesn't respond consider atypical
organism - use erythromycin
URETHRITIS/CERVICITIS
Common Pathogens 1st line Agents 2nd line Agents
*Doxycycline (not in
pregnancy)
100mg BID x 7 days ($)
*Erythromycin (if
pregnant) *Azithromycin 1gm PO
Chlamydia trachomatis x 1 dose ($$) (use
500mg QID x 7 days ($) sachet for single
or one gram dose)
250mg QID x 14 days if
GI
intolerance to 500mg
dose ($)
Neisseria gonorrhoeae
(since a high
percentage of patients *Ceftriaxone 125mg IM x *Ofloxacin
400mg x 1
have coexisting 1 ($) ($)
Chlamydia, all
patients should also *Metronidazole *Cefixime 400mg PO x
be treated for both) 1 ($)
(pregnancy - used after
Trichomoniasis 1st trimester) 2g PO x 1 Metronidazole 500mg
($) BID x 7 days ($)
(partners should be
treated)
Bacterial vaginosis
Gardneralla vaginalis *Metronidazole 500mg BID Clindamycin
300mg PO
x 7 days BID x 7 days ($$)
Mycoplasma hominin
($) (used after the *Clindamycin 2% vag
Basteroides spp crm one appl intr
1st trimester) vag HS x 7 days ($$)
Mobiluncus spp
*Clotrimazole 200mg (2 X
100mg)
Vulvovaginal
Candidiasis vag tab HS X 3 days ($)
Candida albicans *Fluconazole 150mg PO X *Terconazole 0.4%
1 ($) vag crm one appl. HS
Candida spp X 7 days ($$)
*ONLY 1 tab will be
Torulopsis spp dispensed
per RX)
SKIN AND SOFT TISSUE (Adults and Pediatrics)
1st Line Agents
Common 2nd Line
Pathogens (Cost per Agents 3rd Line Agents
source)
*Dicloxacillin
250mg QID x 7
days
($)
*Peds:
Streptococci 20mg/kg/day +
QID
Staphyloccocci
*Erythromycin *Ofloxacin
250mg QID x 10 400mg Q
days 12hr x 10 *Amoxicillin/Clavulanic
days (for Acid
($) Adults)
($$$) 500mg Q12H x 7 days
*Peds: ($$$)
40mg/kg/day + Clindamycin
TD or QID 20mg/Kg QD *Peds: 45mg/kg/day
* If MRSA call divided TID (Amox)+Q12H
Infectious Cephalexin
Disease 250mg QID/500mg
BID x 7 days
($) mod.
infection:
500mg QID ($)
*Peds:
25-50mg/kg/day
+ QID
UNCOMPLICATED URINARY TRACT INFECTIONS
(Adults)
1st line Agents
Common
Pathogens (Cost per 2nd Agents
source)
Escherichia
coli
Proteus *TMP/SMZ (avoid *Ofloxacin
in pregnancy) 200mg QD 12
Enterococci x
1DS BID x 3
Straphylococcus days ($) 3 days ($)
saprophyticus
ACUTE OTITIS MEDIA (Adults and Pediatrics)
Common 1st line 2nd Line
Pathogens Agents (Cost Agents 3rd Line Agents
per course)¤
Streptococus *Amoxicillin *Azithromycin
*Amoxicillin/Clavulanic
pneumonia 500mg TID x 10 500mg x 1 then 875mg Q12H x 10
days
days ($)
Haemophilus 250mg QD x 4 *Peds: for patients 3
influenza *Peds: days ($$) months& older
60mg/kg/day + 45mg/kg/day (Amox) +
Moraxella BID *Peds: 10mg/kg Q12H
catarrhalis QD day 1, then
*TMP/SMZ 1 DS
Staphlococcus BID x 10 days 5mg/kg QD days
aureus ($) 2-5
avoid in *Cefpodoxime
pregnancy 200mg BID x 10
days ($$$)
*Peds:
8-10mg/kg/day *Peds:
(TMP) + BID 10mg/kg/day +
BID or
or 1ml/kg/day
+ BID QD
*Pediazole®
(peds only)
50mg/kg/day
(EES) + TID or
QID
1.25ml/kg/day
+ TID or QID
* May use 5 day courses of therapy in children > than 2
years of age who
are not prone to multiple episodes of acute otitis media
For patients** who you suspect penicillin resistant
streptococcus
pneumoniae infections use:
1. High dose amoxicillin 80mg/Kg per day divided BID
2. Ceftriaxone 50mg/Kg IM x 1
3. Amoxicillin 40mg/Kg per day plus Augmentin 40mg/Kg per
day
divided BID
4. Cefpodoxime 10mg/Kg/Day divided BID or QD
** Patients who attend Day Care or Child Care Centers or
those that
don't respond to multiple courses of antibiotics
SINUSITIS (Adults) * For Peds see Acute Otitis Media
recommendations.
For chronic Otitis Media in Peds use Clindamycin
20mg/Kg/Day divided TID
1st line
Common Agents (Acute) 3rd Line Agents
Pathogens 2nd Agents (Chronic)
(Cost per
course)¤
*TMP/SMZ
(avoid in
Streptococus pregnancy) *Azithromycin
pneumonia 500mg x 1, *Clindamycin 300mg TID
1 DS BID x 10 then 250mg QD x 10 days ($$$)
Haemophilus days ($) x 4 days ($$)
influenza *Cefixine 400mg QD x 10
*Amoxicillin *Cefpodoxime days ($$$) - NO staph
Moraxella 500mg TID x 10 200mg BID x10 coverage
catarrhalis days ($) days ($$$$)
*Amoxicillin/Clavulanic
Staphlococcus *Erythromycin Clarithromycin Acid 875mg Q12H
x 10
aureus 500mg QID x 10 500mg Q12h X days ($$$$)
days ($) for 14 days ($$$)
PCN allergy
¤Cost of selected oral antibiotic suspensions (prices
subject to change).
125mg/5ml 150ml.... $ 0.72
Amoxicillin
250mg/15ml 150ml.... $ 1.25
75ml.. 100ml..
200mg/5ml 50ml.... $ 8.07 $10.45 $15.70
Augmentin
400mg/5ml 50ml.... $15.28 75ml.. 100ml..
$19.81 $29.73
100mg/5ml 15ml.... $15.42
Azithromycin
200mg/5ml 11.5ml.. $15.42
100mg/5ml 50ml.... $18.05
Cefixime
100ml.... $35.53
50mg/5ml 100ml.... $13.01
Cefpodoxime
100mg/5ml 100ml.... $26.02
100ml.... $ 4.38
Erythomycin/sulfisox
200ml.... $ 5.51
TMP/SMZ 100ml.... $ 5.47
The following prescribing guidelines have been endorsed by
the Madigan Army
Medical Center Pharmacy and Therapeutics Committee. These
guidelines serve
as an education tool for accepted antibiotics. While
general prescribing
guidelines can be written, not every patient will fit these
guidelines.
When faced with a therapeutic dilemma, the Infectious
Disease Service
provides timely consults. The costs listed are current at
the time of
writing, but are subject to change.
Comment: In most cases an alternate first (1st) line
antibiotic should be
used in lieu of a second (2nd) line agent when a first
(1st) line agent has
proven unsuccessful.
Last Update - June 1999
Cost Key
$ = $0 to $10.00
$$ = $10.01 - $20.00
$$$ = $20.01 - $30.00
$$$$ = $30.01 - $40.00
$$$$$ = $40.01 and higher
Pharmacy Home Page MAMC Home Page
------------------------------------------------------------------------
Send mail to Pharmacy Pagemaster with questions or comments
about this web
site.
Copyright © 1999
Last modified: January 04, 2000
[PAGE]
@1323
================================================================================
{3} ANTIEMETICS - 22 Feb 2000 (PRIVATE)
481 Lines
----------------------------------------------------------------------------
National
Guideline
Clearinghouse
[HOME] [NGC RESOURCES] [HELP] [WHAT'S NEW] [SITE
MAP] [CONTACT NGC] [ABOUT NGC]
Search NGC: Search Help Detailed Search
Browse NGC: Disease/Condition Treatment/Intervention
Organization
Options: Brief Summary Complete Summary Full Text
Compare Guidelines: Add to Guideline Collection View
Guideline
Collection
------------------------------------------------------------------------
Brief Summary
TITLE:
Recommendations for the use of antiemetics.
SOURCE(S):
J Clin Oncol 1999 Sep;17(9):2971 [277 references]
ADAPTATION:
Not applicable: Guideline was not adapted from another
source.
RELEASE DATE:
1999 Sep
MAJOR RECOMMENDATIONS:
Levels of evidence (I-V) and grades of evidence (A-D, NG)
for
recommendations are defined at the end of the Major
Recommendation field.
I. Chemotherapy-Induced Emesis
A. Acute Emesis (vomiting occurring 0 to 24 hours after
chemotherapy)
1. Antiemetic Agents: Highest Therapeutic Index
a. Serotonin Receptor Antagonists
i. Agent equivalence
Guideline: At equivalent doses,
serotonin receptor antagonists have
equivalent safety and efficacy and can
be used interchangeably based on
convenience, availability, and cost.
Level of Evidence: I
Grade of Recommendation: A
ii. Drug dosage
Guideline: Established, proven doses of
all agents are recommended.
Level of Evidence: I
Grade of Recommendation: A
iii. Drug schedule
Guideline: Single doses of antiemetics
are effective and preferred for
convenience and cost.
Level of Evidence: I
Grade of Recommendation: A
iv. Route of administration
Guideline: At biologically equivalent
doses, oral agents are equally effective
and are as safe as intravenous
antiemetics. In most settings, oral
agents are less costly and more
convenient; for these reasons, they are
recommended over intravenous therapy.
Level of Evidence: I
Grade of Recommendation: A
b. Corticosteroids
i. Agent equivalence and route of
administration
Guideline: At equivalent doses,
corticosteroids have equivalent safety
and efficacy and can be used
interchangeably.
Level of Evidence: IV and Expert
Consensus
Grade of Recommendation: C
ii. Drug dose and schedule
Guideline: Single doses of
corticosteroids are recommended.
Level of Evidence: II
Grade of Recommendation: B
2. Antiemetic Agents: Lower Therapeutic Index -
Dopamine Antagonists, Butyrophenones,
Phenothiazines, and Cannabinoids
Guideline: For chemotherapy with a high risk of
emesis, selective serotonin antagonists (with
dexamethasone) are recommended.
Level of Evidence: I
Grade of Recommendation: A
3. Antiemetic Agents: Adjunctive Drugs -
Benzodiazepines and Antihistamines
Guideline: Benzodiazepines and antihistamines are
useful adjuncts to antiemetic drugs but are not
recommended as single agents.
Level of Evidence: II
Grade of Recommendation: B
4. Antiemetic Agents: Combinations of Antiemetics
Guideline: It is recommended that serotonin
antagonists be given with corticosteroids.
Level of Evidence: I
Grade of Recommendation: A
5. Risk Factors for Acute Emesis
a. Patient Characteristics
b. Chemotherapeutic Agents
c. Guidelines
i. (a) High risk: Cisplatin
Guideline: The combination of a 5-HT3
antagonist plus a corticosteroid is
recommended before chemotherapy.
Level of Evidence: I
Grade of Recommendation: A
i. (b) High risk: noncisplatin
Guideline: The combination of a 5-HT3
antagonist plus a corticosteroid is
recommended before chemotherapy.
Level of Evidence: I, II, III, and
Expert Consensus
Grade of Recommendation: A-B
ii. Intermediate risk
Guideline: A corticosteroid is suggested
for patients being treated with agents
of intermediate emetic risk.
Level of Evidence: III, IV, and Expert
Consensus
Grade of Recommendation: B, D
iii. Low risk:
Guideline: It is suggested that for
patients being treated with agents of
low emetic risk, no antiemetic be
routinely administered before
chemotherapy.
Level of Evidence: V and Expert
Consensus
Grade of Recommendation: D
iv. Combination chemotherapy
Guideline: It is suggested, that when
combination chemotherapy is given, the
patient be given antiemetics appropriate
for the chemotherapeutic agent of
greatest emetic risk.
Level of Evidence: IV
Grade of Recommendation: D
v. Multiple consecutive days of
chemotherapy
Guideline: It is suggested that
antiemetics appropriate for the risk
class of the chemotherapy, as outlined
above, be administered for each day of
the chemotherapy.
Level of Evidence: II and III
Grade of Recommendation: B
B. Delayed Emesis (vomiting occurring >24 hours after
chemotherapy)
1. Antiemetic Agents
a. Single Agents
i. Corticosteroids
ii. Metoclopramide and serotonin receptor
antagonists
b. Combinations of Agents
2. Risk Factors for Delayed Emesis
a. Patient Characteristics
b. Chemotherapeutic Agents
c. Guidelines
i. (a) High risk: cisplatin
Guideline: For all patients receiving
cisplatin, a corticosteroid plus
metoclopramide or plus a 5-HT3
antagonist is recommended for the
prevention of delayed emesis.
Level of Evidence: I
Grade of Recommendation: A
i. (b) High risk: noncisplatin
Guideline: A prophylactic corticosteroid
as a single agent, a prophylactic
corticosteroid plus metoclopramide, and
a prophylactic corticosteroid plus a
5-HT3 antagonist are regimens suggested
for the prevention of delayed emesis.
Level of Evidence: III - V
Grade of Recommendation: B-D
ii. Intermediate- to low-risk
Guideline: No regular preventive use of
antiemetics for delayed emesis is
suggested for patients receiving these
chemotherapeutic agents.
Level of Evidence: V and Expert
Consensus
Grade of Recommendation: D
C. Anticipatory Emesis
1. Prevention
Guideline: Use of the most active antiemetic
regimens appropriate for the chemotherapy being
given to prevent acute or delayed emesis is
suggested. Such regimens must be used with the
initial chemotherapy, rather than after assessment
of the patient's emetic response to less effective
treatment.
Level of Evidence: III
Grade of Recommendation: D
2. Treatment
Guideline: If anticipatory emesis occurs,
behavioral therapy with systematic desensitization
is effective and is suggested.
Level of Evidence: III
Grade of Recommendation: B
D. Special Emetic Problems
1. Emesis in Pediatric Oncology
Guideline: The combination of a 5-HT3 antagonist
plus a corticosteroid is suggested before
chemotherapy in children receiving chemotherapy of
high emetic risk.
Level of Evidence: III
Grade of Recommendation: B
2. High-Dose Chemotherapy
Guideline: A 5-HT3 antagonist plus a
corticosteroid is suggested.
Level of Evidence: II and III
Grade of Recommendation: C
3. Vomiting and Nausea Despite Optimal Prophylaxis in
Current or Prior Cycles
Guideline: It is suggested that clinicians (1)
conduct a careful evaluation of risk, antiemetic,
chemotherapy, tumor, and concurrent disease and
medication factors, (2) ascertain that the best
regimen is being given for the emetic setting, (3)
consider adding an antianxiety agent to the
regimen, and (4) consider substituting a dopamine
receptor antagonist, such as high-dose
metoclopramide, for the 5-HT3 antagonist (or add
the dopamine antagonist to the regimen).
Level of Evidence: V and Panel Consensus
Grade of Recommendation: D and Panel Consensus
II. Radiation-Induced Emesis
A. Risk Factors for Radiation-Induced Emesis
1. Guidelines
a. High Risk: Total Body Irradiation
Guideline: A serotonin receptor antagonist
should be given with or without a
corticosteroid before each fraction and for
at least 24 hours after.
Level of Evidence: II and III
Grade of Recommendation: B and C
b. Intermediate Risk: Hemibody Irradiation,
Upper Abdomen, Abdominal-Pelvic, Mantle,
Cranial Radiosurgery, and Craniospinal
Radiotherapy
Guideline: A serotonin receptor antagonist or
a dopamine receptor antagonist should be
given before each fraction.
Level of Evidence: II and III
Grade of Recommendation: B
c. Low Risk: Radiation of the Cranium Only,
Breast, Head and Neck, Extremities, Pelvis,
and Thorax
Guideline: Treatment should be given on an
as-needed basis only. Dopamine or serotonin
receptor antagonists are advised. Antiemetics
should be continued prophylactically for each
remaining radiation treatment day.
Level of Evidence: IV and V
Grade of Recommendation: B-D
Definitions
Type of Evidence for Recommendation
Level I: Evidence obtained from meta-analysis of multiple
well-designed controlled studies; randomized trials with
low
false-positive and low false-negative errors (high power)
Level II: Evidence obtained from at least one well-designed
experimental study; randomized trials with high
false-positive
and/or negative errors (low power)
Level III: Evidence obtained from well-designed
quasi-experimental studies, such as nonrandomized
controlled
single-group pre-post, cohort, time or matched case-control
series
Level IV: Evidence from well-designed nonexperimental
studies,
such as comparative and correlation descriptive and case
studies
Level V: Evidence from case reports and clinical examples
Grade of Evidence for Recommendation
Category A: There is evidence of type I or consistent
findings
from multiple studies of types II, III, or IV
Category B: There is evidence of types II, III, or IV and
findings are generally consistent
Category C: There is evidence of types II, III, or IV, but
findings are inconsistent
Category D: There is little or no systematic empirical
evidence
Category NG: Grade not given
CLINICAL ALGORITHM(S):
None provided
DEVELOPER(S):
American Society of Clinical Oncology (ASCO) - Medical
Specialty
Society
COMMITTEE:
ASCO Antiemetic Guideline Expert Panel
GROUP COMPOSITION:
The Panel was composed of experts in clinical medicine,
clinical
research, outcomes/health services research, medical
decision-making, and health economics, with a focus on
expertise
in supportive care and in antiemetics. A patient
representative
was also included on the Panel. Clinical experts
represented all
relevant disciplines, including medical oncology, oncology
nursing, radiation oncology, pediatric oncology and
oncologic
pharmacy practice.
Members: Richard J. Gralla, MD (Co-chair); David Osoba, MD
(Co-chair); Mark G. Kris, MD; Peter Kirkbride, MD; Paul J.
Hesketh; Lawrence W. Chinnery; Rebecca Clark-Snow, RN, BSN,
OCN;
David P. Gill, MD; Susan Groshen, PhD; Steven Grunberg, MD;
James
M. Koeller, MD; Gary R. Morrow, PhD; Edith A. Perez, MD;
and
Jeffrey H. Silber, MD, PhD; David G. Pfister, MD.
ENDORSER(S):
Not stated
GUIDELINE STATUS:
This is the current release of the guideline.
An update is not in progress at this time.
GUIDELINE AVAILABILITY:
Electronic copies: Available from the American Society of
Clinical Oncology (ASCO) Web site.
Print copies: Available from ASCO, 225 Reinekers Lane,
Suite 650,
Alexandria, VA 22314; guideline@asco.org
COMPANION DOCUMENTS:
None available
PATIENT RESOURCES:
None available
NGC STATUS:
This summary was completed by ECRI on January 3, 2000. It
was
verified by the guideline developer on January 18, 2000.
COPYRIGHT STATEMENT:
This summary is based on content contained in the original
guideline, which is subject to terms as specified by the
guideline developer. Please refer to the guideline
developer's
disclaimer, available at:
www.asco.org/prof/oc/html/m_dr.htm.
According to this statement, you are free to download a
copy of
the materials and information on a single computer for
personal,
noncommercial use only; provided that any copyright,
trademark or
other proprietary notices are not removed from any
materials and
information downloaded. Any other use requires written
permission
from the guideline developer.
Return to top
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Date Modified: Sunday, January 30, 2000
[PAGE]
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================================================================================
{4} ASTHMA - 22 Feb 2000 (PRIVATE) 1411 Lines
----------------------------------------------------------------------------
National
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[HOME] [NGC RESOURCES] [HELP] [WHAT'S NEW] [SITE
MAP] [CONTACT NGC] [ABOUT NGC]
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Brief Summary
TITLE:
Practice parameters for the diagnosis and treatment of
asthma.
SOURCE(S):
J Allergy Clin Immunol 1995 Nov;96(5 Pt 2):707-870 [1195
references]
ADAPTATION:
Not applicable: Guideline was not adapted from another
source.
RELEASE DATE:
1995 Nov
MAJOR RECOMMENDATIONS:
CONSULTATION WITH AN ASTHMA SPECIALIST
* The cooperative interaction between the patient and/or
the
patient's representative(s), the primary care
physician/provider, and the asthma specialist is necessary
to maximize the possibility of meeting the goals of asthma
therapy, as stated in the guideline document.
* It is important that the primary care physician/provider
recognize the contribution that can be made by the asthma
specialist in the management of asthma.
* The asthma specialist should recognize the importance of
the
primary care physician/provider in the continuing care of
patients with asthma, which enhances the possibility of a
successful outcome for the patient.
* Active participation of an asthma specialist in the
continuing care of patients with asthma is associated with
lower asthma morbidity, including fewer emergency room
visits, decreased hospitalizations, reduced length of stay
in the hospital, reduced number of days lost from school
and
work, and a reduction in the global cost of asthma care
* There are a number of compelling reasons for recommending
that a patient consult an asthma specialist, such as
instability of the patient's asthma, the need for
identification of possible allergenic or non-allergenic
triggers, patient education and when the diagnosis of
asthma
is in doubt. For patients who meet these criteria,
consultation with an asthma specialist should be obtained
early during the treatment program.
DIAGNOSIS AND EVALUATION
A. Clinical evaluation of asthma
* Evaluation of asthma should include a detailed medical
and
environmental history and focus on potential allergic and
non-allergic triggers.
* Other illnesses and medications may impact on the safety
and
effectiveness of treatment.
* Asthma may present only with chronic cough or dyspnea.
* Illnesses other than asthma may also present with cough,
wheezing, dyspnea, and tightness in the chest.
* Asthma severity should be accurately determined on the
basis
of the history, physical examination, and some measure of
pulmonary function.
* Known or suspected "triggers" of asthma can often be
identified in the home, work, school, and recreational
environments.
* An appropriate physical examination is essential.
* Clinical symptoms should be categorized according to
intensity, duration, frequency, environmental or geographic
changes, diurnal or circadian variation, and seasonal or
non-seasonal occurrence.
* A careful assessment of the effectiveness and adverse
effects of past medications is necessary.
* Treatment of patients with asthma must be individualized.
B. Physiologic evaluation
1. Pulmonary function testing
* The patient's perception and the physician's assessment
of
asthma severity may correlate poorly with the degree of
airway obstruction.
* The degree of physiologic impairment of asthma can be
significantly underestimated in some patients unless
appropriate pulmonary function studies are obtained.
* A new patient evaluation for asthma generally should
include
spirometric determinations.
* Asthmatic patients may require some measurement of
pulmonary
function at each follow-up visit.
* Spirometry and peak expiratory flow rates are useful
measures of airway function; spirometry provides more
detailed information than does a peak flow rate.
* Spirometry helps differentiate obstructive from
restrictive
airway disease. However, other tests, such as lung volume
and diffusing capacity, may be required.
* During treatment, lung function may remain significantly
abnormal long after symptoms have abated and physical
findings have returned to normal. Some patients may have
complete resolution of symptoms despite little or no
improvement in pulmonary function.
* A direct correlation exists between the amount of
improvement in pulmonary function measurements after 4 to 6
hours of treatment for acute asthma, the rate of overall
recovery, and the likelihood of relapse.
* High-dose systemic corticosteroid therapy should be
continued for acute asthma until the patient has
sufficiently improved as measured by the clinical response
and/or pulmonary function tests.
2. Bronchoprovocation
* A positive inhalation challenge to "nonspecific"
bronchoconstrictive substances, such as methacholine or
histamine, demonstrates the presence of bronchial
hyperresponsiveness and is highly associated with asthma
but
may also be seen in patients with other pulmonary diseases
and even some normal individuals.
* A positive "nonspecific" challenge can help identify
patients with atypical asthma, patients who have cough,
chest tightness, or dyspnea alone, or patients with asthma
who are in relative remission.
* A negative "nonspecific" bronchoconstrictive
challenge
can
also alert the clinician to the possibility that the
patient's "asthmatic" symptoms could be caused by
other
respiratory disorders such as endobronchial disease (e.g.
tumor) or vocal cord adduction.
* Viral infections, viral vaccines, certain occupational
exposures, and pollutants may produce bronchial
hyperresponsiveness and thus a positive response to
methacholine or other "nonspecific" challenge.
* A relationship may exist between the degree of bronchial
hyper-responsiveness and the extent of treatment required
to
control symptoms in a certain subset of patients.
* Methacholine or other "nonspecific" forms of
challenge
need
not be carried out in those with well-established asthma
and
should not be carried out in those with compromised
pulmonary function.
C. Specific diagnostic techniques
1. Skin testing in the asthmatic patient
* Allergen skin testing, as performed by percutaneous and
intracutaneous techniques, is the most sensitive method for
detecting specific IgE antibody. However, the presence of
specific IgE antibody does not alone establish the clinical
relevance of specific allergens. Determination of the
relevance of the skin test data depends on a detailed and
enlightened evaluation of the history and appropriate
follow-up.
* A positive immediate skin test reaction is a function of
(1)
the presence of IgE antibody for a specific allergen, (2)
the releasability of mast cell mediators, (3) the
reactivity
of the patient's skin to histamine (the primary mediator of
the immediate wheal-and-flare skin test), and (4) the
amount
of allergen injected.
* Allergen skin testing as part of an allergy evaluation is
indicated to (1) aid in establishing an allergic basis for
the patient's symptoms, (2) assist in establishing specific
causes of the patient's symptoms, and/or (3) help evaluate
the degree of sensitivity to a specific allergen.
* The number of skin tests appropriate at any one time may
vary depending on the nature of the clinical problem, the
age of the patient, potential allergen exposures, and the
area of the country in which the patient resides. To
properly interpret the results of allergen skin testing, it
is essential to know which aeroallergens are present
locally
and clinically important. Furthermore, it is important to
know which allergens in the area cross-react extensively
with botanically related species.
* Skin testing is not without risk; although rare, fatal
reactions from skin testing have occurred, more commonly
with intracutaneous than with percutaneous testing. Skin
testing should be deferred in patients experiencing an
asthma exacerbation.
* Most antihistamines will suppress allergen skin tests for
several days, although astemizole may produce skin test
suppression for many weeks. Other medications commonly used
to treat allergic conditions and asthma do not
significantly
suppress immediate skin test reactions to histamine or
allergens.
2. Laboratory evaluation of the asthmatic patient
* No single laboratory test or group of tests can
conclusively
establish the diagnosis of asthma.
* Determination of total serum IgE is an imperfect
determinant
of the presence or absence of allergy. If high, it supports
the presence of allergy and/or a condition such as allergic
bronchopulmonary aspergillosis.
* Determination of allergen-specific IgE by in vitro assays
may be preferable to skin testing in a small number of
asthmatic patients, such as those with severe skin
disorders
or those taking certain medications.
* The eosinophil is considered an important effector cell
in
asthma because of its ability to produce respiratory
epithelial damage and bronchocentric inflammation. Total
serum eosinophil counts may be elevated in untreated
patients with asthma.
* If recurrent pneumonia or sinus infection occurs in
asthmatic patients, immune deficiencies could be evaluated
by determination of quantitative immunoglobulin levels, IgG
subclass levels, and specific antibody responses after
natural infection and immunization.
* Allergic bronchopulmonary aspergillosis can be diagnosed
by
several criteria including elevated total serum IgE levels
and the presence of allergen-specific IgE and IgG
antibodies
3. Allergen inhalation challenge
* Allergen inhalation challenge is used m often as an
experimental procedure to clarify mechanisms of bronchial
hyper-responsiveness.
* Allergen challenge can be used to clarify the role of
specific allergens in patients with asthma or to establish
causal relationship of asthma with an occupational agent.
* Allergen challenges may also be useful to evaluate
therapeutic effectiveness of medications and immunotherapy.
* Allergen inhalation challenge can document specific
allergenic sensitivity in certain patients when skin tests
cannot be performed or as a comparison with in vitro
diagnostic tests when evaluating specific IgE-mediated
sensitivity.
* Allergen inhalation challenge can trigger severe
late-phase
bronchial obstruction in certain patients, and precautions
should be taken to prevent or treat this type of reaction.
4. Other diagnostic techniques
* The presence of eosinophils and other formed elements
(Curschmann's spirals, Charcot-Leyden crystals, and creola
bodies) in the sputum may have diagnostic significance.
* A chest radiograph should be considered in some patients
to
aid in (1) differentiating asthma from other conditions
that
may cause wheezing and (2) demonstrating possible
complications of asthma.
* Sinus radiographs and/or computed tomographic (CT) scans
should be considered if chronic sinusitis is suspected.
* Direct visualization of the upper and/or lower airway may
be
required to determine if wheezing is caused by mechanical
obstruction.
* Special diagnostic procedures may be required to exclude
the
diagnosis of pulmonary embolism.
* Special tests are available to distinguish other
diseases,
such as carcinoid, mastocytosis, cystic fibrosis, and alpha
1-antitrypsin deficiency, which may masquerade as or
coexist
with asthma.
ASTHMA MANAGEMENT
A. Classification of asthma severity
* Attempts have been made to categorize severity of asthma
on
the basis of symptoms, impairment of activity, pulmonary
function, degree of bronchial hyper-reactivity, number of
emergency visits, number of hospitalizations, and
medication
use. Although there is no universal acceptance of formal
severity designations, a combination of subjective and
objective criteria can be used as a guide to severity in
individual patients.
* Severity of asthmatic symptoms can be ranked on the basis
of
duration throughout the day or night, as well as
persistence
throughout the week.
* Restriction of activity in asthmatic patients can be
based
on inability to work or attend school, as well as how many
days per week or month the restriction is present.
* Pulmonary function testing can be used to assess severity
of
asthma, based on the predicted normal value or the
patient's
best attainable value.
* Severity of asthma can be based on the number of office
or
emergency room visits, as well as the number of
hospitalizations required because of exacerbations of
asthma.
* Treatment philosophies vary considerably; however, most
physicians only prescribe daily oral corticosteroids for
patients with severe asthma and avoid their use in patients
with mild asthma. Therefore long-term administration of
oral
corticosteroids can be used to classify asthma as severe.
B. Severe acute intractable asthma
* Severe acute intractable asthma (status asthmaticus)
requires prompt recognition, and intervention.
* The treatment of intractable asthma requires an
understanding of physiologic abnormalities occurring as a
consequence of increased air flow resistance resulting from
bronchospasm, inflammation, and mucus plugging.
* The history must establish the features of the current
attack and the presence of medical conditions that could
complicate treatment of intractable asthma.
* Early in an asthma exacerbation, ventilation/ perfusion
mismatches are the predominant physiologic abnormality, and
partial pressure of oxygen in arterial blood (PaO2)
decreases. Therefore oxygen administration is indicated in
patients with severe acute intractable asthma.
* With increasing obstruction, ventilation is compromised
and
partial pressure of carbon dioxide in arterial blood
(PaCO2)
rises from initially low levels to "normal" levels.
Therefore a PaCO2 of 40 torr may be a sign of severe
asthma.
* Early in the treatment of intractable asthma, parenteral
and
inhaled sympathomimetic agents are equally effective in
most
patients. However, parenteral sympathomimetic agents may be
indicated for patients who are not ventilating well enough
to deliver adequate amounts of nebulized drug to the lower
respiratory tract.
* Patients with severe, acute, intractable asthma will
require
corticosteroid administration. Early use is recommended
because a lag time of several hours may occur before any
clinical effect is noted.
* If aminophylline/theophylline is used, it is especially
important to monitor blood levels and cardiopulmonary
function.
* Overhydration may increase vascular hydrostatic pressure
and
decrease plasma colloid pressure, increasing the
possibility
of pulmonary edema, which is also favored by large negative
peak inspiratory intrapleural pressures associated with
acute asthma.
* The need for mechanical ventilation should be
anticipated,
intubation may be difficult and if possible should be done
by an individual experienced with such procedures.
* Hospital management of an acute asthma exacerbation
includes
repetitive administration of nebulized beta2-selective
agents and systemic corticosteroids.
C. Identification of the fatality-prone asthmatic patient:
Crisis
plans
* Risk factors for life-threatening exacerbations of asthma
include severe asthma, poor control of symptoms, atopy,
psychological factors and failure by patient and/or
physician to recognize the severity of the patient's
asthma.
* Poor asthma control is undesirable; poor control of
asthma
symptoms is a special risk factor in the period after
hospitalization.
* Allergic response to airborne mold (Alternaria) has been
associated with life-threatening or fatal exacerbations in
asthmatic patients.
* Psychological factors that may place the patient at risk
of
severe life-threatening asthmatic exacerbations include
poor
ongoing care by the patient and/or family, disregarding
asthma symptoms, manipulative use of asthma, and
significant
emotional problems.
* Fatality-prone asthmatic patients require special
planning,
including regular follow-up visits for assessment of asthma
control, measurement of pulmonary function in the office
and
at home, monitoring of the patient's course with regard to
the need for specialist referral, specific treatment of
factors that result in fatality-prone status,
identification
of a reliable advocate, involvement of community resources,
development of a crisis plan, and notification of
patient/parents of fatality-prone status.
D. Environmental avoidance
1. Airborne triggers
* Important steps in environmental control are as follows:
* Minimize house dust mite exposure in mite- allergic
patients
with asthma.
* Reduce exposure to domestic animals in appropriate
patients.
* Do not allow smoking in the home.
* Avoid strong odors and chemical fumes.
* Install kitchen and bathroom exhaust fans,
* Use humidifiers with caution in mite and mold sensitive
patients.
* Use air conditioners in bedrooms and family rooms when
appropriate.
* Use high-efficiency particulate air filters (HEPA) or
electrostatic air purifiers.
* Install a dehumidifier and reduce water entry in damp
basements.
* Initiate other measures for specific allergies as
appropriate.
* Health care providers should identify allergic and
nonallergic environmental triggers of asthma and implement
environmental measures to eliminate or to minimize exposure
to these factors.
* House dust mite sensitivity is a significant risk factor
for
many patients with allergic asthma. Extensive cleaning
procedures minimize mite exposure, decrease bronchial
hyper-responsiveness, and reduce asthma morbidity.
Pro-posed
environmental controls should be commensurate with the
severity of the patient's disease, economic status of the
family, and other practical considerations.
* Cockroach allergen has been recognized as a major cause
of
allergic rhinitis and asthma, especially in inner-city
urban
asthmatic patients. Exposure to rodent allergen may also be
a significant factor in some asthmatic patients living in
this setting.
* Tree, grass, and weed pollen can produce significant
exacerbations of asthma at specific times of year. Every
effort should be made to minimize indoor pollen
contamination at home and at work by keeping windows closed
and using filtration devices and air conditioning.
* Molds and fungi are aeroallergens that are recognized as
triggers for asthma and rhinitis. Their ability to produce
severe life-threatening exacerbations of asthma is well
documented. For indoor molds, environmental control
procedures include use of dehumidifiers and air
conditioning. Avoidance out outdoor molds requires an
understanding of areas where extensive mold growth can be
anticipated.
* Nonallergic environmental triggers, such as cigarette
smoke,
chemical irritants, or strong odors, can also produce
significant exacerbations of asthma. Avoidance of these
allergic triggers.
* Domestic animals, especially cats and dogs, are a common
cause of allergic reactions in individuals with allergic
rhinitis and asthma.
2. Food hypersensitivity and asthma
* Allergies to foods can induce wheezing in a small number
of
patients with asthma.
* Evaluation of food hypersensitivity should be considered
in
patients with chronic symptoms, especially those in the
pediatric age group with a history of atopic dermatitis.
* A positive prick test to suspected foods may suggest
specific food allergens that require further study.
* A definitive diagnosis of food allergy is based on a
double-blind, placebo-controlled oral challenge. Under
certain circumstances, a presumptive diagnosis may suffice
based on less stringent criteria.
3. Other nutritional considerations in the asthmatic
patient
* Adequate nutrition is an essential part of the general
treatment plan for asthmatic patients and should be
emphasized especially when there are dietary restrictions
related to food sensitivities or blunted appetite caused by
medications.
E. Pharmacotherapy
Beta-adrenergic agonist bronchodilators
* Treatment of the asthmatic patient must be
individualized.
* Beta-agonist bronchodilators vary in their degree of
selectivity and range from non-selective (e.g.
isoproterenol) to relatively Beta-selective agonists
(beta2-agonists) (e.g. albuterol)
* It is preferable to use a beta 2-agonist rather than a
non-selective beta-agonist because beta 2-agonists have a
longer duration of action and are less likely to produce
cardiovascular side effects.
* The use of sustained release oral beta2-agonists may be
appropriate and indicated for some asthmatic patients,
especially in situations in which a long duration of effect
is desired or the patient does not tolerate inhaled
beta2-agonists. Otherwise, inhaled beta2-agonists are
preferable to oral drugs of this type in the treatment of
chronic asthma because rapid onset of action, are generally
more effective than other routes of administration, and
infrequently produce adverse reactions.
* Inhaled beta2-agonists may be more effective when
administered on an as needed basis rather than on a regular
basis in the treatment of many patients with chronic
asthma.
If greater than eight inhalations per day (or approximately
one canister per month) are needed, the addition of
cromolyn, nedocromil, or inhaled cortosteroids should be
considered.
* Inhaled beta2-agonists are generally the safest and most
effective treatment for acute asthma. In general, oral
beta2-agonists should not be administered for the treatment
of acute severe asthma.
* The administration of beta2-agonists in the treatment of
acute or chronic asthma is not a substitute for the early
use of anti-inflammatory drugs.
* Patients must be carefully instructed, often more than
once,
in the use of inhaled beta2-agonists because a large
percentage of patients fail to use inhaler devices
correctly. Spacers attached to inhaled beta2-agonists
improve drug delivery in patients who do not correctly use
inhalers.
* Inhaled beta2-agonists, when administered 15 to 30
minutes
before exercise, prevent exercise-induced bronchospasm in
many patients. Inhaled beta2-agonists are generally
considered the agent of choice for this purpose.
* Tolerance to beta2-agonists, which is usually reversible
after the administration of corticosteroids, may develop
after continued use of these drugs and may be associated
with an unrecognized decrease in efficacy and delay in
seeking medical attention.
* Bronchial hyper-responsiveness may increase in patients
who
receive inhaled beta2-agonists on a regular basis. This
possibility should be considered in patients whose asthma
is
worsening on a regimen that includes the regular use of
these drugs.
* Tremor and central nervous system effects are minimized
by
inhalation of beta2-agonists, although hypokalemia and
significant cardiovascular effects can occur when these
drugs are administered by this route.
* Serious adverse effects from the administration of
beta2-agonists, when administered in recommended dose, are
uncommon when given orally and extremely uncommon when
administered by inhalation.
* Both beta2-agonists and non-selective beta-agonists, when
administered by inhalation, can produce a sudden
paradoxical
increase in bronchospasm, which may be life-threatening in
some asthmatic patients.
* Salmeterol is a long-acting, highly beta2-selective
beta-agonist bronchodilator.
* Well-controlled studies have shown that the duration of
action of salmeterol is 12 hours or longer in most
patients.
* Pretreatment with single doses of salmeterol also
prevents
bronchospasm from histamine, methacholine, and cold air
challenge.
* Salmeterol can protect patients against exercise-induced
bronchospasm for up to 12 hours after administration.
* Because salmeterol is inherently different than
short-acting
inhaled beta agonists, special recommendations must be
considered when prescribing salmeterol for patients. In
this
regard salmeterol metered dose inhaler: (1) should not be
initiated in patients with significantly worsening or
acutely deteriorating asthma; (2) should not be used to
treat acute symptoms; and (3) should not be considered a
substitute for inhaled or oral corticosteroids.
Theophylline
* For the treatment of acute severe asthma, theophylline is
less effective than inhaled or injected beta2-selective
agonists.
* Maintenance therapy with theophylline is effective in
reducing the frequency and severity of the symptoms of
chronic asthma. It may be similar in effectiveness to
cromolyn or beta2-agonists, and long-acting preparations
allow for effective control of nocturnal symptoms.
* Patients with mild chronic asthma may be controlled at
steady-state theophylline serum concentrations less than 10
ug/ml; patients with more severe disease may require
concentrations greater than 10 ug/ml for effective control
of symptoms. Although patients may experience significant
adverse reactions at less than 10 ug/ml, as the serum
concentration increases the frequency and severity of
toxicity increase. With levels less than 15 ug/ml severe
adverse reactions are unlikely to occur.
* The rate of theophylline metabolism varies greatly among
patients in the same age group and is influenced by
numerous
medical conditions and pharmaceutical interventions.
* The rate of theophylline metabolism is reduced, thereby
leading to increased serum levels and increased potential
for toxicity, in the presence of such conditions as cardiac
decompensation, respiratory failure, hepatic cirrhosis,
sustained high fever, viral infections, hypothyroidism, and
after administration of cimetidine, oral contraceptives,
troleandomycin, erythromycin, ciprofloxacin, and
disulfiram.
In contrast, factors such as cigarette or marijuana
smoking,
hyperthyroidism, rifampin, phenytoin, carbamazipine, and
phenobarbital increase the rate of metabolism.
* Oral slow-release formulations generally provide stable
serum concentrations and favor patient compliance. However,
the rate and extent of absorption vary between
formulations,
between individuals, and possibly in the same individual
from time to time. Food ingestion may also affect the rate
of absorption in different ways depending on the specific
formulation.
* Dosage for long-term therapy is based on the principle of
slowly titrating the dose over several days to circumvent
transient caffeine-like side effects. Final dosage is
usually based on the peak serum concentration measurement
obtained at steady state.
* Elevated blood levels may produce neurologic,
gastrointestinal (including gastroesophageal reflux [GER]),
and/or cardiovascular side effects.
* Orally administered activated charcoal or charcoal
hemoperfusion dialysis should be considered at toxic
theophylline concentrations. Intravenous phenobarbital
should also be considered to prevent seizures; diazepam,
but
not phenytoin, should be used to terminate seizures.
Anticholinergic agents
* The regular use of anticholinergic bronchodilators
appears
to be most effective in patients with chronic obstructive
pulmonary disease who have partially reversible airflow
obstruction.
* Inhaled anticholinergic medication is not sufficiently
effective to be used as a single agent in the treatment of
acute severe asthma but may provide benefit when combined
with a Beta-agonist or other primary therapeutic agent.
* Inhaled anticholinergic agents, such as ipratropium,
appear
to be more effective when used to treat patients with
chronic mild to moderate degrees of airflow obstruction.
* Inhaled anticholinergic medications, such as ipratropium,
may be indicated in patients in whom alternative agents
have
not been sufficiently effective, are inappropriate because
of other medical conditions, or have produced unacceptable
side effects.
Antihistamines
* Antihistamines can be safely used in most patients with
asthma.
* Antihistamines may be effective in the treatment of
asthma
because histamine, acting through H1 receptors, produces
smooth muscle contraction, an increase in vascular
permeability, and stimulation of parasympathetic nerves,
all
of which are pathophysiologic features of asthma.
* Based on their ability to block late-phase responses to
allergen exposure, newer antihistamines may play a greater
role in the future treatment of asthma.
* Antihistamines may alleviate asthma somewhat through
their
direct effect on the bronchial passageways.
* There is a strong clinical impression that improvement of
upper respiratory tract symptoms by antihistamines in
patients who have concomitant allergic rhinitis and asthma
may facilitate the treatment of lower respiratory tract
symptoms.
* Although antihistamines are not the treatment of choice
for
exercise-induced bronchospasm, pretreatment may attenuate
exercise-induced bronchospasm in some patients.
* Histamine is not the only mediator responsible for asthma
symptoms, and therefore antihistamines, if used, should be
considered adjunctive therapy in the treatment of asthma.
Cromolyn and nedocromil
* Cromolyn can be effective in many patients, alone or in
conjunction with bronchodilators, in preventing the
symptoms
of mild-to-moderate asthma.
* Cromolyn has been demonstrated to be extremely safe,
although serious adverse effects, such as bronchospasm,
have
been reported.
* Cromolyn can be effective in preventing or diminishing
exercise-induced asthma when given 15 to 30 minutes before
exercise.
* Overall, there is similar effectiveness with use of the
metered-dose inhaler, Spinhaler, and solution for
nebulization, although individual response must be
considered in the choice of the product.
* Cromolyn has the ability to attenuate both early and
late-phase IgE-mediated reactions.
* Nedocromil sodium is a topically active
anti-inflammatory,
pyranoquinoline that has mast cell-stabilizing properties.
* Nedocromil sodium has a number of putative mechanisms of
action, as suggested by both animal in vivo experiments and
in vitro effects on a variety of animal and human cell
preparations.
* Nedocromil sodium is primarily indicated as a preventive
drug in the management of asthma-associated chronic
inflammation. If used appropriately in this manner, it is
effective in improving symptom scores, reducing use, and in
some cases, other concomitant medications such as inhaled
corticosteroids or cromolyn sodium.
* Clinical dosing is based on its long-term preventive
effects. Because it is not a bronchodilator, it is not
indicated in the treatment of acute asthma.
* Long-term use of nedocromil sodium is generally safe.
* Nedocromil sodium is clinically useful in the preventive
treatment of mild and moderate asthma.
Corticosteroids
* With renewed awareness of the importance of airway
inflammation in the pathogenesis and chronicity of asthma,
it is generally felt that inhaled corticosteroids should be
used as primary therapy in patients with moderate and
severe
chronic asthma.
* Systemic corticosteroids should be considered in the
management of acute asthma when the patient does not
respond
readily to bronchodilators. Early use of corticosteroids
shortens the course of asthma, prevents relapses, and
reduces the need for hospitalization. The early use of
corticosteroids is of particular importance in patients who
have a history consistent with fatality-prone asthma.
* Intravenous corticosteroids may be lifesaving in the
treatment of severe intractable asthma. After episodes of
severe intractable asthma, complete restoration of
pulmonary
function may require weeks of treatment. Therefore after
such events, corticosteroids should be continued at least
until symptoms are controlled and pulmonary function is
restored.
* Because of the potential for significant side effects
from
the prolonged use of systemic corticosteroids (and possibly
high-dose inhaled corticosteroids), the need for oral
corticosteroids should be monitored by pulmonary function
tests, and inadequate control with maximal use of other
treatment approaches should be a prerequisite for the
long-term administration of systemic corticosteroids.
* Patients receiving systemic corticosteroids on a chronic
basis may need to be carefully monitored for changes in the
hypothalamo-pituitary-adrenocortical axis, bone changes,
glucose metabolism, hypertension, and other potential side
effects of such therapy under certain circumstances.
Hydration and pharmacomucolytic agents
* Adequate hydration is recommended for patients with
asthma,
but overhydration should be prevented by careful monitoring
of fluid and electrolyte balance, especially in infants, in
severely ill patients, and in the elderly. Dehydration may
occur with severe asthma and should be corrected. However,
fluid overload may have adverse pulmonary and circulatory
effects and must be prevented by careful monitoring of
fluid
and electrolyte balance.
* Guaifenesin and potassium iodide may be worth a trial in
some asthmatic patients, although the mechanisms of action
are unclear.
Other considerations
a. Alternative therapy
* Whatever the reasons for failure to respond to
corticosteroids, several treatment regimens for asthmatic
patients who have not responded to systemic corticosteroids
now exist.
* Steroid-sparing regimens or alternatives to systemic
corticosteroid therapy include troleandomycin,
methotrexate,
gold and intravenous globulin therapy, which may be
effective in some patients with asthma.
* It should be recognized that certain of these regimens
are
contraindicated in some patients and/or may be associated
with significant adverse effects.
b. Role of antibiotics/antivirals
* Infections associated with asthma exacerbations are
almost
always viral in origin and do not require antibiotic
therapy. Under these circumstances, however, reevaluation
of
the patient's treatment program, including bronchodilators
and corticosteroids, may be important.
* Bacterial infections, such as acute and chronic
sinusitis,
should be treated appropriately, including the prompt and
adequate use of antibiotics.
* Influenza can be associated with increased asthma.
Therefore
appropriate immunization is essential in patients with
moderately severe or severe asthma.
Immunizations
* Routine vaccinations are not contraindicated in patients
with asthma or other allergic conditions.
* Patients who have a history of egg sensitivity should be
skin-tested with the vaccination material. If results of
the
skin test are positive, the patient may be immunized with
small increasing doses with use of an established protocol.
* Short-term, low-to-moderate dose systemic
corticosteroids,
alternate-day corticosteroids, or topical corticosteroids
are not immunosuppressive and are not a contraindication
for
immunization.
* Influenza vaccine and pneumococcal vaccine are
recommended
for patients with chronic pulmonary disease including
asthma.
Comparability of therapeutic products
* Comparability of inhaled products cannot be assumed
because
of potential differences in patient response to excipients
or other "inactive" components in these products.
* Substitution of a theophylline product different from the
one the patient was previously receiving can produce
decreased efficacy or toxicity in some patients.
* Any adverse reaction that is temporally related to use of
a
drug product may be caused by the drug product even if the
patient has tolerated the same drug in another product.
Polypharmacy
* Polypharmacy may be necessary and indeed desirable in the
management of patients with asthma. *The physician must
guard against the unnecessary addition of medications that
could increase morbidity and mortality in asthmatic
patients.
F. Immunotherapy in the asthmatic patient
* Allergen immunotherapy can be effective in patients with
asthma and may reduce the effect of chronic allergen
stimulation on hyper-responsive airways. In most cases
allergen immunotherapy should be considered as a part of a
well-planned program that includes pharmacotherapy and
avoidance measures.
* Allergen immunotherapy should be considered a long-term
therapeutic modality in patients with allergic asthma.
* Patient compliance is essential for the effective and
safe
application of allergen immunotherapy.
* Although precise mechanisms for efficacy of allergen
immunotherapy are unknown, several specific
immunomodulatory
pathways have been implicated.
* Immediate and delayed local and systemic reactions may
occur
in the course of allergen immunotherapy.
* Patients should be informed about the relative risks of
immediate and delayed reactions associated with allergen
immunotherapy.
* Both patients and medical personnel should be instructed
in
detail about prevention and treatment of reactions to
allergen immunotherapy.
* Although life-threatening reactions during allergen
immunotherapy are rare, fatalities can occur. Therefore
supervising health care providers should be prepared to
treat such reactions as promptly and effectively as
possible.
G. Patient education
Cooperative management through education
* Educating asthmatic patients, parents, and family about
their disease and methods of treatment is essential in the
effective control of asthma.
* Educational programs for asthmatic patients have
generally
been successful in producing increased patient
understanding
of asthma and decreased morbidity.
* Patients should be educated to effectively monitor their
asthmatic status and know how to respond to changes in
their
status.
* Patients should be educated in the proper technique
required
for the effective use of inhaled medications.
* Physicians should recognize patient concerns and resolve
these concerns through increased patient confidence in the
management approach and their ability to implement this
approach in the treatment of their asthma.
* Asthma education requires an understanding by the patient
and physician of certain basic concepts related to
pathophysiology and treatment but must also be
individualized for each asthmatic patient.
Compliance in asthma
* Patient non-compliance can be manifested as underuse,
overuse, or erratic use of prescribed medication.
* Improvement in patient compliance may be influenced by
knowledge about therapy, the patient-physician
relationship,
perceived seriousness of the condition, perceived benefit
of
intervention, complexity of the program, frequency of
taking
the medication, and cost.
* The most successful programs to improve patient
compliance
combine techniques of education, reinforcement, and family
interactions.
* Lack of patient compliance is one of the most important
under-recognized problems in medicine today and can be the
result of psychological, economic, or educational factors.
Rehabilitation of the patient with asthma
* Specific goals of rehabilitation include maximizing
school/work attendance, encouraging participation and
productivity, encouraging participation in age-appropriate
physical activities with peers, promoting self-esteem and
self-confidence, and decreasing anxiety about the illness.
* Information needed to evaluate the need for and the
effectiveness of a rehabilitation program should be
obtained
on a regular basis in the continuing care of a patient.
* Problems in any area of rehabilitation should prompt the
initiation of specific measures to correct this deficiency.
* Community resources including structured fitness programs
are available and should be used when appropriate.
* Rehabilitation goals should be coordinated and monitored
by
the physician so that therapy can be adjusted
appropriately.
Asthma camps
* The major goal of a camp for children with asthma is to
provide a positive learning experience in an enjoyable
setting. The camp provides an environment that encourages
social interests, reduces anxiety, and allows for a sense
of
independence.
* Operational guidelines for the camp should include
administrative structure, medical structure, appropriate
structure of activities, and camp format.
SPECIAL CONDITIONS
A. Concomitant Conditions
* Weight control should be advised in patients with asthma
because exogenous obesity may complicate the treatment of
asthma.
* Although the coexistence of obstructive sleep apnea and
asthma is rare, nocturnal asthma may be exacerbated in
patients with both conditions.
* A decision regarding antituberculous chemotherapy in an
asthmatic patient who requires corticosteroids should be
carefully individualized if there is a documented past
history of tuberculosis.
* Hyperthyroidism may aggravate asthma and complicate the
management of asthmatic patients.
* Asthma in patients with Addison's disease is usually
severe
but improves with glucocorticoids.
* The best method of avoiding the diabetogenic properties
of
corticosteroids in asthmatic patients with diabetes is use
of inhaled corticosteroids if the patient's asthma can be
controlled with this form of therapy.
* The treatment of asthma in patients with coexisting
hypertension and/or heart disease should be based on an
understanding of the potential for asthma medications to
exacerbate cardiovascular status and the potential for
antihypersensitive medication and cardiac drugs to
exacerbate asthma.
* Asthma medications are often useful in managing so-called
"fixed" obstructive lung diseases in adults and
children.
* Cessation of smoking by patient and family members should
be
a major goal in the overall management of asthma.
B. Asthma and anaphylaxis
* Anaphylaxis may be accompanied by sudden severe
bronchospasm.
* Patients taking beta-blockers who develop
life-threatening
anaphylaxis may respond poorly to usual treatment for
anaphylaxis.
* Inhaled beta2-selective agonist bronchodilators and
intravenous aminophylline may be required to reverse
bronchospasm in patients not immediately responsive to
subcutaneous epinephrine.
* Oxygen, 5 to 10 L/min, should be used when bronchospasm
is
accompanied by significant dyspnea or cyanosis.
* Prolonged therapy, including corticosteroids, may be
necessary to reverse protracted anaphylaxis or anaphylaxis
that occurs later after exposure to the triggering agent.
C. Management of asthma during pregnancy
* There is more risk to the mother and fetus during
pregnancy
from poorly controlled asthma than from the usual
medications used to treat asthma.
* Asthmatic patients should not smoke, especially during
pregnancy.
* Identification and avoidance of potential triggers of
asthma
are essential during pregnancy.
* Assessment of asthma should include regular measurements
of
pulmonary function during pregnancy.
* Pregnancy is not a contraindication to continued allergen
immunotherapy in patients who are at maintenance.
* Additional considerations apply to the management of
asthma
during labor and delivery.
* In general, the same medications used during pregnancy
are
appropriate during labor and delivery.
* Oxytocin is the preferred medication for labor induction,
and intracervical prostaglandin E2 gel can be used for
cervical ripening before labor induction.
* For regional anesthesia during labor and delivery, the
concomitant use of epidural analgesia should be considered;
for general anesthesia, ketamine may be the agent of
choice,
possibly with preanesthetic use of a beta2-agonist.
* Currently, oxytocin is considered the medication of
choice
for postpartum hemorrhage. Ergonovine and methylergonovine
have been associated with bronchospasm.
D. Nocturnal Asthma
* A high percentage of deaths occur during nocturnal and
early
morning periods.
* Nocturnal asthma has been associated with factors such as
decreased pulmonary function, hypoxemia, decreased
mucociliary clearance, and circadian variations of
histamine, epinephrine, and cortisol concentrations.
* A general goal of asthma therapy should be the complete
control of nocturnal symptoms.
* Longer acting, sustained-release theophylline
preparations,
long-acting preparations of oral beta2-agonists, or
long-acting beta2-agonists may be an effective way to
control nocturnal asthma in many patients.
* Better overall control of the patient's asthma may be
necessary before nocturnal symptoms will be adequately
controlled (i.e., avoidance, immunotherapy, and daytime
medications, especially anti-inflammatory drugs such as
corticosteroids and cromolyn).
E. Exercise-induced asthma
* Exercise-induced asthma (EIA) occurs in up to 90% of
patients with asthma.
* EIA is probably triggered by heat and water loss from the
respiratory tract, which causes mediator release resulting
from bronchial hyperosmolality.
* Inhalation of a beta2-agonist 15 to 30 minutes before
exercise is the treatment of choice for EIA.
* Inhaled cromolyn sodium, taken alone or in conjunction
with
an inhaled beta2-agonist 15 to 30 minutes before exercise,
can also effectively prevent or modify EIA.
* Pretreatment with theophylline, anticholinergic agents,
antihistaminic agents, and other medications (see text) may
benefit some patients with EIA.
* General stabilization of the patient's asthma may be
required before effective control of EIA can be achieved.
* Nonpharmacologic methods can be effectively used in some
patients to prevent EIA (e.g., exercise under conditions in
which warm, humid air is inhaled).
F. Nasal and sinus disease and asthma
* Frequently there is an association between asthma and
sinusitis, and improvement in asthma may occur when
sinusitis is properly treated.
* Sinusitis should be considered in patients with
refractory
asthma.
* Evaluation of sinus disease may require sinus
radiographs,
CT scans, and/or endoscopic procedures.
* Many local and/or systemic factors may increase the risk
of
sinusitis developing. Certain diseases, such as cystic
fibrosis, and local factors, such as nasal polyps, may
increase the risk of developing sinusitis.
* Nasal polyps may occur in association with sinus disease
and
both conditions may affect asthma.
G. Gastroesophageal reflux (GER) and asthma
* GER occurs commonly in patients with asthma.
* GER should be suspected in patients with nocturnal asthma
or
in patients who are not responding adequately to optimal
medical management.
* A number of objective diagnostic modalities are available
for establishing a relationship between GER and asthma.
* Medical or surgical treatment of GER in asthmatic
patients
may improve their respiratory symptoms.
* Surgical correction of GER should only be considered when
medical therapy is unsuccessful and a causal relationship
between GER and asthma has been objectively established.
H. Aspirin-sensitive asthma/nonsteroidal anti-inflammatory
drug/preservative sensitivity
* Aspirin-sensitive asthma (ASA) and nonsteroidal
anti-inflammatory drug (NSAID) idiosyncrasy occurs in up to
10% to 15% of all asthmatic patients and in 30% to 40% of
asthmatic patients with nasal polyps and pansinusitis.
These
reactions are non-IgE mediated and designated as
idiosyncracies.
* Ultimately, many of these patients become steroid
dependent.
* ASA desensitization may be a useful therapeutic adjunct
in
some of these patients, especially those who have
concurrent
diseases that require ASA or NSAIDS.
* Sulfite additives in drugs and foods may induce severe
adverse reactions in susceptible asthmatic patients.
* Tartrazine in foods or drugs may induce asthma in a small
number of patients with ASA idiosyncrasy.
* Similar to ASA reactions, almost all of the reactions to
tartrazine are not IgE mediated.
* Asthma may occur in a few monosodium
glutamate-susceptible
patients after challenge with this food-flavoring agent.
* Several other dye and preservative additives in foods and
drugs have also been implicated as inducers of asthma.
I. The effects of air pollution in asthmatic patients
* Although asthmatic patients living in urban environments
are
generally exposed to a large number of pollutants, only a
few have been implicated in causing adverse effects.
* Inhalation of sulfur dioxide, nitrogen dioxide, or ozone
is
capable of inducing bronchospasm in patients with asthma.
* One of the common sources of air pollution in residential
areas, especially in western states, is household
woodburning devices.
* Albuterol is the most selective and potent blocker of
sulfur
dioxide (SO)-induced airflow obstruction in asthmatic
patients, and cromolyn sodium has also been shown to block
S02-induced bronchoconstriction.
J. Psychological factors
* Asthma affects psychological and social aspects of life
for
virtually all patients with this disease.
* The patient may or may not be aware of the presence of
psychological problems, which may constitute significant
impediments to the optimal management of asthma.
* The management of psychological or social problems that
accompany asthma depends on the extent to which they
interfere with medical management or produce severe
dysfunction in the patient's life.
* Age and maturity are important considerations in both the
medical and psychological treatment of asthma.
* Family members of patients with severe asthma or asthma
that
is out of control require support from the clinician
because
of the demands of caring for an individual with asthma.
Referral to support groups and/or counseling can be helpful
in these situations.
K. Occupational asthma
* Occupational asthma may be induced or aggravated by
variable
periods of exposure to fumes, gases, dusts, or vapors.
* Symptom patterns of occupational asthma are variable and
range from acute symptoms at work to late-onset responses
after work.
* Specific causes of occupational asthma include
immunologic,
irritant, and direct pharmacologic stimuli. Many patients
with immunologically induced occupational asthma have
IgE-mediated sensitization to a variety of animal and
plant-derived proteins that provoke their symptoms.
* Preexisting atopy may constitute an increased risk factor
for asthma caused by many occupational proteins but not by
most low molecular weight chemicals.
* Other obstructive airway diseases such as chronic
bronchitis, bronchiolitis obliterans, and emphysema may
mimic occupational asthma.
* Some low molecular weight chemicals may also induce
IgE-mediated clinical sensitization.
* After careful review of past medical records and a
detailed
history and physical examination, the diagnosis of
occupational asthma can be accomplished by a combination of
pulmonary function tests, skin tests, and blood tests.
inhalation challenge should be done when warranted.
* Removal of either the patient or the precipitant from the
workplace environment is the most effective long-term
treatment strategy.
* Some workers have persistent asthma for years after they
are
removed from the offending occupational agent.
L. Asthma in the school setting
* Asthma must be identified early to optimize treatment
that
can decrease school absenteeism and increase opportunities
for participation in physical activity.
* Asthma can be effectively treated in most children by the
use of readily available inhaled medications.
* Every effort should be made to normalize physical
activity
in children with asthma.
* Education programs for patients, parents, and teachers
should be encouraged to provide better management of asthma
in the school setting.
M. Special problems in asthma management due to
socioeconomic,
geographic, and cultural factors
* Asthma may present special problems in management related
to
living conditions, geographic location, availability of and
access to health care professionals and health care
facilities, socioeconomic status of the patient, and
cultural differences in orientations to disease.
* Exposure to outdoor and indoor respiratory pollutants and
allergens may be intensified in relation to socioeconomic
and geographic factors.
* Inaccessibility to specialists who care for asthma may
lead
to episodic care, lack of follow-up, inadequate patient
education, and possibly increased asthma mortality in urban
African-Americans.
* Inaccessibility to specialists who care for asthma can be
the result of difficult geographic or economic conditions,
lack of health care coverage, and structured health care
plans ("gatekeeper" concept).
* The selection of medications for the treatment of
specific
patients with asthma should take into consideration the
education of the patient, the patient's mental status, the
economic status of the patient, cultural approaches to the
use of medications, and accessibility to medical care while
providing the best approach to treatment possible for that
individual patient.
N. Asthma in children
* Asthma is the most common chronic condition of childhood.
The prevalence and severity of childhood asthma have
increased substantially in recent years. Age-related
differences in diagnostic and therapeutic considerations in
childhood require special attention.
* Asthma can begin in infancy, although rarely in the first
few months of life. Wheezing is a common symptom
encountered
in infancy through the first 2 to 3 years of life and may
be
a transient phenomenon in this age group. Many children
develop persistent or recurrent wheezing, i.e., asthma.
Persistent asthma that begins early is likely to be more
severe.
* Atopy in the child, parental atopy or asthmatic history
and
maternal smoking are risk factors for persistent and
recurrent asthma. Low lung function and maternal smoking
are
risk factors for transient wheezing.
* The history and physical examination, the mainstay of
diagnosis in all age groups, present special problems in
infants and young children. The diagnosis and estimation of
asthma severity must depend more on the history and
response
to therapy as assessed by inconstant third-party
observations than more continuous as well as more objective
assessments possible in the older child and adult.
Information from observers in and out of the home is
important. Education of parents and other caretakers
regarding how to assess possible signs and symptoms, their
severity, and possible incitants can aid in diagnosis and
therapy.
* Recurrent symptoms of prolonged cough, often with
shortness
of breath, with or without wheeze, suggest asthma.
Demonstration of a favorable clinical response to
bronchodilator therapy and, when measurable,
bronchodilation
as demonstrated by pulmonary function testing helps confirm
the diagnosis. A positive family history for allergic
diseases or asthma, although not essential, tends to
support
a suspected diagnosis of asthma.
* It is important to realize that asthma may coexist with
other conditions. Alternative or additional diagnosis
should
be entertained when the history is atypical or the response
to good medical management is poor.
* Any aspect of the history that is atypical for asthma,
such
as a history of sudden onset of symptoms, coughing or
wheezing with feedings, neonatal requirement for
ventilatory
support, or symptoms of stridor, may suggest the need to
consider alternative diagnoses.
* A large number of conditions can result in symptoms
suggestive of asthma. The most common nonasthmatic
conditions in childhood that involve obstruction of the
large airways include foreign body in the trachea, bronchus
or esophagus, and laryngotracheomalacia. Obstruction
involving both the large and small airways are most
commonly
due to viral bronchiolitis and cystic fibrosis.
* The differential diagnosis of the child with wheezing can
be
approached on an age-related basis. Infants are at a higher
risk for congenital abnormalities and some infectious
conditions. Aspiration of a foreign body and cystic
fibrosis
may occur in any age group, but most commonly present early
in life. GER with pulmonary involvement may occur at any
age. Vocal cord dysfunction and the hyperventilation
syndrome merit consideration mainly in the adolescent age
group.
* General observations that may be helpful in the
evaluation
of the infant or young child include assessment of clubbing
of fingers or toes (suggesting cystic fibrosis, other
chronic lung disease such as bronchiectasis, congenital
heart disease, hepatobiliary disease rather than asthma),
activity level, and status of growth and nutrition.
* In addition to physical findings pertinent to all age
groups, the evaluation of respiratory effort and
speech-hoarseness, stridor, and the ability to speak or cry
normally-is particularly helpful in the infant and young
child, especially during symptomatic episodes.
* Objective measurement of pulmonary function is important
whenever possible not only to confirm the clinical
diagnosis
but to monitor asthma as well. Expiratory spirometry should
be used as soon as the child is old enough to cooperate.
Peak flow monitoring and pulmonary function measurements
can
generally be done by age 6 or 7 years and in some children
peak flow measured as young as 3 to 4 years old.
* A chest x-ray film should be obtained at least once in
any
child with asthmatic symptoms sufficient to require
hospitalization.
* The child who has had several exacerbations of asthma
requiring in-hospital treatment or who has had a history of
recurrent pneumonia should be considered a candidate for a
sweat chloride test to rule out cystic fibrosis.
* Children with recurrent wheezing who have repeated
bronchopneumonia confirmed by x-ray film should have an
immunologic evaluation, including quantitative
immunoglobulins and possibly specific antibody titers.
* The determination of specific IgE antibody by skin or in
vitro tests is useful to evaluate potential allergic
trigger
factors in children with asthma or when a history
suspicious
of atopic etiology is obtained. Allergy testing can be used
even in infancy, but it is most commonly useful in children
over two years of age.
* Treatment of the child with asthma includes all of the
following: (1) environmental control; (2) use of
appropriate
medications; (3) immunotherapy when indicated; (4)
education
of patient, family, and caregivers; and (4) close
monitoring
and follow-up.
* Aspects of responsibility for treatment may apply to all
environments in which the child spends a significant amount
of time, such as preschool, school, or day care.
* Environmental control for the child includes limiting
exposure to cigarette smoke and other irritants, as well as
to house dust mite, cockroach, mold, animal, and pollen
allergens. The greatest effort is spent in relation to the
bedroom, where children spend a major part of their time.
* Pharmacologic management of the child with asthma
includes
the use of short-acting beta2-adrenergic bronchodilators as
needed to relieve acute symptoms and anti-inflammatory
agents routinely to control chronic symptoms.
Anti-inflammatory agents for the child include cromolyn
sodium and inhaled steroids. Nedocromil sodium is approved
for use beginning in adolescence. Theophylline and oral
long-acting beta2-adrenergic agents are used as adjunctive
therapy. Systemic corticosteroids are used in short bursts
(usually days) for acute severe asthma; long-term use is
reserved for severe chronic asthma not adequately
con-trolled with inhaled steroids at approved higher doses,
and bronchodilators.
* Aerosolized preparations are preferred for the child
because
these generally induce fewer side effects; however, not all
agents are available for use or have Food and Drug
Administration approval for use in this age group.
beta-agonists, ipratropium bromide, and cromolyn sodium can
be delivered by nebulizer; nebulized corticosteroids are
not
available in the United States. Spacers with a face mask
can
be helpful for delivery of medications through metered dose
inhalers in very young children.
* Present data are inadequate to establish if inhaled
steroids
pose a risk for a more complicated course with varicella or
other viral infections in children. The use of acyclovir
and/or varicella immune globulin should be considered in
children who have a negative varicella history and/or
antibody titer and who receive or recently have received
systemic steroids and have been exposed to varicella.
* Immunotherapy can be safe and effective for children with
well-defined allergies whose clinical symptoms correlate
with the sensitivities identified on allergy testing.
* Exercise-induced bronchospasm is common in children.
Pretreatment with beta2-agonists and/or cromolyn sodium can
prevent symptoms; beta2-agonists are useful in reversing
symptoms. Optimal control of chronic asthma by
anti-inflammatory therapy also can decrease the frequency
and intensity of exercise induced asthma.
* Children with asthma need to have their medications
conveniently available at school. Designated school
personnel and children themselves need to understand the
use
of each medication. The physician and parent have a joint
responsibility to provide simple instructions for
medication
use.
CLINICAL ALGORITHM(S):
None provided
DEVELOPER(S):
American Academy of Allergy, Asthma and Immunology (AAAAI)
-
Medical Specialty Society
American College of Allergy, Asthma and Immunology (ACAAI)
-
Medical Specialty Society
Joint Council of Allergy, Asthma and Immunology (JCAAI) -
Medical
Specialty Society
COMMITTEE:
Joint Task Force on Practice Parameters
GROUP COMPOSITION:
Editors: Sheldon l. Spector, MD; Richard A. Nicklas, MD.
Associate Editors: I. Leonard Bernstein, MD; Joann
Blessing-Moore, MD; Robert C. Strunk, MD.
Contributors: Hugh A. Sampson, MD; Michael Schatz, MD;
Sheldon C.
Siegel, MD; Ronald A. Simon, MD; Raymond G. Slavin, MD; R.
Michael Sly, MD; Samuel V. Spagnolo, MD; Sheldon L.
Spector, MD;
Robert C. Strunk, MD; Stanley J. Szefler, MD; Abba I. Terr,
MD;
David G. Tinkelman, MD; Frank S. Virant, MD; George W.
Ward, Jr.,
MD; James H. Wedner, MD; Miles Weinberger, MD; Stephen C.
Weisberg, MD; Michael J. Welch, MD; Paul V. Williams, MD;
Bruce
L. Wolf, MD.
Additional Contributors: Joseph Gaddy, MD; Elaine K.
Kravitz, MD;
Nancy Ostrow.
ENDORSER(S):
Not stated
GUIDELINE STATUS:
This is the current release of the guideline.
This is the second version of the guideline. An update of
the
current guideline is in progress at this time.
GUIDELINE AVAILABILITY:
Electronic copies: Available from the Joint Council of
Allergy,
Asthma, and Immunology (JCAAI) Web site at:
http://www.jcaai.org/Param/Asthma.htm (HTML format) and
http://www.jcaai.org/Param/ParamDocs/Asthma.doc (MSWord
format).
Print copies: Available from JCAAI, 50 N. Brockway, Ste 3-3
Palatine, IL 60067.
COMPANION DOCUMENTS:
None available
PATIENT RESOURCES:
Not stated
NGC STATUS:
This summary was completed by ECRI on October 1, 1998. The
information was verified by the guideline developer on
December
15, 1998.
COPYRIGHT STATEMENT:
This NGC summary is based on the original guideline, which
is
subject to the guideline developer's copyright
restrictions. This
copyrighted material may only be used personally and may
not be
distributed further. All rights reserved. Mosby-Year Book,
Inc.
[Practice parameters for the diagnosis and treatment of
asthmaJ
Allergy Clin Immunol. 1995 Nov;96(5 Pt 2):707-870]
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I. TITLE: MADIGAN ARMY MEDICAL CENTER CLINICAL STANDARD FOR
THE MANAGEMENT
OF ASTHMA.
Three clinical pathways: pathway #1 - acute outpatient
management, pathway
# 2 - Inpatient management, and pathway # 3 - chronic
outpatient
management.
II. INDICATIONS FOR THE STANDARD:
Asthma is the most common chronic respiratory illness of
childhood and
adulthood. The morbidity and cost of treating asthma are
tremendous. The
National Heart, Lung, and Blood Institute (NHLBI) has
emphasized the
importance of consistency in treating asthma across all
care provider
groups. This prompted the publication of the NHLBI
Guidelines. The
Department of Defense has mandated that military facilities
comply with
these guidelines. Our proposed asthma pathways are derived
from the NHLBI
Guidelines and are designed to facilitate and ensure the
consistency of
asthma care amongst care providers at MAMC.
III. METRICS WHICH WILL BE USED TO MONITOR ADHERENCE TO THE
PRACTICE RECOMMENDATIONS:
The proposed asthma clinical pathways will be used to
manage more than 1000
asthmatics per year. Documentation of the following
parameters are
recommended to be used to assess adherence to these
management
recommendations.
For assessing adherence to attachment # 1 (acute outpatient
asthma) these
following metrics will be audited:
Prompt use of aerosolized beta agonists.
Corticosteroids administered at the appropriate time.
Written asthma plan provided, and appropriate instruction
on
MDI/nebulizer use documented.
Follow-up care was arranged.
Primary care provider identified or a referral to obtain
one was
made.
For assessing adherence to attachment # 2 (inpatient
asthma) the following
metrics will be audited:
Corticosteroids administered in the appropriate dosage.
Oxygen saturation monitored, and supplemental oxygen
administered
when indicated.
Asthma education and written instructions provided.
Follow-up care arranged.
Primary care provider identified or the referral made.
For the assessing adherence to attachment # 3 (chronic
outpatient asthma)
the following metrics will be audited:
The prescribing of controller asthma medications for
patients
with persistent asthma.
Written asthma plan given to the patient.
Identification of a primary care provider or a referral
made for
establishing a primary care provider.
IV. DATE: Completed 17 October 1997.
V. AUTHORS:
LTC Ted Carter, Dept. of Pediatrics
LTC Marcia Muggleberg, Division of Allergy/Immunology,
Dept. of Medicine,
LTC Paul Whittaker, Dept. of Family Practice,
CPT Risa Bator, Dept. of Nursing
LTC Suzanne Evans, Utilization Management
MS Marion Christiansen, Clinical Pathways Coordinator
Point of Contact: LTC Edward (Ted) Carter: ccmail: LTC
Edward Carter
phone: 968-1876
FAX: 968-0384
VI. AREAS OF DISAGREEMENT:
There were no major areas of disagreement. Discussion
centered about the
timing of follow-up appointments, drug doses, and the best
use of peak flow
meters. A consensus opinion concerning asthma management
was achieved.
VII. PUBLISHED STANDARDS OF CARE RELATING TO CURRENT
STANDARD:
The three proposed asthma clinical pathways were based upon
the National
Heart, Lung,
and Blood Institute revised guidelines for the management
of asthma.
Guidelines for the Diagnosis and Management of Asthma:
Expert Panel Report
2 - Clinical Practice Guidelines. April 1997. NIH
Publication No. 97-4051.
VIII. CLINICAL PRACTICE RECOMMENDATIONS:
Please refer to the three attachments which accompany this
document.
Attachment # 1 - acute outpatient asthma clinical pathway,
attachment # 2 -
inpatient asthma clinical pathway, and attachment # 3 -
chronic outpatient
asthma clinical pathway.
IX. IMPACT TO THE INSTITUTION:
These clinical pathways impact many areas of the hospital
and all providers
who care for patients with asthma. This includes all of the
primary care
divisions, allergy and pulmonology divisions, and the
emergency department.
It will also impact upon the Department of Respiratory Care
and the
Department of Nursing.
X. LINKS WITHIN THE MAMC INTRANET:
All three of the proposed clinical pathways should be
published on the MAMC
Intranet under the heading of: clinical pathways - asthma.
The chronic
outpatient asthma clinical pathway (attachment # 3) should
be linked to the
pediatric referral guideline and adult referral guidelines
for the referral
of asthmatics for subspecialty evaluation. The pathways for
the management
of acute asthma (outpatient - attachment # 1, and inpatient
Asthma -
attachment # 2) should be installed in CIS to be used in
the Emergency
Department, observation units, and inpatient arena. We also
recommend
placing a brief reminder about the asthma pathways in CHCS
when a provider
prescribes a "controller" asthma medication. Any time
that
a provider
prescribes inhaled corticosteroids, cromolyn, nedocromil,
or a leukotriene
antagonist, a statement will appear which refers them to
the asthma
clinical pathways.
XI. METHODS OF PROVIDER EDUCATION:
Inservices to discuss the guidelines and emphasize the use
of the
clinical asthma pathways should be conducted annually. For
these
pathways to be effective and universally implemented staff
physicians in the primary care areas must not only be aware
of
them, but they must also emphasize their use. Initially
this will
require frequent reminding and some pressure to comply with
the
pathways. Department Chiefs must be aware of the pathways
and
emphasize their use. Each time that an asthmatic patient is
presented at morning report the pathways should be
mentioned.
The acute outpatient pathway (attachment # 1) should be
available
on paper at the time a patient is being treated for an
acute
exacerbation of asthma. The pathway can become a part of
the
clinic note for that visit.
Make the inpatient pathway ( attachment # 2) a part of the
CIS
notes in such a manner that it can be used to chart a
patients
course with prompts for medication doses, PEF monitoring,
and
discharge planning. At a minimum have the pathway available
on
CIS so that providers can refer to them when a patient is
admitted to an observation unit or the hospital.
Make the chronic asthma pathway (attachment # 3) readily
available in the clinic, and encourage providers to place a
copy
of this pathway in each asthmatic patients outpatient
record and
continuity file.
Have a reminder concerning the asthma clinical pathways
appear on
the CHCS screen when "controller" asthma medications
are
being
ordered.
Link the asthma pathways to the asthma referral guidelines.
All three asthma pathways should be listed on the MAMC
Intranet
as well as on the MAMC Internet site.
XII. REVISION FREQUENCY:
These pathways should be reviewed by the Clinical Standards
Committee
annually. However, major revisions should only be required
every 3-5 years.
Minor changes, especially in controller medications, may be
necessary each
year. The point of contact for this proposal, LTC Ted
Carter, should review
the asthma pathways with a group of pediatric and adult
asthma experts each
year, and ask them to suggest revisions. These revisions
will be
incorporated into revisions of the asthma clinical
pathways, which will
then be forwarded to the Clinical Standards Committee for
approval.
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------------------------------------------------------------------------
Brief Summary
TITLE:
Assessing response to bronchodilator therapy at point of
care
SOURCE(S):
Respir Care 1995 Dec;40(12):1300-7 [67 references]
ADAPTATION:
Not applicable: The guideline was not adapted from another
source.
RELEASE DATE:
1995 Dec
MAJOR RECOMMENDATIONS:
Description:
Assessment of airflow (i.e., forced expiratory maneuvers
and
other clinical indicators) is important to determine the
presence
or absence of an immediate response (ie, at time of
expected
onset of effect), proper dose, frequency of administration,
and
overall response to long-term therapy). It is essential
that the
clinician have complete knowledge of the main effects, mode
of
action, time course, side effects, and dosage constraints
of any
medications administered.
Setting:
Settings include:
* critical care;
* acute care;
* extended care or skilled care facility;
* outpatient clinic;
* home; and
* pulmonary rehabilitation program.
Indications:
Assessment of airflow and other clinical indicators are
indicated
when the need exists:
* to confirm the appropriateness of therapy;
* to individualize the patient's medication dose per
treatment
and/or frequency of administration;
* to help determine patient status during acute and
long-term
pharmacologic therapy;
* to determine a need for change in therapy (dose,
frequency,
or type of medication).
Limitations of Procedure or Device:
* Conventional spirometry:
1. cost and accessibility;
2. the patient's inability to perform forced vital
capacity.
* peak-flow measurement:
1. Patient's inability to perform peak-flow maneuver or
forced
expiration;
2. The accuracy and reproducibility of peak-flow meters may
vary among models and among units of the same model.
a. For consistency and reproducibility of results the same
device (unit) should be used for a given patient.
b. If peak-flow meter is changed, the patient's range
should be
re-established because of variability among units and
models.
c. Peak flow measurement primarily reflects changes in
upper
airway conductance and may be of limited use in evaluation
of changes in peripheral airway conductance.
d. Evaluation of peak flow performance is subjective and
therefore acceptability criteria are lacking. Because the
maneuver is effort and volume dependent, the patient must
be
encouraged to perform as vigorously as clinically feasible.
(Three trials are desirable, with the best reported.) Nose
clips are not necessary and the standard position is
preferred.
* The results of subjective evaluation may be difficult to
interpret consistently. A validated dyspnea rating scale
may
be useful including:
1. Breath sound interpretation; and
2. Symptoms (eg, dyspnea).
* The presence of an artificial airway increases resistance
and, thus, increases work of breathing in the spontaneously
breathing patient and may limit inspiratory and expiratory
flows.
* Techniques for monitoring response to bronchodilator in
intubated, mechanically ventilated patients are different
(eg, the flow-volume curve generated through an intubated
airway may be difficult to interpret). Accuracy and
reproducibility of results may be affected by the mental
and
physical condition of the patient. The measurement
technology and, therefore, the results may vary from
ventilator to ventilator.
Assessment of Need:
* Response to therapy should be evaluated in all patients
receiving bronchodilator therapy. (However, patient's in
severe distress may need immediate treatment that precludes
establishing a quantitative baseline).
* Assessment of response must be made with due regard for
the
patient's history, clinical presentation, and results of
physical exam.
Resources:
* Equipment and other aids
1. Instruments to measure expiratory flows: the choice of
devices is based on cost, availability, and portability.
When a portable laboratory spirometer that meets ATS
standards is available it should be used because results
yield more information than is available from peak-flow
measurement alone. Conventional spirometry with forced
expiratory maneuvers is the standard for diagnostic
measurement of bronchodilator response. Peak flow
measurement can be used for pre- and post-treatment
measurement and for daily and trend monitoring. Other
instruments include:
a. stethoscope;
b. pulse oximeter;
c. structured interview form for complete history;
validated
dyspnea indices;
d. materials for patient and family education and diary.
Personnel:
* Level II personnel-licensed or credentialed respiratory
care
practitioners (eg, RRT, RPFT, CPFT, CRTT) or persons with
equivalent knowledge, training, and ability, who have
documented that knowledge and demonstrated the necessary
skills: to perform initial assessments and care for the
unstable patient; to assess patient condition and response
to therapy; to identify the indications for and effects of
specific medication and equipment; to instruct patients in
proper breathing patterns and coughing techniques; to
modify
therapy and appropriately care for the patient in response
to adverse reactions; to modify dose, frequency, or
delivery
method or to change medication according to the patient's
response, within the constraints of the protocol or the
physician's direction; to use proper technique for
administration of aerosols; to perform, interpret, and
document conventional spirometry, peak expiratory flowrate,
and ventilatory mechanics and to perform and document
auscultation, inspection and assessment of vital signs, and
to teach proper use of symptom diary and peak-flow meter;
to
develop, teach, and assess self-care plan for patient and
family care giver; to properly use equipment, administer
treatment, and make assessment in compliance with Universal
Precautions and other infection-control procedures.
* Level I personnel-licensed or credentialed respiratory
care
practitioners (eg, RRT, RPFT, CPFT, CRTT) or persons with
equivalent knowledge, training, and ability, who have
documented that knowledge and demonstrated the necessary
skills: to observe, measure, monitor, and document response
variables established with the patient's care plan (eg, use
of diary and peak flow meter); to use proper technique for
administration of medication; to properly use and clean
equipment; to instruct patients in proper breathing
patterns
and coughing techniques; to modify therapy and patient care
(within the constraints of the protocol or physician's
directions) in response to changes in monitored variables,
severity of symptoms, or adverse reactions and to
communicate any modifications to Level-II provider or
physician; to properly use equipment, administer treatment,
and make assessment in compliance with Universal
Precautions
and other infection-control procedures.
* Patient or family/caregiver providing maintenance therapy
must know and demonstrate ability: to monitor or measure
response to bronchodilator in accordance with the patient's
care plan (use of symptom diary and peak-flow meter); to
use
proper technique for administration of medication and
correct use of devices (eg, MDI, spacer, peak-flow meter,
small volume nebulizer); to properly use and clean
equipment; to modify doses and frequency as prescribed and
instructed in response to adverse reactions or increase in
severity of symptoms and to appropriately communicate with
physician regarding severity of symptoms.
Monitoring:
Monitoring seeks to establish baseline function and reveal
the
presence or absence of a desirable response to
bronchodilator or
other airway medication and to identify changes in airway
reactivity in response to allergens, exercise, infection,
or
other causes. Desirable responses are:
* From observation of the patient
1. General appearance is improved.
2. Use of accessory muscles is decreased.
3. Sputum expectoration is increased.
* From auscultation
Breath sounds may be improved, with a decrease in wheezing
or
adventitious breath sounds and the volume of air moved is
increased. (Decreased wheezing, eg, the 'silent' chest
coupled
with decreased volume of air moved can be an indication of
a
worsening condition rather than improvement.)
* Vital signs are more nearly normal.
* Patient reports improvement(eg, less dyspneic)
* From pulmonary function measurement: It is important to
note
that although correlation is generally high between values
obtained by conventional spirometry and measurement of PEF,
agreement may be poor for individual patients.
1. FEVl, FVC, and/or FEF25-75% are improved. Note: The ATS
standards for a positive bronchodilator response in adults
is "12% increase, calculated from the prebronchodilator
response values,and a 200-mL increase in either FVC or
FEV1." Dynamic compression of the airways during forced
maneuvers may mask bronchodilator response in some
patients,
and for these patients the additional measurement of airway
resistance and calculation of specific conductance may
provide more diagnostic evidence.
2. PEF is increased. Note: National Asthma Education and
Prevention (NAEPP) Guidelines provide detailed directions
for use of the PEF in the asthmatic population.
* SaO2 (or SpO2),(2) and/or arterial blood gas values are
improved (Effects of underlying chronic respiratory,
metabolic, or other condition should be considered.)
* Exercise performance is improved as reflected by a more
normal PEF during exercise or immediately following or an
increase in distance achieved during the 6-minute walking
test.
* Ventilator variables are improved.
1. Lower PIP (during volume ventilation)
2. Lower plateau pressure, increased static lung
compliance.
3. Decreased inspiratory and expiratory resistance
4. Increased expiratory flow, improved flow-volume loop
5. Decreased auto-PEEP
Frequency:
* Acute-unstable patients:
1. Whenever possible, perform a full assessment and obtain
a
pretreatment baseline.
2. Perform arterial blood gas analysis on admission if
patient
is in severe distress.
3. Assess and document all appropriate variables before and
after each treatment, (breath sounds, vital signs, side
effects during therapy, PEF or FEVl.
4. The frequency with which physical exam, PEF, and/or FEV1
are
repeated should be based on the acuteness and severity of
the patient's condition.
5. SpO2 should be monitored continuously, if possible.
6. Assessment should continue at each level of medication
dose
to optimal response for patient (eg, asthmatic patient
achieves 70-90% of predicted or "personal best" or is
symptom free)
* Stable patients:
1. In the hospital setting, the PEF should be measured
initially before and after each bronchodilator
administration--to establish baseline function and to
determine relative changes in function. Thereafter, twice
daily determinations may be adequate.
2. In the home, use the PEF 3-4 times a day (on rising,
noon,
4-7 pm, and at bedtime) to establish baseline function and
to determine relative changes in function.
a. For the stable COPD patient at home, twice a day
measurements may be adequate.
b. Asthmatic patients in the home will need to adjust the
frequency of peak flow measurement according to their level
of severity, with the development of symptoms, or with any
deviation from baseline. Twice daily measurements (about 7
am and 7 pm) are recommended for routine
monitoring--(variability between these two measurements is
a
measure of severity.)
c. The pre- and postbronchodilator PEFRs, medication
dosage,
date and time, and the dyspnea score should be documented.
d. The patient should be periodically re-evaluated for
response
to therapy.
Infection Control:
* Universal Precautions and precautions related to the
spread
of tuberculosis as published by the Centers for Disease
Control should be followed.
* (B) All equipment and supplies should be appropriately
disposed of or subjected to high-level disinfection between
patients.
CLINICAL ALGORITHM(S):
None provided
DEVELOPER(S):
American Association for Respiratory Care (AARC) -
Professional
Association
COMMITTEE:
Aerosol Therapy Focus Group
GROUP COMPOSITION:
Names of Committee Members: Jon O. Nilsestuen, PhD, RRT,
Chairman; James Fink, MS, RRT; Theodore Witek Jr, DrPH,
RPFT,
RRT; James Volpe III, RRT, MEd
ENDORSER(S):
Not stated
GUIDELINE STATUS:
This is the current release of the guideline.
An update is not in progress at this time.
GUIDELINE AVAILABILITY:
Electronic copies: Available from the American Association
for
Respiratory Care (AARC) Web site
http://www.rcjournal.com/online_resources/cpgs/arbdcpg.html
Print copies: Available from AARC, CPG Desk, 11030 Ables
Ln,
Dallas, TX 75229-4593
COMPANION DOCUMENTS:
The following is available:
The AARC Clinical Practice Guidelines. Respir Care
1991;36(12):1398-1401.
Print copies: Available from AARC, CPG Desk, 11030 Ables
Ln,
Dallas, TX 75229-4593.
PATIENT RESOURCES:
Not stated
NGC STATUS:
This summary was completed by ECRI on November 30, 1998.
The
information was verified by the guideline developer on
December
15, 1998.
COPYRIGHT STATEMENT:
Interested persons may copy the guidelines for
noncommercial
purposes of scientific or educational advancement. Please
credit
The American Association for Respiratory Care (AARC) and
Respiratory Care Journal.
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{6} CANCER PAIN - 22 Feb 2000 (PRIVATE) 569 Lines
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------------------------------------------------------------------------
Brief Summary
TITLE:
Practice guidelines for cancer pain management.
SOURCE(S):
Anesthesiology 1996 May;84(5):1243-57 [0 references]
ADAPTATION:
Not applicable: Guideline was not adapted from another
source.
RELEASE DATE:
1996
MAJOR RECOMMENDATIONS:
I. Comprehensive Evaluation and Assessment of the Patient
with
Cancer Pain
Recommendations:
1. General Constructs. The Task Force identifies four
fundamental features that should guide the
comprehensive evaluation of the patient with cancer
pain.
a. The patient's general medical condition and the
extent of disease must be assessed.
b. A knowledge of common pain syndromes is a
prerequisite for conducting a cancer pain
evaluation. Common pain syndromes include but are
not limited to bone metastases, abdominal
(visceral) pain, neuropathic pain (e.g.,
peripheral neuropathies, acute herpes zoster and
postherpetic neuralgia, plexopathies), and
mucositis.
c. A knowledge of oncologic emergencies (e.g.,
hypercalcemia, spinal cord compression, cardiac
tamponade, superior vena cava syndrome) is also
required to conduct a comprehensive cancer pain
evaluation.
d. A thorough knowledge of the modalities that can be
employed in the treatment of painful crisis (i.e.,
pain emergency) is also necessary.
2. Elements. The Task Force identifies six essential
features of a comprehensive evaluation and treatment
plan. These features are:
a. History: medical, oncologic, and pain
b. Psychosocial evaluation
c. Physical examination
d. Impression and differential diagnosis
e. Diagnostic evaluation
f. Treatment plan
II. Longitudinal Monitoring of Pain
Recommendations: The Task Force identifies three
fundamental
concepts in the longitudinal monitoring of pain.
1. Patient Self-Report. Reports of pain made by the
patient should be the primary source of pain assessment
and should take precedence, whenever possible, over
inferences and observations made by others. Continuous
assessment over time (e.g., pain diaries) is
appropriate for outpatients. For some age groups and
populations (e.g., the cognitively or developmentally
impaired), external observation may be preferable.
Age-appropriate instruments should be used in children.
2. Rating Scale. The longitudinal monitoring of pain
intensity should be based on rating scales that are
easy to use and interpret. Typical examples of rating
scales include discrete numeric scales (e.g., 0-10),
categorical scales (none, mild, moderate, severe, worst
possible), and continuous visual analog scales of pain
or pain relief.
3. Frequency of Pain Ratings. Self-report should be
obtained at regular intervals. Increased frequency and
evaluation of self-reports may be indicated: (1) at the
onset of new pain, (2) when established pain exhibits
changes in pattern and/or intensity, or (3) when a
major therapeutic intervention is performed.
III. Involvement of Specialists from Multiple Disciplines
Recommendations: Anesthesiologists who engage in cancer
pain
management should avail themselves of interdisciplinary
expertise in their clinical environments. It is important
to
note that the patient's primary physician must be a part of
the coordination of pain management. The Task Force
recognizes that full interdisciplinary coordination of
cancer pain treatment is not feasible in every clinical
setting.
IV. Paradigm for the Management of Cancer Pain
A. Indirect Delivery Systems: Systemic Analgesia
Recommendations:
1. General Recommendations. Oral medications should
be used as the first line approach in most
patients when initiating analgesic therapy.
Because it is not effective in all patients and
may not be optimal therapy in painful crisis
(i.e., the pain emergency), the indications,
risks, and potential benefits of alternative
interventions must be understood and assessed.
Any proposed systemic regimen must be
individualized for the patient, and inflexible
reliance should not be placed on any "standard"
mixture of medications and/or dosing regimens. For
patients with moderate or severe pain, opioid
therapy is recommended. Once an opioid and a route
of administration are chosen, the dose should be
increased until a favorable response occurs or
when unmanageable or intolerable adverse effects
ensue. There is no predetermined maximum dose of
an opioid. Dose titration may be required
periodically because of the natural history of the
primary disease or the development of tolerance.
When pain is continuous or occurs frequently,
medication generally should be administered
around-the-clock with additional "rescue" doses
available for breakthrough pain. The practitioner
should be aware of the potential adverse sequelae
of opioids and their appropriate treatment.
When considering changing opioids or routes of
administration, dose adjustments should be made to
correct for differences in potency. Apparent
differences in potency among opioids are the
result of physicochemical and pharmacokinetic
differences rather than pharmacodynamic
distinctions. When tolerance to a particular
opioid develops, another opioid may be substituted
at approximately 50-75% of the equianalgesic dose,
because cross-tolerance is incomplete. The size of
the reduction should be based on the severity of
pain, the presence of adverse effects, and the
medical status of the patient. Based on clinical
observation, a switch to methadone should be done
with a reduction of 75% of the equianalgesic dose.
Adjuvant agents should be used as coanalgesics
(e.g., corticosteroids, antidepressants) or to
treat adverse drug effects. These agents may be
added at any stage.
2. Specific Recommendations.
a. Oral medications: Oral medications such as
acetaminophen, acetylsalicylic acid or other
nonsteroidal antiinflammatory drugs (NSAIDs)
should be employed first for mild to moderate
pain. (Note: the simultaneous use of more
than one NSAID or the concomitant use of an
NSAID with a glucocorticoid is not
recommended because the risk of toxicity is
increased, and additional analgesia is not
achieved.) If pain is not relieved or
increases or if moderate pain is present at
presentation, an opioid conventionally used
for moderate pain (e.g., codeine,
dihydrocodeine, oxycodone (compounded with a
coanalgesic), or hydrocodone) should be used,
usually combined with a nonopioid analgesic.
When increasing opioid dose, an increment of
25-50% is usually the minimum required to
observe effect. If pain is not relieved,
increases, or is severe at presentation, an
opioid conventionally used for severe pain
(e.g., morphine, hydromorphone, methadone,
oxycodone (not compounded with a
coanalgesic), fentanyl, or levorphanol)
should be selected. (Note: Besides
consideration of a change in opioid, an
increase in pain intensity should prompt a
reevaluation of the cause of pain.) When
analgesia with acceptable adverse effects is
no longer attained with the oral route of
administration or when oral administration is
no longer viable (inability to swallow and/or
absorb medication), an alternate systemic
route of administration should be chosen.
(Note: The enteral route should be used in
patients with percutaneous feeding tubes and
inability to swallow, as long as absorption
still occurs.) If dose-limiting toxicity
precludes effective therapy, a trial of a
different opioid, a reduction of adverse
effects by optimization of adjuvants,
neuraxial drug delivery, or neuroablative
therapy should be considered.
b. Rectal and transdermal: Use of an alternative
route of administration, specifically rectal
or transdermal, should be chosen before use
of invasive therapies. Rectal administration
usually is considered when oral therapy is
temporarily unavailable (e.g., nausea and
vomiting refractory to therapy), although
long-term use is effective in some patients.
Transdermal fentanyl should be used in
patients with stable pain states who are (1)
noncompliant with oral medication, (2) unable
to swallow or absorb, or (3) may benefit from
a trial of fentanyl.
c. Subcutaneous and intravenous administration:
The subcutaneous route of administration
should be used in (1) patients unable to
swallow or absorb opioids who may benefit
from a continuous infusion of opioid and (2)
similar patients with dynamic pain states
requiring frequent "rescue" doses for
breakthrough pain. Subcutaneous
administration of opioids may be used in the
home setting. The recommendations for
intravenous administration are the same as
for subcutaneous administration. Intravenous
administration may be preferred when the
patient has permanent venous access. (Note:
Intramuscular injection is not recommended as
either short- or long-term therapy for cancer
pain management because of the attendant
discomfort, variable blood concentrations,
and fluctuating levels of analgesia.)
B. Direct Delivery Systems: Neuraxial Drug Delivery and
Neuroablation
Recommendations:
1. General Recommendations. When adequate analgesia
cannot be achieved or intolerable side effects
occur with indirect methods of drug delivery,
direct drug delivery systems should be considered.
In certain specific circumstances, neuraxial drug
delivery or neuroablative therapies should be
considered at the initiation of therapy or early
in the natural history of the pain (see below).
Neuraxial drug delivery and neuroablative
therapies should not be used: (1) in individuals
who are unmotivated or noncompliant or do not
possess the cognitive functioning necessary to
understand the risks and benefits and (2) when an
appropriate logistical system does not exist.
Patients must have access to a logistical system
that provides the resources and availability of
personnel to respond to patient needs on an
around-the-clock basis. The establishment of an
office or network with professional support may be
necessary. For long-term therapies, appropriate
home care must be available and functionally
integrated into the office, hospital, and
community.
2. Specific Recommendations.
a. Neuraxial drug delivery: Neuraxial drug delivery
should be used: (1) when severe pain cannot be
controlled with systemic drugs because of
dose-limiting toxicity, (2) when there is
immediate need for local anesthetic (some
neuropathic pains), (3) after failed
neuroablation, or (4) patient preference indicates
its use. The choice between epidural or
subarachnoid catheterization is determined in part
by patient life expectancy. When extended life
expectancy is anticipated, subarachnoid catheter
placement should be considered because epidural
catheters may become obstructed. The presence of
epidural metastases necessitates subarachnoid
catheterization. Before insertion of an indwelling
neuraxial drug delivery system, efficacy and
appropriate dose range should be ascertained by
trial injection or use of a temporary delivery
system. Patients should have access to "rescue"
doses for breakthrough pain. "Rescue" doses may be
given by any route of administration as deemed
appropriate by the practitioner. Intraventricular
administration of opioids may be considered in
patients with head and neck cancer and Ommaya
reservoirs. (Note: Neural blockade should be used
before neuraxial drug delivery because of (1) the
presence of pain therapeutically amenable to
neural blockade (e.g., myofascial pain,
sympathetically-maintained pain, pain of acute
herpes zoster); or (2) patient preference, when
appropriate.)
b. Neuroablation: Neuroablative techniques should be
initiated (1) when systemic therapies have failed
to provide adequate pain control or when adverse
side effects from systemic therapies are
unacceptable; (2) after failure of neuraxial drug
administration; (3) early in the natural history
of the cancer pain in the presence of selected
focal somatic lesions (e.g., rib metastases),
visceral (e.g., cancer of the pancreas), or
neuropathic (e.g., craniofacial) pain that is
believed to be highly responsive to neuroablation
with limited risk; or (4) patient preference
indicates use of neuroablative techniques, if
appropriate. Except for the aforementioned
specific indications, chemical, radiofrequency
(thermal), and surgical neuroablation should be
deferred until anticipated life expectancy is
short-term, thereby minimizing the potential for
deafferentation pain. On the other hand,
consideration of life expectancy is moot with
cryoanalgesia because of the potential for nerve
regeneration associated with the technique. The
cryoanalgesic procedure often must be repeated
because the endoneurium is spared, allowing
regrowth over time. After performance of
successful chemical, thermal, or surgical
neurolysis, opioid administration should not be
immediately curtailed to avoid precipitation of
withdrawal. Dosage should be immediately reduced,
and opioids should be weaned to avoid respiratory
depression, which may occur in the setting of
abrupt pain relief. Neural blockade should be used
prognostically to determine the possible efficacy
of neuroablation. However, even with proper needle
placement under fluoroscopic guidance, successful
neural blockade does not ensure the subsequent
success of a neurodestructive procedure. Neural
blockade should be performed at the time of
potential neuroablation and should not be
performed as a separate procedure. If analgesia is
not achieved with neural blockade or significant
adverse sequelae result, neuroablation should be
reconsidered. Definitive neuroablation should be
performed with the aid of imaging techniques when
feasible or with direct visualization of the
intended neural target in the case of open
surgical ablation.
V. Management of Cancer-related Symptoms and Adverse
Effects of
Pain Therapy
Recommendations:
1. General Recommendations. Adverse effects should be
promptly identified and assessed, and appropriate
remedies should be offered. Opioids should not be
withheld from cancer patients for fear of producing
respiratory depression, tolerance, physical dependence,
or addiction.
2. Specific Recommendations.
a. Constipation: All patients with an increased risk
for constipation should receive prophylaxis.
Prophylactic or symptomatic therapy should involve
the use of bulk agents, osmotic laxatives (e.g.,
magnesium or sodium salts, lactulose or sorbitol),
and/or stimulant cathartics (e.g., senna or
bisacodyl). A stool softener may be concomitantly
used with the aforementioned agents. Occasionally,
patients require enemas.
b. Sedation: Sedation should be treated by (1)
eliminating contributory factors such as
nonessential drugs and metabolic disturbances, (2)
reducing the dose of an opioid by 25-50% if
analgesia is satisfactory, (3) lowering the
requirement for opioids by the addition of a
nonopioid analgesic or adjuvant analgesic, (4)
switching to another opioid, (5) the use of
psychostimulants, or (6) considering more invasive
modalities if sedation is refractory to therapy.
c. Nausea and vomiting: Persistent nausea is rare,
and prophylactic therapy is not indicated.
Transitory nausea and vomiting should be treated
initially with standard antiemetics, such as
promethazine, prochlorperazine, haloperidol,
metoclopramide, or hydroxyzine. In some cases,
ondansetron or meclizine can be helpful. Some
patients may benefit from the use of low-dose
corticosteroid, alternative treatment for
gastroparesis (i.e., cisapride), or a
benzodiazepine (i.e., lorazepam). Treatment of
factors contributing to nausea (e.g.,
constipation) should be considered when
appropriate.
d. Mental clouding: The treatment of cognitive
impairment should mirror the management of
sedation. The addition of low-dose haloperidol
occasionally may be necessary for confusional
states induced by opioids. Psychostimulants can be
administered to reverse mental clouding in the
absence of sedation but should not be administered
to agitated patients.
e. Myoclonus: Myoclonus is not usually a clinical
problem, and reassurance should be given to
patients regarding its benign nature. However, if
myoclonus impairs function, prevents sleep, or
increases pain, clonazepam or valproate should be
administered. A reduction in opioid dose or a
switch to a different opioid should be considered
in the face of refractory or severe myoclonus.
f. Pruritus: Pruritus is rarely a problem with
chronic opioid administration, and consideration
should be given to an initial trial of
diphenhydramine if it occurs.
g. Urinary retention: Urinary retention is also rare
with chronic opioid administration and should be
treated by administration of a direct
cholinomimetic agent, such as bethanecol.
h. Respiratory depression: The least amount of
naloxone should be administered to preserve
analgesia and avoid withdrawal. Because of the
short half-life of naloxone, a continuous infusion
may be necessary.
VI. Recognition, Assessment, and Management of Psychosocial
Factors
Recommendations: A psychosocial assessment should be
conducted initially as an integral part of the
comprehensive
pain evaluation. Results of the psychosocial assessment
should be considered when formulating a pain treatment
plan.
Pain diaries and counseling should be considered to enhance
medication compliance, if needed. The anesthesiologist
should recognize that pharmacologic and neurolytic
techniques may not be fully effective in controlling pain
and that relaxation training, hypnosis, biofeedback, and
behavior therapy are important adjuncts. The
anesthesiologist should collaborate with psychologists and
other health professionals when psychosocial interventions
are indicated. The anesthesiologist should recognize that
psychosocial manifestations related to cancer (but not to
cancer pain) may require referral to appropriate mental
health professionals.
VII. Home Parenteral Therapy
Recommendations: Before changing from the oral route of
administration, the anesthesiologist should ascertain the
availability of family and professional support systems.
The
patient and family must be educated in the use of the home
therapy system. The anesthesiologist should determine
whether the patient and/or significant others are motivated
and competent to care for sophisticated delivery systems.
An
assessment must be made as to whether appropriate
professional services and supplies are obtainable in
specific locales, because special planning may be required
in rural areas. Communication among the patient, the home
health-care professional, and the prescribing physician
must
be maintained at all times.
VIII. End-of-Life Care
Recommendations: The management of cancer pain must be
integrated into a comprehensive care system that may
include
hospice and psychosocial support for patients and their
families. Assessing and monitoring a patient's palliative
care needs are essential parts of the
evaluative/therapeutic
process. When cancer patients are approaching the end of
life, the anesthesiologist should integrate pain management
with palliative care needs. Collaboration with palliative
care providers is recommended to maximize patient comfort
and improve patient and family quality of life.
IX. Recognition and Management of Special Features of
Pediatric
Cancer Pain Management
Recommendations: The anesthesiologist should give special
attention to the assessment of pain in pediatric patients.
For children unable to communicate verbally, observation of
patient behavior should be the primary assessment tool. For
children who can communicate verbally, age-appropriate pain
scales are the recommended self-report instruments when
evaluating the efficacy of pain therapy. Observation should
be used as an adjunct to self-report.
Administration of oral medications to children should
follow
the schema of the WHO analgesic ladder, with particular
attention paid to age-appropriate dosing regimens. Liquids
or suspensions should be employed whenever possible,
because
many children find them more palatable than pills. (Note:
Continuous-release morphine preparations cannot be crushed
and still maintain their continuous release properties.)
Every attempt should be made to minimize repetitive
exposure
to needles, if possible. Patient-controlled analgesia
(intravenous or subcutaneous) is a viable alternative when
children are of sufficient cognitive age. Invasive systemic
therapies and direct delivery systems should be used when
oral and noninvasive analgesic deliveries do not achieve
sufficient analgesia, or side effects make their continued
use untenable. Psychological and other nonpharmacologic
methods of pain management should be considered as
adjuvants.
CLINICAL ALGORITHM(S):
An algorithm is provided for comprehensive evaluation and
longitudinal assessment of cancer pain.
DEVELOPER(S):
American Society of Anesthesiologists (ASA) - Medical
Specialty
Society
COMMITTEE:
Task Force on Pain Management, Cancer Pain Section
GROUP COMPOSITION:
Names of Task Force Members: F. Michael Ferrante, M.D.,
F.A.B.P.M. (Chair); Marshall Bedder, M.D., F.R.C.P.(C.);
Robert
A. Caplan, M.D.; Hui-Ming Chang, M.D.; Richard T. Connis,
Ph.D.
(Methodologist); Patricia Harrison, M.D.; Robert N.
Jamison,
Ph.D; Elliot J. Krane, M.D.; Srdjan Nedeljkovic, M.D.;
Richard
Patt, M.D. and Russell K. Portenoy, M.D.
ENDORSER(S):
Not stated
GUIDELINE STATUS:
This is the current release of the guideline.
An update is not in progress at this time.
GUIDELINE AVAILABILITY:
Electronic copies: Available from the American Society for
Anesthesiologists (ASA) Web site
Print copies: Available from ASA, 520 North Northwest Hwy,
Park
Ridge, IL 60068-2573.
COMPANION DOCUMENTS:
The following is available:
Arens JF. A practice parameters overview. Anesthesiology.
1993
Feb;78(2):229-30
PATIENT RESOURCES:
Not stated
NGC STATUS:
This summary was completed by ECRI on February 20, 1999.
The
information was verified by the guideline developer on
April 23,
1999.
COPYRIGHT STATEMENT:
This NGC summary is based on the original guideline that is
copyrighted by the American Society of Anesthesiologists.
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Brief Summary
TITLE:
Management of patients with valvular heart disease.
SOURCE(S):
J Am Coll Cardiol 1998 Nov;32(5):1486-588 [737 references]
ADAPTATION:
Not applicable: Guideline was not adapted from another
source.
RELEASE DATE:
1998 Nov 1
MAJOR RECOMMENDATIONS:
The ACC/AHA classification (Class I-III) of indications for
diagnostic and therapeutic procedures for management of
patients
with valvular heart disease is given at the end of this
Major
Recommendations field.
Recommendations for Echocardiography in Asymptomatic
Patients
with Cardiac Murmurs
Indication Class
1 Diastolic or continuous murmurs. I
2 Holosystolic or late systolic murmurs. I
3 Grade 3 or midsystolic murmurs. I
4 Murmurs associated with abnormal physical findings on IIa
cardiac palpation or auscultation.
5 Murmurs associated with an abnormal ECG or chest x-ray.
IIa
6 Grade 2 or softer midsystolic murmur identified as
innocent III
or functional by an experienced observer.
7 To detect "silent" AR or MR in patients without
cardiac
III
murmurs, then recommend endocarditis prophylaxis.
Recommendations for Echocardiography in Symptomatic
Patients with
Cardiac Murmurs
Indication Class
1 Symptoms or signs of congestive heart failure, myocardial
I
ischemia, or syncope.
2 Symptoms or signs consistent with infective endocarditis
or I
thromboembolism.
3 Symptoms or signs likely due to noncardiac disease with
IIa
cardiac disease not excluded by standard cardiovascular
evaluation.
4 Symptoms or signs of noncardiac disease with an isolated
III
midsystolic "innocent" murmur.
Recommendations for Endocarditis Prophylaxis
Indication Class
High-Risk Category I
* Prosthetic heart valves, including bioprosthetic
homograft
and allograft valves.
* Previous bacterial endocarditis.
* Complex cyanotic congenital heart disease, (eg, single
ventricle states, transposition of the great arteries,
tetralogy of Fallot).
* Surgically constructed systemic-pulmonary shunts or
conduits.
Moderate-Risk Category I
* Most other congenital cardiac malformations (other than
above or below).
* Acquired valvular dysfunction (eg, rheumatic heart
disease).
* Hypertrophic cardiomyopathy.*
* MVP with auscultatory evidence of valvular regurgitation
and/ or thickened leaflets.**
Low- or Negligible-Risk Category III
* Isolated secundum atrial septal defect.
* Surgical repair of atrial septal defect, ventricular
septal defect, or patent ductus arteriosus (without
residua >6 mo).
* Previous coronary artery bypass graft surgery.
* MVP without valvular regurgitation.**
* Physiological, functional, or innocent heart murmurs.***
* Previous Kawasaki disease without valvular dysfunction.
* Cardiac pacemakers and implanted defibrillators.
Adapted from Dajani et al. with permission.
*This committee recommends prophylaxis in hypertrophic
cardiomyopathy
only when there is latent or resting obstruction.
**Patients with MVP without regurgitation require
additional clinical
judgment. Indications for antibiotic prophylaxis in MVP are
discussed
below and in section III.D.2. of the guideline document.
Patients who
do not have MR but do have echocardiographic evidence of
thickening
and/or redundancy of the valve leaflets and especially men
> 2 45 years
may be at increased risk for bacterial endocarditis.
Additionally,
approximately one third of patients with MVP without MR at
rest may
have exercise-induced MR. Some patients may exhibit MR at
rest on 1
occasion and not on others. There are no data available to
address this
latter issue, and at present, the decision must be left to
clinical
judgment, taking into account the nature of the invasive
procedure, the
previous history of endocarditis, and the presence or
absence of valve
thickening and/or redundancy.
***In patients with echocardiographic evidence of
physiological MR in
the absence of a murmur and with structurally normal
valves,
prophylaxis is not recommended. The committee also does NOT
recommend
prophylaxis for physiological tricuspid and pulmonary
regurgitation
detected by Doppler in the absence of a murmur, as such
findings occur
in a large number of normal individuals and the risk of
endocarditis is
extremely low. Recommendations regarding Doppler
echocardiography for
purposes of antibiotic prophylaxis in patients who have
received
anorectic drugs are given below and in section III.H. of
the guideline
document.
Recommendations for Echocardiography in Aortic Stenosis
Indication Class
1 Diagnosis and assessment of severity of AS. I
2 Assessment of LV size, function, and/or hemodynamics. I
3 Reevaluation of patients with known AS with changing
symptoms I
or signs.
4 Assessment of changes in hemodynamic severity and
ventricular I
function in patients with known AS during pregnancy.
5 Reevaluation of asymptomatic patients with severe AS. I
6 Reevaluation of asymptomatic patients with mild to
moderate AS IIa
and evidence of LV dysfunction or hypertrophy.
7 Routine reevaluation of asymptomatic adult patients with
mild III
AS having stable physical signs and normal LV size and
function.
From the ACC/AHA Guidelines for the Clinical Application of
Echocardiography.
Recommendations for Cardiac Catheterization in Aortic
Stenosis
Indication Class
1 Coronary angiography before AVR in patients at risk for
CAD I
(see below and section VIII.B. of the guideline document).
2 Assessment of severity of AS in symptomatic patients when
AVR I
is planned or when noninvasive tests are inconclusive or
there
is a discrepancy with clinical findings regarding severity
of
AS or need for surgery.
3 Assessment of severity of AS before AVR when noninvasive
tests IIb
are adequate and concordant with clinical findings and
coronary angiography is not needed.
4 Assessment of LV function and severity of AS in
asymptomatic III
patients when noninvasive tests are adequate.
Recommendations for Aortic Valve Replacement in Aortic
Stenosis
Indication Class
1 Symptomatic patients with severe AS. I
2 Patients with severe AS undergoing coronary artery bypass
I
surgery.
3 Patients with severe AS undergoing surgery on the aorta
or I
other heart valves.
4 Patients with moderate AS undergoing coronary artery
bypass IIa
surgery or surgery on the aorta or other heart valves (see
below and sections III.F.6., III.F.7., and VIII.D. of the
guideline document).
5 Asymptomatic patients with severe AS and
* LV systolic dysfunction IIa
* Abnormal response to exercise (eg, hypotension) IIa
* Ventricular tachycardia IIb
* Marked or excessive LV hypertrophy ( > 2 15 mm) Ilb
* Valve area <0.6 cm 2 IIb
6 Prevention of sudden death in asymptomatic patients with
III
none of the findings listed under indication 5.
Recommendations for Aortic Balloon Valvotomy in Adults with
Aortic Stenosis*
Indication Class
1 A "bridge" to surgery in hemodynamically unstable
patients IIa
who are at high risk for AVR.
2 Palliation in patients with serious comorbid conditions.
IIb
3 Patients who require urgent noncardiac surgery. IIb
4 An alternative to AVR. III
*Recommendations for aortic balloon valvotomy in
adolescents and young
adults with AS are provided below and in section VI.A. of
the guideline
document.
Recommendations for Echocardiography in Aortic
Regurgitation
Indication Class
1 Confirm presence and severity of acute AR. I
2 Diagnosis of chronic AR in patients with equivocal
physical I
findings.
3 Assessment of etiology of regurgitation (including valve
I
morphology and aortic root size and morphology).
4 Assessment of LV hypertrophy, dimension (or volume), and
I
systolic function.
5 Semiquantitative estimate of severity of AR. I
6 Reevaluation of patients with mild, moderate, or severe I
regurgitation with new or changing symptoms.
7 Reevaluation of LV size and function in asymptomatic I
patients with severe regurgitation (recommended timing of
reevaluation is given in Figure 2).
8 Reevaluation of asymptomatic patients with mild,
moderate, I
or severe regurgitation and enlarged aortic root.
9 Yearly reevaluation of asymptomatic patients with mild to
III
moderate regurgitation with stable physical signs and
normal
or near-normal LV chamber size.
Recommendations for Exercise Testing in Chronic
Regurgitation*
Indication Class
1 Assessment of functional capacity and symptomatic
responses I
in patients with a history of equivocal symptoms.
2 Evaluation of symptoms and functional capacity before IIa
participation in athletic activities.
3 Prognostic assessment before AVR in patients with LV IIa
dysfunction.
4 Exercise hemodynamic measurements to determine the effect
of IIb
AR on LV function.
5 Exercise radionuclide angiography for assessing LV
function IIb
in asymptomatic or symptomatic patients.
6 Exercise echocardiography or dobutamine stress III
echocardiography for assessing LV function in asymptomatic
or symptomatic patients.
*These recommendations differ from the ACC/AHA Guidelines
for Exercise
Testing. The committee believes that indications 1, 2, and
3 above
warrant a higher recommendation than IIb.
Recommendations for Radionuclide Angiography in Aortic
Regurgitation
Indication Class
1 Initial and serial assessment of LV volume and function
at I
rest in patients with suboptimal echocardiograms or
equivocal echocardiographic data.*
2 Serial assessment of LV volume and function at rest when
I
serial echocardiograms are not used.*
3 Assessment of LV volume and function in asymptomatic I
patients with moderate to severe regurgitation when
echocardiographic evidence of declining LV function is
suggestive but not definitive.*
4 Confirmation of subnormal LV ejection fraction before I
recommending surgery in an asymptomatic patient with
borderline echocardiographic evidence of LV dysfunction.*
5 Assessment of LV volume and function in patients with I
moderate to severe regurgitation when clinical assessment
and echocardiographic data are discordant.*
6 Routine assessment of exercise ejection fraction. IIb
7 Quantification of AR in patients with unsatisfactory IIb
echocardiograms
8 Quantification of AR in patients with satisfactory III
echocardiograms.
9 Initial and serial assessment of LV volume and function
at III
rest in addition to echocardiography.
*In centers with expertise in cardiac magnetic resonance
imaging (MRI),
cardiac MRI may be used in place of radionuclide
angiography for these
indications.
Recommendations for Vasodilator Therapy for Chronic Aortic
Regurgitation
Indication Class
1 Chronic therapy in patients with severe regurgitation who
I
have symptoms and/or LV dysfunction when surgery is not
recommended because of additional cardiac or noncardiac
factors.
2 Long-term therapy in asymptomatic patients with severe I
regurgitation who have LV dilatation but normal systolic
function.
3 Long-term therapy in asymptomatic patients with
hypertension I
and any degree of regurgitation.
4 Long-term ACE inhibitor therapy in patients with
persistent I
LV systolic dysfunction after AVR.
5 Short-term therapy to improve the hemodynamic profile of
I
patients with severe heart failure symptoms and severe LV
dysfunction before proceeding with AVR.
6 Long-term therapy in asymptomatic patients with mild to
III
moderate AR and normal LV systolic function.
7 Long-term therapy in asymptomatic patients with LV
systolic III
dysfunction who are otherwise candidates for valve
replacement.
8 Long-term therapy in symptomatic patients with either
normal III
LV function or mild to moderate LV systolic dysfunction who
are otherwise candidates for valve replacement.
Recommendations for Cardiac Catheterization in Chronic
Aortic
Regurgitation
Indication Class
1 Coronary angiography before AVR in patients at risk for
CAD I
(see below and section VIII.B. of the guideline document).
2 Assessing severity of regurgitation when noninvasive
tests I
are inconclusive or discordant with clinical findings
regarding severity of regurgitation or need for surgery.
3 Assessing LV function when noninvasive tests are I
inconclusive or discordant with clinical findings regarding
LV dysfunction and need for surgery in patients with severe
AR.
4 Assessment of LV function and severity of regurgitation
IIb
before AVR when noninvasive tests are adequate and
concordant with clinical findings and coronary angiography
is not needed.
5 Assessment of LV function and severity of regurgitation
in III
asymptomatic patients when noninvasive tests are adequate.
Recommendations for Aortic Valve Replacement in Chronic
Severe
Aortic Regurgitation
Indication Class
1 Patients with NYHA functional Class III or IV symptoms
and I
preserved LV systolic function, defined as normal ejection
fraction at rest (ejection fraction > 0.50).
2 Patients with NYHA functional class II symptoms and I
preserved LV systolic function (ejection fraction > 0.50 at
rest) but with progressive LV dilatation or declining
ejection fraction at rest on serial studies or declining
effort tolerance on exercise testing.
3 Patients with Canadian Heart Association functional Class
II I
or greater angina with or without CAD.
4 Asymptomatic or symptomatic patients with mild to
moderate I
LV dysfunction at rest (ejection fraction 0.25 to 0.49).
5 Patients undergoing coronary artery bypass surgery or I
surgery on the aorta or other heart valves.
6 Patients with NYHA functional Class II symptoms and LV
IIa
systolic function (ejection fraction > 0.50 at rest) with
stable LV size and systolic function on serial studies and
stable exercise tolerance.
7 Asymptomatic patients with normal LV systolic function
IIa
(ejection fraction >0.50) but with severe LV dilatation
diastolic dimension >75 mm or end-systolic dimension >55
mm).*
8 Patients with severe LV dysfunction (ejection fraction
IIb
<0.25).
9 Asymptomatic patients with normal systolic function at
rest IIb
(ejection fraction >0.50) and progressive LV dilatation
when
the degree of dilatation is moderately severe
(end-diastolic
dimension 70 to 75 mm, end-systolic dimension 50 to 55 mm).
10 Asymptomatic patients with normal systolic function at
rest
(ejection fraction >0.50) but with decline in ejection
fraction during
* Exercise radionuclide angiography IIb
* Stress echocardiography III
11 Asymptomatic patients with normal systolic function at
rest III
(ejection fraction >0.50) and LV dilatation when degree of
dilatation is not severe (end-diastolic dimension <70 mm,
end-systolic dimension <50 mm).
*Consider lower threshold values for patients of small
stature of either
gender. Clinical judgment is required.
Recommendations for Echocardiography in Mitral Stenosis
Indication Class
1 Diagnosis of MS, assessment of hemodynamic severity (mean
I
gradient, mitral valve area, pulmonary artery pressure),
and
assessment of right ventricular size and function.
2 Assessment of valve morphology to determine suitability
for I
percutaneous mitral balloon valvotomy.
3 Diagnosis and assessment of concomitant valvular lesions.
I
4 Reevaluation of patients with known MS with changing I
symptoms or signs.
5 Assessment of hemodynamic response of mean gradient and
IIa
pulmonary artery pressures by exercise Doppler
echocardiography in patients when there is a discrepancy
between resting hemodynamics and clinical findings.
6 Reevaluation of asymptomatic patients with moderate to
IIb
severe MS to assess pulmonary artery pressure.
7 Routine reevaluation of the asymptomatic patient with
mild III
MS and stable clinical findings.
Recommendations for Transesophageal Echocardiography in
Mitral
Stenosis
Indication Class
1 Assess for presence or absence of left atrial thrombus in
IIa
patients being considered for percutaneous mitral balloon
valvotomy or cardioversion.
2 Evaluate mitral valve morphology and hemodynamics when
IIa
transthoracic echocardiography provides suboptimal data.
3 Routine evaluation of mitral valve morphology and III
hemodynamics when complete transthoracic echocardiographic
data are satisfactory.
Recommendations for Anticoagulation in Mitral Stenosis
Indication Class
1 Patients with atrial fibrillation, paroxysmal or chronic.
I
2 Patients with a prior embolic event. I
3 Patients with severe MS and left atrial dimension > 55 mm
by IIb
echocardiography.*
4 All other patients with MS. III
*Based on grade C recommendation given this indication by
American
College of Chest Physicians Fourth Consensus Conference on
Antithrombotic Therapy. The Working Group of the European
Society of
Cardiology recommended a lower threshold of left atrial
dimension (>50
mm) for recommending anticoagulation.
Recommendations for Cardiac Catheterization in Mitral
Stenosis
Indication Class
1 Perform percutaneous mitral balloon valvotomy in properly
I
selected patients.
2 Assess severity of MR in patients being considered for
IIa
percutaneous mitral balloon valvotomy when clinical and
echocardiographic data are discordant.
3 Assess pulmonary artery, left atrial, and LV diastolic
IIa
pressures when symptoms and/or estimated pulmonary artery
pressure are discordant with the severity of MS by 2-D and
Doppler echocardiography.
4 Assess hemodynamic response of pulmonary artery and left
IIa
atrial pressures to stress when clinical symptoms and
resting hemodynamics are discordant.
5 Assess mitral valve hemodynamics when 2-D and Doppler III
echocardiographic data are concordant with clinical
findings.
Recommendations for Percutaneous Mitral Balloon Valvotomy
Indication Class
1 Symptomatic patients (NYHA functional Class II, III, or
IV), I
moderate or severe MS (mitral valve area < 1.5 cm2 ),* and
valve morphology favorable for percutaneous balloon
valvotomy in the absence of left atrial thrombus or
moderate
to severe MR.
2 Asymptomatic patients with moderate or severe MS (mitral
IIa
valve area < 1.5 cm2 )* and valve morphology favorable for
percutaneous balloon valvotomy who have pulmonary
hypertension (pulmonary artery systolic pressure >50 mm Hg
at rest or 60 mm Hg with exercise) in the absence of left
atrial thrombus or moderate to severe MR.
3 Patients with NYHA functional Class III-IV symptoms, IIa
moderate or severe MS (mitral valve area < 1.5 cm2 ),* and
a
nonpliable calcified valve who are at high risk for surgery
in the absence of left atrial thrombus or moderate to
severe
MR.
4 Asymptomatic patients, moderate or severe MS (mitral
valve IIb
area < 1.5 cm2)* and valve morphology favorable for
percutaneous balloon valvotomy who have new onset of atrial
fibrillation in the absence of left atrial thrombus or
moderate to severe MR.
5 Patients in NYHA functional Class III-IV, moderate or
severe IIb
MS (MVA < 1.5 cm2), and a nonpliable calcified valve who
are
low-risk candidates for surgery.
6 Patients with mild MS. III
*The committee recognizes that there may be variability in
the
measurement of mitral valve area and that the mean
transmitral gradient,
pulmonary artery wedge pressure, and pulmonary artery
pressure at rest
or during exercise should also be taken into consideration.
Recommendations for Mitral Valve Repair for Mitral Stenosis
Indication Class
1 Patients with NYHA functional Class III-IV symptoms, I
moderate or severe MS (mitral valve area < 1.5 cm2),* and
valve morphology favorable for repair if percutaneous
mitral
balloon valvotomy is not available.
2 Patients with NYHA functional Class III-IV symptoms, I
moderate or severe MS (mitral valve area < 1.5 cm2),* and
valve morphology favorable for repair if a left atrial
thrombus is present despite anticoagulation.
3 Patients with NYHA functional Class III-IV symptoms, I
moderate or severe MS (mitral valve area < 1.5 cm2),* and a
nonpliable or calcified valve with the decision to proceed
with either repair or replacement made at the time of the
operation.
4 Patients in NYHA functional Class I, moderate or severe
MS IIb
(mitral valve area < 1.5 cm2),* and valve morphology
favorable for repair who have had recurrent episodes of
embolic events on adequate anticoagulation.
5 Patients with NYHA functional Class I-IV symptoms and
mild III
MS.
*The committee recognizes that there may be a variability
in the
measurement of mitral valve area and that the mean
transmitral gradient,
pulmonary artery wedge pressure, and pulmonary artery
pressure at rest
or during exercise should also be considered.
Recommendations for Mitral Valve Replacement for Mitral
Stenosis
Indication Class
1 Patients with moderate or severe MS (mitral valve area <
1.5 I
cm2)* and NYHA functional Class III-IV symptoms who are not
considered candidates for percutaneous balloon valvotomy or
mitral valve repair.
2 Patients with severe MS (mitral valve area < 1 cm2)* and
IIa
severe pulmonary hypertension (pulmonary artery systolic
pressure >60 to 80 mm Hg) with NYHA functional Class I-II
symptoms who are not considered candidates for percutaneous
balloon valvotomy or mitral valve repair.
*The committee recognizes that there may be a variability
in the
measurement of mitral valve area and that the mean
transmitral gradient,
pulmonary artery wedge pressure, and pulmonary artery
pressure should
also be considered.
Recommendations for Echocardiography in Mitral Valve
Prolapse*
Indication Class
1 Diagnosis, assessment of hemodynamic severity of MR,
leaflet I
morphology, and ventricular compensation in patients with
physical signs of MVP.
2 To exclude MVP in patients who have been given the
diagnosis I
when there is no clinical evidence to support the
diagnosis.
3 To exclude MVP in patients with first-degree relatives
with IIa
known myxomatous valve disease.
4 Risk stratification in patients with physical signs of
MVP IIa
or known MVP.
5 To exclude MVP in patients in the absence of physical III
findings suggestive of MVP or a positive family history.
6 Routine repetition of echocardiography in patients with
MVP III
with mild or no regurgitation and no changes in clinical
signs or symptoms.
*From the ACC/AHA Guidelines for the Clinical Application
of
Echocardiography.
Recommendations for Antibiotic Endocarditis Prophylaxis for
Patients with Mitral Valve Prolapse Undergoing Procedures
Associated with Bacteremia*
Indication Class
1 Patients with characteristic systolic click-murmur
complex. I
2 Patients with isolated systolic click and
echocardiographic I
evidence of MVP and MR.
3 Patients with isolated systolic click, echocardiographic
IIa
evidence of high-risk MVP.
4 Patients with isolated systolic click and equivocal or no
III
evidence of MVP.
*These procedures are listed in Tables 4 and 5, in the
guideline
document.
Recommendations for Aspirin and Oral Anticoagulants in
Mitral
Prolapse
Indication Class
1 Aspirin therapy for cerebral transient ischemic attacks.
I
2 Warfarin therapy for patients aged > 2 65 years, in
atrial I
fibrillation with hypertension, MR murmur, or history of
heart failure.
3 Aspirin therapy for patients aged <65 years in atrial I
fibrillation with no history of MR, hypertension, or heart
failure.
4 Warfarin therapy for poststroke patients. I
5 Warfarin therapy for transient ischemic attacks despite
IIa
aspirin therapy.
6 Aspirin therapy for poststroke patients with IIa
contraindications to anticoagulants.
7 Aspirin therapy for patients in sinus rhythm with IIb
echocardiographic evidence of high-risk MVP.
Recommendations for Transthoracic Echocardiography in
Mitral
Regurgitation
Indication Class
1 For baseline evaluation to quantify severity of MR and LV
I
function in any patient suspected of having MR.
2 For delineation of mechanism of MR. I
3 For annual or semiannual surveillance of LV function I
(estimated by ejection fraction and end-systolic dimension)
in asymptomatic severe MR.
4 To establish cardiac status after a change in symptoms. I
5 For evaluation after MVR or mitral valve repair to
establish I
baseline status.
6 Routine follow-up evaluation of mild MR with normal LV
size III
and systolic function.
Recommendations for Transesophageal Echocardiography in
Mitral
Regurgitation
Indication Class
1 Intraoperative transesophageal echocardiography to
establish I
the anatomic basis for MR and to guide repair.
2 For evaluation of MR patients in whom transthoracic I
echocardiography provides nondiagnostic images regarding
severity of MR, mechanism of MR, and/or status of LV
function.
3 In routine follow-up or surveillance of patients with
native III
valve MR.
Recommendations for Coronary Angiography in Mitral
Regurgitation
Indication Class
1 When mitral valve surgery is contemplated in patients
with I
angina or previous myocardial infarction.
2 When mitral valve surgery is contemplated in patients
with > I
2 1 risk factor for CAD (see section VIII.B. of these
guidelines).
3 When ischemia is suspected as an etiologic factor in MR.
I
4 To confirm noninvasive tests in patients not suspected of
IIb
having CAD.
5 When mitral valve surgery is contemplated in patients
aged III
<35 years and there is no clinical suspicion of CAD.
Recommendations for Left Ventriculography and Hemodynamic
Measurements in Mitral Regurgitation
Indication Class
1 When noninvasive tests are inconclusive regarding
severity I
of MR, LV function, or the need for surgery.
2 When there is a discrepancy between clinical and
noninvasive I
findings regarding severity of MR.
3 In patients in whom valve surgery is not contemplated.
III
Recommendations for Mitral Valve Surgery in Nonischemic
Severe
Mitral Regurgitation
Indication Class
1 Acute symptomatic MR in which repair is likely. I
2 Patients with NYHA functional Class II, III, or IV
symptoms I
with normal LV function defined as ejection fraction >0.60
end-systolic dimension <45 mm.
3 Symptomatic or asymptomatic patients with mild LV I
dysfunction, ejection fraction 0.50 to 0.60, and
end-systolic dimension 45 to 50 mm.
4 Symptomatic or asymptomatic patients with moderate LV I
dysfunction, ejection fraction 0.30 to 0.50, and/or
end-systolic dimension 50 to 55 mm.
5 Asymptomatic patients with preserved LV function and
atrial IIa
fibrillation.
6 Asymptomatic patients with preserved LV function and IIa
pulmonary hypertension (pulmonary artery systolic pressure
>50 mm Hg at rest or >60 mm Hg with exercise).
7 Asymptomatic patients with ejection fraction 0.50 to 0.60
IIa
and end-systolic dimension <45 mm and asymptomatic patients
with ejection fraction >0.60 and end-systolic dimension 45
to 55 mm.
8 Patients with severe LV dysfunction (ejection fraction
<0.30 IIa
and/or end-systolic dimension >55 mm) in whom chordal
preservation is highly likely.
9 Asymptomatic patients with chronic MR with preserved LV
IIb
function in whom mitral valve repair is highly likely.
10 Patients with MVP and preserved LV function who have IIb
recurrent ventricular arrhythmias despite medical therapy.
11 Asymptomatic patients with preserved LV function in whom
III
significant doubt about the feasibility of repair exists.
Recommendations for Surgery for Tricuspid Regurgitation
Indication Class
1 Annuloplasty for severe TR and pulmonary hypertension in
I
patients with mitral valve disease requiring mitral valve
surgery.
2 Valve replacement for severe TR secondary to IIa
diseased/abnormal tricuspid valve leaflets not amenable to
annuloplasty or repair.
3 Valve replacement or annuloplasty for severe TR with mean
IIa
pulmonary artery pressure <60 mm Hg when symptomatic.
4 Annuloplasty for mild TR in patients with pulmonary IIb
hypertension secondary to mitral valve disease requiring
mitral valve surgery
5 Valve replacement or annuloplasty for TR with pulmonary
III
artery systolic pressure <60 mm Hg in the presence of a
normal mitral valve, in asymptomatic patients, or in
symptomatic patients who have not received a trial of
diuretic therapy.
Recommendations for Patients Who Have Used Anorectic Drugs*
Indication Class
1 Discontinuation of the anorectic drug(s). I
2 Cardiac physical examination. I
3 Echocardiography in patients with symptoms, heart
murmurs, I
or associated physical findings.
4 Doppler echocardiography in patients for whom cardiac I
auscultation cannot be performed adequately because of body
habitus.
5 Repeat physical examination in 6 to 8 months for those
IIa
without murmurs.
6 Echocardiography in all patients before dental procedures
in IIb
the absence of symptoms, heart murmurs, or associated
physical findings.
7 Echocardiography in all patients without heart murmurs.
III
*Fenfluramine or dexfenfluramine or the combination of
fenfluramine-phentermine or dexfenfluramine-phentermine.
Recommendations for Echocardiography in Infective
Endocarditis:
Native Valves
Indication Class
1 Detection and characterization of valvular lesions, their
I
hemodynamic severity, and/or ventricular compensation.*
2 Detection of vegetations and characterization of lesions
in I
patients with congenital heart disease in whom infective
endocarditis is suspected.
3 Detection of associated abnormalities (eg, abscesses, I
shunts).*
4 Reevaluation studies in complex endocarditis (eg,
virulent I
organism, severe hemodynamic lesion, aortic valve
involvement, persistent fever or bacteremia, clinical
change, or symptomatic deterioration).
5 Evaluation of patients with high clinical suspicion of I
culture-negative endocarditis.*
6 Evaluation of bacteremia without a known source.* IIa
7 Risk stratification in established endocarditis.* IIa
8 Routine reevaluation in uncomplicated endocarditis during
IIb
antibiotic therapy.
9 Evaluation of fever and nonpathological murmur without
III
evidence of bacteremia.
*Transesophageal echocardiography may provide incremental
value in
addition to information obtained by transthoracic imaging.
From the
ACC/AHA Guidelines for the Clinical Application of
Echocardiography.
Recommendations for Echocardiography in Infective
Endocarditis:
Prosthetic Valves
Indication Class
1 Detection and characterization of valvular lesions, their
I
hemodynamic severity, and/or ventricular compensation.*
2 Detection of associated abnormalities (eg, abscesses, I
shunts).*
3 Reevaluation in complex endocarditis (eg, virulent
organism, I
severe hemodynamic lesion, aortic valve involvement,
persistent fever or bacteremia, clinical change, or
symptomatic deterioration).
4 Evaluation of suspected endocarditis and negative
cultures.* I
5 Evaluation of bacteremia without a known source.* I
6 Evaluation of persistent fever without evidence of IIa
bacteremia or new murmur.*
7 Routine reevaluation in uncomplicated endocarditis during
IIb
antibiotic therapy.*
8 Evaluation of transient fever without evidence of
bacteremia III
or new murmur.
*Transesophageal echocardiography may provide incremental
value in
addition to that obtained by transthoracic imaging. From
the ACC/AHA
Guidelines for the Clinical Application of
Echocardiography.
Recommendations for Surgery for Native Valve Endocarditis*
Indication Class
1 Acute AR or MR with heart failure. I
2 Acute AR with tachycardia and early closure of the mitral
I
valve.
3 Fungal endocarditis. I
4 Evidence of annular or aortic abscess, sinus or aortic
true I
or false aneurysm.
5 Evidence of valve dysfunction and persistent infection
after I
a prolonged period (7 to 10 days) of appropriate antibiotic
therapy, as indicated by presence of fever, leukocytosis,
and bacteremia, provided there are no noncardiac causes for
infection.
6 Recurrent emboli after appropriate antibiotic therapy.
IIa
7 Infection with gram-negative organisms or organisms with
a IIa
poor response to antibiotics in patients with evidence of
valve dysfunction.
8 Mobile vegetations >10 mm. IIb
9 Early infections of the mitral valve that can likely be
III
repaired.
10 Persistent pyrexia and leukocytosis with negative blood
III
cultures.
*Criteria also apply to repaired mitral and aortic
allograft or
autograft valves. Endocarditis defined by clinical criteria
with or
without laboratory verification; there must be evidence
that function of
a cardiac valve is impaired.
Recommendations for Surgery for Prosthetic Valve
Endocarditis*
Indication Class
1 Early prosthetic valve endocarditis (first 2 months or
less I
after surgery).
2 Heart failure with prosthetic valve dysfunction. I
3 Fungal endocarditis. I
4 Staphylococcal endocarditis not responding to antibiotic
I
therapy.
5 Evidence of paravalvular leak, annular or aortic abscess,
I
sinus or aortic true or false aneurysm, fistula formation,
or new-onset conduction disturbances.
6 Infection with gram-negative organisms or organisms with
a I
poor response to antibiotics.
7 Persistent bacteremia after a prolonged course (7 to 10
IIa
days) of appropriate antibiotic therapy without noncardiac
causes for bacteremia.
8 Recurrent peripheral embolus despite therapy. IIa
9 Vegetation of any size on or near the prosthesis. IIb
*Criteria exclude repaired mitral valves or aortic
allograft or
autograft valves. Endocarditis is defined by clinical
criteria with or
without laboratory verification.
Recommendations for Anticoagulation During Pregnancy in
Patients
with Mechanical Prosthetic Valves: Weeks 1 Through 35
Indication Class
1 The decision whether to use heparin during the first I
trimester or to continue oral anticoagulation throughout
pregnancy should be made after full discussion with the
patient and her partner; if she chooses to change to
heparin
for the first trimester, she should be made aware that
heparin is less safe for her, with a higher risk of both
thrombosis and bleeding, and that any risk to the mother
also jeopardizes the baby.*
2 High-risk women (a history of thromboembolism or an older
I
generation mechanical prosthesis in the mitral position)
who
choose not to take warfarin during the first trimester
should receive continuous unfractionated heparin
intravenously in a dose to prolong the midinterval (6 hours
after dosing) aPTT to 2 to 3 times control. Transition to
warfarin can occur thereafter.
3 In patients receiving warfarin, INR should be maintained
IIa
between 2.0 and 3.0 with the lowest possible dose of
warfarin, and low-dose aspirin should be added.
4 Women at low risk (no history of thromboembolism, newer
IIb
low-profile prosthesis) may be managed with adjusted-dose
subcutaneous heparin (17,500 to 20,000 U BID) to prolong
the
mid-interval (6 hours after dosing) aPTT to 2 to 3 times
control.
*From the European Society of Cardiology Guidelines for
Prevention of
Thromboembolic Events in Valvular Heart Disease.
Recommendations for Anticoagulation During Pregnancy in
Patients
With Mechanical Prosthetic Valves: After the 36th Week
Indication Class
1 Warfarin should be stopped no later than week 36 and
heparin IIa
substituted in anticipation of labor.
2 If labor begins during treatment with warfarin, a
caesarian IIa
section should be performed.
3 In the absence of significant bleeding, heparin can be
IIa
resumed4 to 6 hours after delivery and warfarin begun
orally.
Recommendations for Diagnostic Evaluation of the Adolescent
or
Young Adult with Aortic Stenosis*
Indication Class
1 ECG.* I
2 Echo-Doppler study.* I
3 Graded exercise test.** IIa
4 Cardiac catheterization** for evaluation of gradient. IIa
5 Chest x-ray.* IIb
6 Coronary arteriography in the absence of history
suggestive III
of concomitant CAD.
*Yearly if echo-Doppler gradient >36 mm Hg (velocity < 3
m/s). Every 2
years if echo-Doppler gradient <36 mm Hg (peak velocity <3
m/s).
**If echo-Doppler gradient >36 mm Hg (velocity >3 m/s) and
patient
interested in athletic participation or if clinical
findings and
echo-Doppler are disparate.
Recommendations for Aortic Balloon Valvotomy in the
Adolescent or
Young Adult [21 years of age or younger]) With Normal
Cardiac
Output*
Indication Class
1 Symptoms of angina, syncope, and dyspnea on exertion,
with I
catheterization peak gradient > 50 mm Hg.**
2 Catheterization peak gradient >60 mm Hg. I
3 New-onset ischemic or repolarization changes on ECG at
rest I
or with exercise (ST depression, T-wave inversion over left
precordium) with gradient >50 mm Hg).**
4 Catheterization peak gradient >50 mm Hg if patient wants
to IIa
play competitive sports or desires to become pregnant.
5 Catheterization gradient <50 mm Hg without symptoms or
ECG III
changes.
*Adolescents and young adults almost invariably have normal
or increased
cardiac output. If cardiac index <2 L/min/m2 , lower
gradients should be
used.
**If gradient <50 mm Hg, other causes of symptoms should be
explored.
Recommendations for Aortic Valve Surgery (Replacement With
Mechanical Valve, Homograft, or Pulmonary Autograft) in the
Adolescent or Young Adult With Chronic Aortic Regurgitation
Indication Class
1 Onset of symptoms. I
2 Asymptomatic patients with LV systolic dysfunction
(ejection I
fraction <0.50) on serial studies 1 to 3 months apart.
3 Asymptomatic patients with progressive LV enlargement I
(end-diastolic dimension >4 SD above normal).
4 Moderate AS (gradient >40 mm Hg) (peak-to-peak gradient
at IIb
cardiac catheterization).
5 Onset of ischemic or repolarization abnormalities (ST IIb
depression, T-wave inversion) over left precordium at rest.
Recommendations for Mitral Valve Surgery in the Adolescent
or
Young Adult with Congenital Mitral Regurgitation with
Severe MR
Indication Class
1 NYHA functional Class III or IV symptoms. I
2 Asymptomatic patients with LV systolic dysfunction
(ejection I
fraction < 2 0.60).
3 NYHA functional Class II symptoms with preserved LV
systolic IIa
function if valve repair rather than replacement is likely.
4 Asymptomatic patients with preserved LV systolic function
in IIb
whom valve replacement is highly likely
Recommendations for Mitral Valve Surgery in the Adolescent
or
Young Adult with Congenital Mitral Stenosis
Indication Class
1 Symptomatic patients (NYHA functional Class III or IV)
and I
mean mitral valve gradient >10 mm Hg on Doppler
echocardiography.
2 Mildly symptomatic patients (NYHA functional Class II)
and IIa
mean mitral valve gradient >10 mm Hg on Doppler
echocardiographic study.
3 Systolic pulmonary artery pressure 50 to 60 mm Hg with a
IIa
mean mitral valve gradient ?10 mm Hg.
4 New-onset atrial fibrillation or multiple systemic emboli
IIb
while receiving adequate anticoagulation.
Recommendations for Diagnostic Evaluation* of Ebstein's
Anomaly
of the Tricuspid Valve in the Adolescent or Young Adult
Indication Class
1 ECG. I
2 Chest x-ray I
3 Echo-Doppler study. I
4 Pulse oximetry at rest and/or during exercise. IIa
5 Electrophysiological study if documented or suspected
atrial IIa
arrhythmia.
*Initial evaluation and every 1 to 3 years, depending upon
severity.
Recommendations for Surgery in the Adolescent or Young
Adult with
Ebstein's Anomaly with Severe Tricuspid Regurgitation
Indication Class
1 Congestive heart failure. I
2 Deteriorating exercise capacity (NYHA functional Class
III I
or IV).
3 Progressive cyanosis with arterial saturation <80% at
rest I
or with exercise.
4 Progressive cardiac enlargement with cardiothoracic ratio
IIa
>60%.
5 Systemic emboli despite adequate anticoagulation. IIa
6 NYHA functional Class II symptoms with valve probably IIa
reparable.
7 Atrial fibrillation. IIa
8 Deteriorating exercise tolerance (NYHA functional Class
II). IIa
9 Asymptomatic patients with increasing heart size. IIb
10 Asymptomatic patients with stable heart size. III
Recommendations for Initial Diagnostic Workup of Pulmonic
Stenosis
Severity of
Pulmonic
Stenosis
Indication Mild*
Moderate-Severe**
Class Class
1 ECG. I I
2 Echo-Doppler study (transthoracic). I I
3 Chest x-ray. IIa IIa
4 Diagnostic cardiac catheterization. III IIb***
*Right ventricular to pulmonary artery maximum
instantaneous gradient <30
mm
Hg by Doppler echocardiography.
**Right ventricular to pulmonary artery gradient >30 mm Hg
by Doppler
echocardiography.
***If catheterization gradient >50 mm Hg, balloon
valvuloplasty should be
performed (see recommendations for intervention).
Recommendations for Intervention in the Adolescent or Young
Adult
with Pulmonic Stenosis (Balloon Valvotomy or Surgery)
Indication Class
1 Patients with exertional dyspnea, angina, syncope, or I
presyncope.
2 Asymptomatic patients with normal cardiac output
(estimated
clinically or determined by catheterization).
* Asymptomatic patients with normal cardiac output I
(estimated clinically or determined by
catheterization).
* Right ventricular to pulmonary artery peak gradient IIa
40 to 49 mm Hg
* Right ventricular to pulmonary artery peak gradient IIb
30 to 39 mm Hg
* Right ventricular to pulmonary artery peak gradient III
<30 mm Hg
Recommendations for Follow-up Exams in Pulmonic Stenosis
Severity of
Pulmonic
Stenosis
Indication Mild* Class
Moderate** to
Severe
Class
1 ECG. I I
2 Echo Doppler. I I
3 Chest x-ray. IIb IIa
4 Catheterization (for evaluation of gradient). III III
* <29 mm Hg gradient; testing every 5 to 10 years.
** >30 mm Hg gradient; testing every 3 years consideration
should be
given to
balloon or surgical valvuloplasty).
Recommendations for Antithrombotic Therapy in Patients with
Prosthetic Heart Valves
Indication Class
1. First 3 months after valve Warfarin, INR 2.5 to 3.5 I
replacement:
2. < 3 months after valve
replacement:
A. Mechanical valve
AVR and no risk factor*
Bileaflet valve or Warfarin, INR 2 to 3 I
Medtronic Hall valve
Other disk valves or Warfarin, INR 2.5 to 3.5 I
Starr-Edwards valve
AVR + risk factor* Warfarin INR 2.5 to 3.5 I
MVR Warfarin INR 2.5 to 3.5 I
B. Bioprosthesis
AVR and no risk factor* Aspirin 80 to 100 mg/d I
AVR and risk factor* Warfarin, NR 2 to 3 I
MVR and no risk factor* Aspirin, 80 to 100 mg/d I
MVR and risk factor* Warfarin, NR 2.5 to 3.5 I
3. Addition of aspirin, 80 to 100 mg once daily if not on
IIa
aspirin.
4. Warfarin, INR 3.5 to 4.5 in high-risk patients when IIa
aspirin cannot be used.
5. Warfarin, INR 2.0 to 3.0 in patients with Starr-Edwards
IIb
AVR and no risk factor.
6. Mechanical valve, no warfarin therapy. III
7. Mechanical valve, aspirin therapy only. III
8. Bioprosthesis, no warfarin and no aspirin therapy. III
*Risk factors: Atrial fibrillation, LV dysfunction,
previous
thromboembolism, and hypercoagulable condition.
Recommendations for Follow-up Strategy of Patients With
Prosthetic Heart Valves
[PAGE]
@1323
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------------------------------------------------------------------------
Brief Summary
TITLE:
Practice parameter: carpal tunnel syndrome.
SOURCE(S):
Neurology 1993 Nov;43(11):2406-9 [27 references]
ADAPTATION:
Not applicable: Guideline was not adapted from another
source.
RELEASE DATE:
1992 (reviewed 1998)
MAJOR RECOMMENDATIONS:
These recommendations are options (definitions follow
recommendations), unless otherwise specified:
I. HISTORY
A. The likelihood of CTS increases with the number of
standard symptoms and provocative factors list below.
1. Dull, aching discomfort in the hand, forearm or
upper arm
2. Paresthesias in the hand
3. Weakness or clumsiness of the hand
4. Dry skin, swelling, or color changes in the hand
5. Occurrence of any of these symptoms in the median
distribution
B. Provocative factors
1. Sleep
2. Sustained hand and/or arm positions
3. Repetitive actions of the hand or wrist
C. Mitigating factors
1. Changes in hand posture
2. Shaking the hand
II. PHYSICAL EXAMINATION (standard)
A. May be normal
B. Symptoms elicited by tapping or direct pressure over
the median nerve at the wrist (Tinel's sign), or with
forced flexion or extension of the wrist (Phalen's
sign)
C. Sensory loss in the median nerve distribution
D. Weakness or atrophy in the thenar muscles
E. Dry skin on the digits I-III
III. DIFFERENTIAL DIAGNOSIS
A. Cervical radiculopathy (especially C-7)
B. Brachial plexopathy (especially upper trunk)
C. Proximal median neuropathy (especially at the pronator
teres muscle)
D. Peripheral neuropathy
E. Vascular or neurogenic thoracic outlet syndrome
F. Central disorders such as multiple sclerosis and
cerebral infaraction
IV. CONFIRMATORY STUDIES (guideline)
If the diagnosis is uncertain with only a few of the
clinical features present, confirmatory testing or a
therapeutic trial is needed, and may include:
A. Electromyography (EMG) and nerve conduction studies
(NCS), which can confirm a median neuropathy at the
wrist, but are not able to exclude the diagnosis of
CTS. EMG/NCS can help define the severity of damage.
B. Therapeutic trials with one of the non-invasive
treatment listed in Treatment section I.C.1.
V. FURTHER DIAGNOSTIC TESTING
A. Indications (guideline) for further testing include:
1. Exclusion or confirmation of associated disease
2. Exclusion or confirmation of alternative diagnoses
B. Contraindications - none
C. Imaging (radiography or magnetic) - local structural
disease
1. Wrist - for previous fractures, local deformity,
primary bone or joint disease, evidence of local
tumor
2. Cervical spine - for cervical radiculopathy
3. Chest - for brachial plexopathy or thoracic outlet
syndrome
D. Endocrine, hematologic or serologic test for pregnancy
or systemic disorders such as diabetes, hypothyroidism,
acromegaly and gout
E. Neuropathy evaluation - protein electrophoresis, tissue
biopsy for amyloid, spinal fluid examination,
assessment for connective tissue disorders
F. Electrophysiologic testing - EMG/NCS testing for
diffuse disorders
G. The benefits of the following diagnostic techniques
have yet to be fully established:
1. Carpal tunnel pressure measurements
2. Sensory quantitation, including vibrometry
3. MRI quantitation of the carpal tunnel
4. Ultrasound of the carpal tunnel
5. Current perception threshold
VI. DOCUMENT IN THE MEDICAL RECORD (standard):
A. Positive findings by history or physical examination
B. Justification for the studies performed
C. Each treatment given and its justification
TREATMENT
I. CLASSIC CTS
A. Indications (guideline) - treat if the symptoms
interfere with the patient's daily life
B. Contraindications (guideline) - underlying systemic
disease requires special considerations
C. Non-invasive treatment is tried first unless there is
progressing motor or severe sensory deficit or severe
electrodiagnostic abnormality.
1. Treatment may include:
a. wrist splints
b. modification of activities
c. removal of constrictions
d. non-steroidal, anti-inflammatory drugs, or
e. diuretic in patients with limb swelling.
2. Complications - none
3. Expected duration of care - some improvement in
two weeks, continuing for six months
4. Anticipated outcome - Return to full activity in
90% of patients with mild disease
5. Recommended setting - outpatient office
6. Qualifications - physician
D. Invasive treatment is indicated if non-invasive
treatments are not effective, or if there is
progressing motor deficit, severe deficit or severe
electrodiagnostic abnormality.
1. Steroid injection can be considered, if not tried
before and the findings are not severe.
a. Technique - local injection into carpal
tunnel.
b. Complications - local infection, tendon
rupture, increased median nerve deficit,
reflex sympathetic dystrophy
c. Expected duration of care - repeat injection
up to three time at 3-6 week intervals, if no
or only temporary benefit occurs
d. Anticipated outcome - complete relief
depending on severity
e. Recommended setting - outpatient office
f. Qualifications for performance - physician
with training in use of local injections.
2. Surgical therapy (guideline) should be considered
if non-surgical therapy fails to relieve pain or a
progressive motor or sensory deficit.
a. Technique -
* Open division of the transverse carpal
ligament and adjacent palmar aponeurosis
in conjunction with tenosynovectomy, if
there is proliferative synovitis
* Post operative elevation of hand, and
graduated exercise of hand and forearm
* Wrist splint in neutral or slight
extension position for 2-3 weeks
b. Complications - deep wound infection in 0.5%;
reflex sympathetic dystrophy in less than
0.5%
c. Duration of care - recovery over 6 months.
Return visits at 2-6 week intervals
d. Anticipated outcome - complete relief if
symptoms and signs are not severe
* Ambulatory surgery in a operating room
* Hospitalization for concurrent medical
or surgical problems requiring in
patient treatment
e. Recommended setting -
* Ambulatory surgery in an operating room
* Hospitalization for concurrent medical
and surgical problems requiring
inpatient treatment
f. Qualifications for performance - surgeon
trained or experienced in the surgical
therapy of carpal tunnel
II. OTHER FORMS OF CTS
A. CTS in the presence of systemic disease, large mass
lesions at the wrist, major bony deformity, or
injection requires treatment of primary disease first
(guideline).
B. Therapeutic options specifically for the CTS are
generally less successful and are associated with
greater risk.
C. Treatment - must be carefully selected
1. Non-invasive therapy has a lower risk of
complications.
2. Local injections are not indicated
3. Surgical release
a. Early, if a specific mass or bony compression
has been identified
b. May result in useful improvement even in the
presence of systemic disease
D. Documentation is required for all therapies (standard).
E. Complications - additional nerve damage with the
treatment is more likely in the presence of a
generalized neuropathy.
F. Duration of care (option) - up to 12 months
G. Anticipated outcome - partial relief
III. EVOLVING THERAPIES
A. Endoscopic release - inadequate experience with no
controlled studies
B. Concurrent Guyon canal release has not been shown to be
of benefit.
C. Ergonomic modifications in the workplace
IV. DOCUMENTATION of the justification for and specifics of
any
therapy must be provided (standard)
DEFINITIONS:
Standards: generally accepted principles for patient
management
which reflect a high degree of clinical certainty (i.e.
based on
Class I evidence, or, when circumstances preclude
randomized
clinical trials, overwhelming evidence from Class II
studies that
directly address the question at hand or from decision
analysis
that directly addresses all the issues).
Guidelines: recommendations for patient management which
may
identify a particular strategy or range of management
strategies
and which reflect moderate clinical certainty (i.e. based
on
Class II evidence that directly address the issue, decision
analysis that directly addresses the issue, or strong
consensus
of Class II evidence).
Practice options/advisories: other strategies for patient
management for which there is unclear clinical certainty
(i.e.
based on inconclusive or conflicting evidence of opinion).
CLINICAL ALGORITHM(S):
An algorithm is provided for diagnosis and treatment of
carpal
tunnel syndrome.
DEVELOPER(S):
American Academy of Neurology (AAN) - Medical Specialty
Society
COMMITTEE:
Quality Standards Subcommittee
GROUP COMPOSITION:
Names of Subcommittee: Paul H. Altrocchi, M.D.; Jasper R.
Daube,
M.D.; Benjamin M. Frishberg, M.D.; Michael K. Greenberg,
M.D.;
Douglas J. Lanska, M.D.; George Paulson, M.D.; Richard A.
Pearl,
M.D.; Jay H. Rosenberg, M.D.; Cathy A. Sila, M.D.; Leon A.
Weisberg, M.D.
ENDORSER(S):
Not stated
GUIDELINE STATUS:
This is the current release of the guideline.
This paper, provided to the Academy membership as an
educational
tool, will be subjected to periodic revision as new
information
becomes available.
The guideline developer considers this guideline to be
current.
An update is not in progress at this time.
GUIDELINE AVAILABILITY:
Electronic copies: A list of American Academy of Neurology
(AAN)
guidelines, along with a link to a Portable Document Format
(PDF)
file for this guideline, is available at the AAN Web site.
Print copies: Available from the AAN Member Services
Center,
(800) 879-1960, or from AAN, 1080 Montreal Avenue, St.
Paul, MN
55116.
COMPANION DOCUMENTS:
None available
PATIENT RESOURCES:
Not stated
NGC STATUS:
This NGC summary was completed by ECRI on December 1, 1998.
The
information was verified by the guideline developer as of
February 12, 1999.
COPYRIGHT STATEMENT:
This NGC summary is based on the original guideline, which
is
copyrighted by the American Academy of Neurology.
Return to top
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[Contact NGC] [Site Map]
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© 2000 National Guideline Clearinghouse
Date Modified: Monday, June 14, 1999
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{9} CATARACT - 22 Feb 2000 (PRIVATE) 377
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National
Guideline
Clearinghouse
[HOME] [NGC RESOURCES] [HELP] [WHAT'S NEW] [SITE
MAP] [CONTACT NGC] [ABOUT NGC]
Search NGC: Search Help Detailed Search
Browse NGC: Disease/Condition Treatment/Intervention
Organization
Options: Brief Summary Complete Summary
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------------------------------------------------------------------------
Brief Summary
TITLE:
Cataract in the adult eye.
SOURCE(S):
San Francisco (CA): AAO; 1996. 25 p [73 references]
ADAPTATION:
Not applicable: The guideline was not adapted from another
source.
RELEASE DATE:
1996 Sep
MAJOR RECOMMENDATIONS:
AAO Suggested Medical Review Criteria
The following items are suggested for possible medical
review
criteria for a patient undergoing cataract surgery.
* Cataract-impaired vision no longer meets the patient's
needs
or there is another indication for cataract removal.
* The patient understands that cataract extraction is
expected
to relieve or improve the reasons for undergoing cataract
surgery.
* A discussion with the patient of the relative benefits
and
risks of surgery and alternatives to treatment with the
patient.
* Informed consent for surgery.
The preoperative examination should contain the following
elements:
* Patient history (including patient's assessment of
functional status).
* Snellen acuity and refraction.
* Measurement of intraocular pressure.
* Assessment of pupillary function.
* External examination.
* Slit-lamp examination.
* Dilated examination of the fundus.
The postoperative examination should contain the following
elements:
* Assessment of visual function, e.g., Snellen acuity,
pinhole
testing, etc. (each visit).
* Measurement of intraocular pressure (each visit).
* Slit-lamp examination (each visit).
* Management plan (each visit).
* Patient's assessment of postoperative visual functional
status: a history is taken directly from the patient or a
questionnaire is utilized to elicit the patient's
assessment
of the impact of surgery on his or her vision, function and
activities.
A dilated exam of the fundus to include the peripheral
retina
should be performed at least once during the postoperative
period.
For a patient undergoing a Neodymium-Yttrium-Aluminum
Garnet
(Nd:YAG) laser capsulotomy, the following should be
documented:
* The functional impairment attributable to posterior
capsular
opacification.
* A discussion of the risks and benefits of the surgical
procedure with the patient.
* A discussion with the patient about the symptoms of
vitreous
detachment, retinal tears and retinal detachment, and the
need for immediate examination if they are noticed.
Specific recommendations (excerpted by NGC):
Diagnosis
Evaluation of Visual Impairment
The impact of cataract on patients' function can be
measured in
terms of Snellen visual acuity, contrast sensitivity, glare
disability, self-assessment of functional status or
difficulty
with vision. There is no single test that adequately
describes
the effect of cataract on a patient's visual status or
functional
ability. Likewise, no single test defines the threshold for
performing cataract surgery. The decision to perform
cataract
surgery should not be made on the basis of Snellen visual
acuity
alone, because Snellen visual acuity is only one factor
involved
in determining visual function.
Disease-specific instruments developed for cataract include
one
by Bernth-Peterson, the Visual Activities Questionnaire,
the
Activities of Daily Vision Scale (ADVS) and the VF-14.
These
instruments provide a standardized approach to assess the
patient's function, which can be analyzed and compared
across
time periods and populations. However, there is no gold
standard
at this time regarding functional impairment related to
vision.
The assessment of functional status is a pertinent part of
the
patient's history, and can be obtained by means of an
interview
or a questionnaire. Questionnaires are not intended to be
the
sole basis for determining the need for surgery and should
not be
used to set a threshold of surgery.
Physical Examination
The goals of the physical examination of a patient whose
chief
complaint might be related to a cataract are (1) to
diagnose or
confirm the presence of a cataract, (2) to confirm that the
cataract is a significant factor related to the visual
impairment
and symptoms described by the patient and (3) to exclude or
identify other ocular or systemic conditions that might
contribute to the patient's visual impairment or affect the
surgical plan or ultimate outcome.
The maximum interval between the preoperative ophthalmic
examination and the date of surgery is 3 months, in case
there
are significant changes in the patient's health or vision.
Patients should be educated to contact the ophthalmologist
if
they have a change in visual symptoms during the interval
between
the examination and surgery.
Management
Nonsurgical Management
Nonsurgical methods of management center on educating
patients,
providing reassurance about the cause of the visual
disability
and prescribing new glasses. In the developmental stage of
nuclear sclerosis, myopia is induced, and changing the
spectacle
lens prescription often improves vision. Use of strong
bifocals
and magnifying lenses often satisfies near-vision
requirements as
the cataract progresses, but does not serve as a substitute
for
cataract surgery in the majority of patients without
significantly influencing other subjective complaints
related to
cataract formation. Patients should understand the relative
benefits and costs of a trial of glasses compared with
surgical
management when deciding which option to choose. Special
consideration of the benefits and risks also needs to be
paid in
the case of a patient who is functionally monocular.
Surgical Management
Indications for Surgery
Primary indication: Cataract-impaired vision no longer
meets the
patient's needs
Other indications: When there is evidence of lens-induced
disease
(e.g., phakomorphic glaucoma, phakolytic glaucoma, etc.) or
when
it is necessary to visualize the fundus in an eye that has
the
potential for sight (the latter includes the diabetic
patient who
is at risk of visual loss from retinopathy or other special
investigations that demonstrate intraocular pathology, both
of
which require clear media for optimal management).
Contraindications to Surgery
Surgery for visually impairing cataract should not be
performed
under the following circumstances:
* The patient does not desire surgery.
* Glasses or visual aids provide satisfactory functional
vision.
* Surgery will not improve visual function.
* The patient's quality of life is not compromised.
* The patient is unable to undergo surgery because of
coexisting medical or ocular conditions.
* A legal consent cannot be obtained.
* The patient is unable to obtain adequate postoperative
care.
Preoperative Preparation
The ophthalmologist who is to perform the surgery has the
following responsibilities:
* To examine the patient preoperatively.
* To inform the patient about the risks, benefits and
expected
outcomes of surgery.
* To obtain an informed consent.
* To ensure that the criteria outlined in this document are
met prior to surgery.
* To ensure that keratometry and A-scan measurements have
been
performed if an IOL is to be implanted.
* To select the appropriate IOL power when IOL implantation
is
planned.
* To formulate a surgical plan (anesthesia, desired wound
placement and construction, desired refractive results and
expected postoperative refraction).
* To review the results of presurgical and diagnostic
evaluations with the patient or, in appropriate cases, with
another responsible adult acting for the patient.
Bilateral Cataract Surgery
Surgery should not be performed in both eyes at the same
time
because of the potential for bilateral visual loss.
However,
there may be rare circumstances under which bilateral
surgery may
be performed, but these should be critically considered.
Postoperative Care
The ophthalmologist performing the surgery is responsible
for the
care of the patient during the postoperative period, which
is the
interval from the end of surgery to the achievement of
stable
visual function. The ophthalmologist who performs the
surgery has
an ethical obligation to the patient that continues until
postoperative rehabilitation is complete. The operating
ophthalmologist should also provide those aspects of
postoperative eye care that are within the unique
competence of
the ophthalmologist. If such follow-up care is not
possible, the
operating ophthalmologist must make arrangements before
surgery
to refer the patient to another ophthalmologist for
postoperative
care, with the approval of both the patient and the other
ophthalmologist.
The ophthalmologist who performs the surgery has an
obligation to
educate and instruct the patient about appropriate signs
and
symptoms of possible complications, eye protection,
activities,
medications, required visits and details for access to
emergency
care. The ophthalmologist should also inform the patient of
the
patient's responsibility to follow advice and instructions
provided during the postoperative phase and to notify him
or her
promptly if problems occur.
Normal Follow-up
The frequency of postoperative examinations should be based
on
the goal of optimizing the outcome of surgery. High-risk
patients, including functionally monocular patients,
patients
with glaucoma or glaucoma suspects and patients who had
intraoperative complications, should be seen the day
following
surgery. A patient without signs or symptoms of possible
complications should visit his or her ophthalmologist with
the
following frequency:
First visit: Within 48 hours following surgery ( to
detect and treat early complications, such as wound
leak, hypotony or increased intraocular pressure).
Second visit: 4 to 7 days following surgery to detect
and treat infectious endophthalmitis which most
commonly occurs between 4 to 6 days after surgery.
[With the trend towards small-incision surgery, it has
been suggested that the timing of the second visit can
be extended to 14 days. Under these circumstances, the
ophthalmologist performing the surgery has the added
responsibility to ensure that (1) the patient is
educated about signs and symptoms related to
complications, particularly endophthalmitis; (2) a
reliable system of communicating with the patient is
established; and (3) the risks of complications
occurring during the period between visits is explained
to the patient and the patient understands the risks of
not being seen.]
In the absence of complications, the frequency and timing
of
additional visits depends largely on the size or
configuration of
the incision and when refraction, visual function and the
medical
condition of the eye are stabilized. A final refractive
visit
should be made to provide an accurate prescription for
spectacles
to allow for the patient's optimal visual function. More
frequent
postoperative visits may be indicated if unusual findings
and/or
complications occur, and the patient should have ready
access to
the ophthalmologist's office to ask questions or seek care.
Posterior Capsular Opacification and Neodymium Yttrium-
Aluminum-Garnet (Nd:YAG) Laser Capsulotomy
The indication for performing Nd:YAG laser capsulotomy is
vision
impaired by posterior capsular opacification that does not
meet
the patient's functional needs or when it is necessary to
visualize the fundus. The decision to perform surgery
should take
into account the patient's needs, preferences, benefits and
risks
of the laser surgery. Nd:YAG laser capsulotomy should not
be
performed prophylactically (i.e., when the capsule remains
clear)
or scheduled at the same time cataract surgery is
scheduled.
Follow-up visits after a Nd:YAG laser capsulotomy vary in
frequency, depending on the patient's condition,
pre-existing
comorbidities, etc. The intraocular pressure of patients
with
compromised optic nerve status should be monitored after
this
surgical procedure. A dilated ophthalmic exam should be
performed
within one year to visualize the capsule and to check for
possible retinal detachment. Patients with risk factors for
retinal detachment should be examined within one month
after
surgery (e.g., young high myopes and patients with longer
axial
length, pre-existing lattice degeneration, or a history of
retinal detachment in either eye). Most importantly,
patients
should be educated and instructed about the symptoms of
posterior
vitreous detachment, retinal tears and detachment, and the
need
for immediate examination if these symptoms are noticed.
CLINICAL ALGORITHM(S):
None provided
DEVELOPER(S):
American Academy of Ophthalmology - Medical Specialty
Society
COMMITTEE:
Anterior Segment Panel; Preferred Practice Patterns
Committee
GROUP COMPOSITION:
Names of Committee Members: Anterior Segment Panel Members:
Stephen A. Obstbaum, MD, David M. Dillman, MD, I. Howard
Fine,
MD, Thomas P. Kidwell, MD, Samuel Masket, MD, Oliver D.
Schein,
MD, Jack Singer, MD, Earl P. Steinberg, MD, MPP,
Consultant,
Maureen Maguire, PhD, Methodology Consultant, Virginia
Boyce,
Patient Representative.
Preferred Practice Patterns Committee Members: Arlo C.
Terry, MD,
Chair, J. Bronwyn Bateman, MD, Joseph Caprioli, MD, Sid
Mandelbaum, MD, Alice Y. Matoba, MD, Stephen A. Obstbaum,
MD,
Oliver D. Schein, MD, Charles P. Wilkinson, MD.
ENDORSER(S):
Not stated
GUIDELINE STATUS:
This guideline has been reviewed by its parent panel and is
considered to be current.
All Preferred Practice Patterns are reviewed by their
parent
panel annually or earlier if developments warrant.
An update is not in progress at this time.
GUIDELINE AVAILABILITY:
Print and CD-ROM copies: Available from the American
Academy of
Ophthalmology (AAO), P.O. Box 7424, San Francisco, CA
94120-7424.
COMPANION DOCUMENTS:
None available
PATIENT RESOURCES:
Not stated
NGC STATUS:
This summary was completed by ECRI on February 20, 1999.
The
information was verified by the guideline developer on
April 23,
1999.
COPYRIGHT STATEMENT:
This NGC summary is based on the original guideline, which
is
subject to the guideline developer's copyright
restrictions.
Information about the content, ordering, and copyright
permissions can be obtained by calling the American Academy
of
Ophthalmology at (415) 561-8500.
Return to top
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Date Modified: Thursday, June 03, 1999
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{43} CHOLESTEROL DRUGS (MAMC) - 22 Feb 2000 (PRIVATE) 338
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Department of Pharmacy
[Mamclogo.gif (11446 bytes)]
Hyperlipidemia Management Guidelines
(HMG CoA Reductase Inhibitor "Statin"
Prescribing Guidelines)
The following is the prescribing guidelines for HMG CoA
Reductase
Inhibitors for Madigan Army Medical Center (MAMC). A more
complete
guideline for the management of hyperlipidemia is currently
being
developed.
Effective 1 October 1999, cerivastatin (Baycol® ) and
simvastatin (Zocor® )
are the only HMG-CoA reductase inhibitors ("statins")
available at all
Department of Defense (DoD) pharmacies. Patient(s) that are
currently on
Lescol® (fluvastatin), Lipitor® (atorvastatin) and
Pravacol® (pravastatin)
need to be converted to one of the new formulary
medications.
Use of the recommended statin will provide the greatest
overall clinical
and economic value for your patient and the Military Health
System. Your
support in this conversion process is instrumental in
ensuring that our
patients continue to receive a rational, uniform, and value
based pharmacy
benefit. The projected cost avoidance (FY2000) for MAMC is
$381,767 and the
overall savings for the DoD is $22,404,700.
Drug/Dose Conversion Recommendations
Patients_receiving: Can be converted to:
Cost/Patient/Yr
Pravastatin
10mg Cerivastatin 0.2mg
$110
Pravastatin
20mg Cerivastatin 0.2mg-0.3mg
$110
Pravastatin
40mg Cerivastatin 0.3mg-0.4mg
$110
Atorvastatin
10mg Cerivastatin 0.4mg
$110
Atorvastatin
20mg Cerivastatin 0.8mg (2 x 0.4mg)
$220
Atorvastatin
40mg Simvastatin 80mg
$391
Atorvastatin
80mg Continue Atorvastatin 80mg*
$1,418
Fluvastatin
20mg Cerivastatin 0.2mg
$110
Fluvastatin
40mg Cerivastatin 0.2mg
$110
Fluvastatin
80mg Cerivastatin 0.3mg-0.4mg
$110
*Atorvastatin will be available through a non-formulary
drug request.
See important dosing, monitoring, and safety guidelines
before prescribing
statins.
Therapeutic substitution of statins will start at MAMC on 1
November 1999
as follows:
New Prescriptions and Refills (MTF Providers):
New prescriptions for pravastatin, fluvastatin, and
atorvastatin (lower
doses) will no longer be accepted. As approved by the P&T,
orders for any
of these agents will be switched to a 30 DAY supply of
either cerivastatin
or simvastatin at the Outpatient Pharmacy according to the
above dosage
conversion table. A patient information letter will be
provided to the
patient that will detail the switch and dosing conversion
and tell the
patient that a standard liver function test must be done
six weeks after
starting the new drug. The patient will make arrangements
with his/her
provider for a new prescription and laboratory test(s).
New Prescriptions (Civilian/Non-MTF Providers):
The patient will be given a patient informational letter
telling the
patient to contact his/her provider to write a prescription
for a formulary
statin.
Refills (Civilian/Non-MTF Providers):
The patient will be given a supply of the current statin
(not exceeding 3
months, with no refills) and an information letter which
states that the
patient must contact his/her non-MTF provider in order to
have a new
prescription written for one of the formulary statins.
Efficacy:
Data from the National Health and Nutrition Examination
Survey III (NHANES
III) suggest that approximately 65% of patients will meet
established
National Cholesterol Education Program (NCEP) goals with a
35% reduction in
LDL-C, mean reduction associated with cerivastatin 0.4mg
and 44% with
cerivastatin 0.8mg. Simvastatin should be reserved for
those patients
requiring greater than a 44% reduction in LDL-C, or those
patients who
failed to achieve their NCEP goal with cerivastatin 0.8mg.
There may be a
small subset of patients that require LDL-C reductions that
only
atorvastatin 40-80mg will achieve (less than 3% according
to DoD usage
data). In those few cases, the non-formulary request
process should be used
to acquire this non-contracted statin. All patients should
have an
established baseline lipid panel and a follow-up no sooner
than 4 week
intervals. Medication quantities should be limited until
optimal medication
and dose, are obtained in meeting LDL-C goal.
Safety:
In controlled clinical trails, both cerivastatin and
simvastatin have
demonstrated a side effect profile comparable to that of
placebo. However,
it is recommended that patients receive a liver function
test after 6 weeks
in order to assess for biochemical alterations in liver
enzymes (incidence
of less than 1% of patients). Also, as with all statins,
patients rarely
will experience myopathy. Patients on digoxin may see a
0.3ng/ml rise in
serum levels of digoxin when taking simvastatin
concurrently. Patients on
anticoagulants may see a potentiation of effect of the
anticoagulant when
taking simvastatin concurrently. Thus, doses of digoxin
and/or warfarin may
require adjustment when on simvastatin concurrently.
Background:
Coronary Heart Disease (CHD) is the leading cause of death
in men and women
in the United States. Although CHD risk in women lags
approximately 10
years behind that of men, the incidence of CHD in women
increases
progressively after menopause until ultimately as many
women as men die of
CHD. While gender is one differential risk factor in the
onset of CHD,
strong evidence exists that other risk factors contribute
to the prevalence
and incidence of CHD. (Table 1). These risk factors can be
present for many
years before a clinical condition of CHD develops. This
long lead time
presents an opportunity to modify the risk factors to avoid
or delay
morbidity and mortality. However a substantial investment
in disease state
management is required before the long-term benefits are
realized. Within
MAMC, the drug therapy of hyperlipidemia has cost
$1,218,492 for FY 99. HMG
CoA Reductase Inhibitors "statins" accounted for
$1,171,067
(FY 99).
Table 1. CHD Risk Factors other than LDL-C
Positive Risk Factors Negative Risk
Factors
Age. Male ³ 45 years of age
Female ³ 55 years of age or premature
menopause without High HDL level (>60mg/dl)*
estrogen replacement therapy
Family history of premature CHD. Any parent or
sibling with CHD younger than 55 years of age
if male and younger than 65 years of age if
female.
Cigarette smoking
Hypertension. Blood pressure ³ 140/90 mm Hg
Low HDL-C level (<35mg/dl). For every 1mg/dl
decrease in HDL-C, the risk of CHD is increased
by 2-3%
Diabetes mellitus
* If HDL-C is ³ 60mg/dl, subtract one risk factor.
Dietary modifications, weight control, and increased
physical activity are
essential first steps in the treatment of hyperlipidemia.
Based in the
National Cholesterol Education Program (NCEP) Expert Panel
on Detection,
Evaluation, and Treatment of High Blood Cholesterol in
Adults, dietary
therapy should be initiated at the LDL levels listed in
Table 2. The
overall reduction in LDL produced by diet is small, ranging
from 3% to 14%.
However, diet, exercise, and weight reduction reduce the
risk for CHD in
ways beyond lowering LDL levels. Weight reduction and
increased physical
activity increases HDL levels which may decrease CHD risk.
Additionally,
these interventions reduce triglycerides, blood pressure,
and the risk for
diabetes mellitus.
Table 2. NCEP Guidelines
Patient Stratification by LDL Level for LDL Level for
LDL Goal
Risk Category Initiation of Dietary Initiation of
Drug of Therapy
Therapy Therapy
With CHD Secondary prevention* >100mg/dL >130mg/dL
<100mg/dL
Without CHD and with 2 or more risk
factors >130mg/dL >160mg/dL
<130mg/dL
- Primary prevention +2 (high risk)
Without CHD and with fewer than 2
risk factors >160mg/dL >190mg/dL
<160mg/dL
- Primary prevention (low risk)**
* With CHD includes patients with existing CHD or other
atherosclerotic
disease such as cerebral vascular disease or peripheral
vascular disease.
In patients with LDLs of 100-129mg/dL, clinicians should
consider adding
drug therapy to dietary therapy.
** In very young men (<35 years) and premenopausal women
with LDLs of
190-219mg/dL, drug therapy should be delayed until LDL
>220mg/dL, unless
the patient has multiple risk factors, particularly
diabetes or a positive
family history of CHD.
The percent of LDL-C reduction and dosing equivalency
between HMG CoA
Reductase Inhibitors is addressed in table 3. The actual
percent of LDL-C
reduction and adverse side effect profile will vary between
patients .
Table 3. HMG CoA Reductase Inhibitor "Statin"
Prescribing
Guidelines
LDLC (mg/dl) HMG-CoA Reductase
Inhibitors
LDL-C Goal %LDL-C Reduction
Secondary Primary (2+) Primary Cerivastatin Simvastatin
Atorvastatin
90 120 150
100 130 160 0.2mg 5mg
($110/Yr) ($164/Yr)
24% 23%
120 150 180
10mg
0.3mg 10mg
($303/Yr)
($110/Yr) ($241/Yr)
35%
130 160 190 31% 30%
0.4mg 20mg
140 170 200 ($110/Yr) ($391/Yr)
35% 35%
40mg
0.8mg ($391/Yr)
20mg
($220/Yr) 40%
($468/Yr)
44%
43%
170 200 230 80mg
($391/Yr)
180 210 240 47%
40mg
($719/Yr)
51%
80mg
200 230 260
($1438/Yr)
53%
220 250 280
Dosing Impaired Renal Function: (Ccr £ 60ml/min/1.73m2 )
The initial
starting dose should be; Cervistatin 0.2 or 0.3mg, and
Simvastatin 5mg
Secondary: Primary (+2): Primary:
With CHD and/or Without CHD and/or Without CHD and/or
Diabetes. Diabetes Plus 2 or more Diabetes
risk factors. And fewer then 2 risk
factors.
Monitoring:
Lipid Panels. To ensure patients are meeting the NCEP
goals, patients
should have lipid panels completed prior to statin therapy
to establish
baseline lipid levels. There should be a follow-up lipid
panel between
weeks 4 and 8 to titrate dose and one completed
semiannually or annually
thereafter.
SAFETY INFORMATION:
Statins are contraindicated in patients with
hypersensitivity to any
ocomponent of these medications, in patients with active
liver disease or
unexplained persistent elevations of serum transaminases,
in women during
pregnancy, and in nursing mothers.
Myopathy should be considered in any patient with diffuse
myalgias, muscle
tenderness or weakness, and/or marked elevation of plasma
creatine kinase
(CK). Patients should be advised to report promptly
unexplained muscle
pain, tenderness, or weakness, articularly if accompanied
by malaise or
fever. Statin therapy should be discontinued if markedly
elevated CK levels
occur or myopathy is diagnosed or suspected.
Adverse events include rhinitis, pharyngitis, headache,
dyspepsia,
diarrhea, arthralgia and myalgia.
Cerivastatin (BaycolÒ )
It is recommended that liver function tests be performed
before the
initiation of treatment, at 6 and 12 weeks after initiation
of therapy or
elevation in dose, and periodically thereafter, e.g.,
semiannually.
Simvastatin (ZOCORÒ )
It is recommended that liver function tests be performed
before the
initiation of treatment, and periodically thereafter (e.g.,
semiannually)
for the first year of treatment or until one year after the
last elevation
in dose. Patients titrated to the 80-mg dose should receive
an additional
test at 3 months. Patients who develop increased
transaminase levels should
be monitored with a second liver function evaluation to
confirm the finding
and be followed thereafter with frequent liver function
tests until the
abnormality(ies) return to normal. Should an increase in
AST or ALT of 3X
ULN or greater persist, withdrawal of therapy with
Simvastatin is
recommended.
Drug-Drug Interactions:
Precipitant Drug Object Drug Description
Bile Acids Statin ¯ Decrease bioavailability of
HMG-CoA
Cyclosporine Statin Increase risk of myopathy or
rhabdomyolysis
Erythromycin Statin Increase risk of myopathy or
rhabdomyolysis
Fibric Acids Statin Increase risk of myopathy or
rhabdomyolysis
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------------------------------------------------------------------------
Brief Summary
TITLE:
The management of chronic pain in older persons.
SOURCE(S):
J Am Geriatr Soc 1998 May;46(5):635-51 [116 references]
Geriatrics 1998 Oct;53(Suppl 3):S8-24 [116 references]
ADAPTATION:
Not applicable: Guideline was not adapted from another
source.
RELEASE DATE:
1998 Oct
MAJOR RECOMMENDATIONS:
Overview of Key Recommendations:
1. Pain should be an important part of each assessment of
older
patients; along with efforts to alleviate the underlying
cause, pain itself should be aggressively treated.
2. Pain and its response to treatment should be objectively
measured, preferably using a validated pain scale.
3. Nonsteroidal anti-inflammatory drugs (NSAIDs) should be
used
with caution. In older patients NSAIDs have significant
side
effects and are the most common cause of adverse drug
reactions.
4. Acetaminophen is the drug of choice for relieving mild
to
moderate musculoskeletal pain.
5. Opioid analgesic drugs are effective for relieving
moderate
to severe pain.
6. Non-opioid analgesic medications may be appropriate for
some
patients with neuropathic pain and other chronic pain
syndromes.
7. Nonpharmacologic approaches (e.g., patient and caregiver
education, cognitive-behavioral therapy, exercises, etc.),
used alone or in combination with appropriate pharmacologic
strategies, should be an integral part of care plans for
most chronic pain patients.
8. Referral to a multidisciplinary pain management center
should be considered when pain management efforts do not
meet the patient's or the health care provider's goals.
9. Regulatory agencies should review existing policies to
enhance access to effective opioid analgesic drugs for
older
patients in pain.
10. Pain management education should be improved at all
levels
for all health care professionals.
Specific Recommendations: Assessment of Chronic Pain in
Older
Persons
I. On initial presentation of any older person to any
health
care service, a health care professional should assess the
patient for evidence of chronic pain.
II. Any persistent or recurrent pain that has a significant
impact on function or quality of life should be recognized
as a significant problem.
III. A variety of terms synonymous with pain should be used
to
screen older patients (eg. burning, discomfort, aching,
soreness, heaviness, tightness).
IV. For those with cognitive or language impairments,
nonverbal
pain behavior, recent changes in function, and
vocalizations
suggest pain as a potential cause (e.g., changes in gait,
withdrawn or agitated behavior, moaning, groaning, or
crying).
V. For those with cognitive or language impairments,
reports
from a caregiver should be sought.
VI. Conditions that require specific interventions should
be
identified and treated definitively if possible.
A. Underlying disease should be managed optimally.
B. Patients who need specialized services or skilled
procedures should be referred for consultation to a
healthcare specialist who has expertise in such
services and procedures.
1. Patients identified as having debilitating
psychiatric complications should be referred for
psychiatric consultation.
2. Patients identified as abusing or as being
addicted to any legal or illicit substance should
be referred for consultation with an expert who
has experience in pain and addiction management.
3. Patients with life-altering intractable pain
should be referred to a multidisciplinary pain
management center.
VII. All patients with chronic pain should undergo
comprehensive
pain assessment. The guideline document provides an example
of a medical record form that can be used to summarize the
initial pain assessment.
A. Comprehensive pain assessment should include a medical
history and physical examination, as well as a review
of the results of the pertinent laboratory and other
diagnostic tests, with the goals of recording a
temporal sequence of events that led to the present
pain complaint and establishing a definitive diagnosis,
plan for care, and likely prognosis.
B. Initial evaluation of the present pain complaint should
include characteristics such as intensity, character,
frequency (or pattern, or both), location, duration,
and precipitating and relieving factors.
C. Initial evaluation should include a thorough analgesic
medication history, including current and previously
used prescription medications, over-the-counter
medications, and "natural" remedies. The effectiveness
and any side effects of current and previously used
medications should be recorded.
D. Initial evaluation should include a comprehensive
physical examination with particular focus on the
neuromuscular system (e.g., search for neurologic
impairments, weakness, hyperalgesia, hyperpathia,
allodynia, numbness, paresthesia) and the
musculoskeletal system (e.g., palpation for tenderness,
inflammation, deformity, trigger points).
E. Initial evaluation should include evaluation of
physical function.
1. Evaluation of physical function should include a
focus on pain-associated disabilities, including
activities of daily living (e.g., Katz ADLs,
Lawton IADLs, FIMS, Barthel Index).
2. Evaluation of physical function should include
performance measures of function (e.g., range of
motion, Up-and-Go Test, Tinetti Gait and Balance
Test).
F. Initial evaluation should include evaluation of
psychosocial function.
1. Evaluation of psychosocial function should include
assessment of the patient's mood, especially for
depression (e.g., a geriatric depression scale,
CES-D scale).
2. Evaluation of psychosocial function should include
assessment of the patient's social networks,
including any dysfunctional relationships.
G. A quantitative assessment of pain should be recorded by
the use of a standard pain scale (e.g., visual analogue
scale, word descriptor scale, numerical scale)
1. Patients with cognitive or language barriers
should be presented with scales that are tailored
for their needs and disabilities (e.g., scales
adapted for speakers of a foreign language, scales
in large print, or scales for the visually
impaired that do not require visual-spatial
skills).
2. Quantitative estimates of pain based on clinical
impressions or surrogate reports should not be
used unless the patient is unable to reliably make
his or her needs known.
VIII. Patients with chronic pain and their caregivers
should be
instructed to use a pain log or pain diary with regular
entries for pain intensity, medication use, response to
treatment, and associated activities. provides an example
of
a medical record form that can be used as a pain diary or
to
record pain assessments over time.
IX. Patients with chronic pain should be reassessed
regularly
for improvement, deterioration, or complications
attributable to treatment. The frequency of follow-up
should
be a function of the severity of the pain syndrome and the
potential for adverse effects of treatment.
A. Reassessment should include evaluation of significant
issues identified in the initial evaluation.
B. The same quantitative assessment scales should be used
for follow-up assessments.
C. Reassessment should include an evaluation of analgesic
medication use, side effects, and adherence problems.
D. Reassessment should include an evaluation of the
positive and negative effects of any nonpharmacologic
treatments.
PHARMACOLOGIC TREATMENTS OF CHRONIC PAIN IN OLDER PERSONS
I. All older patients with diminished quality of life as a
result of chronic pain are candidates for pharmacologic
therapy.
II. The least invasive route of administration should be
used
(this is usually the oral route).
III. Fast-onset, short-acting analgesic drugs should be
used for
episodic (i.e., chronic recurrent or noncontinuous) pain.
IV. Acetaminophen is the drug of choice for relieving mild
to
moderate musculoskeletal pain. The maximum dosage of
acetaminophen should not exceed 4,000 mg per day.
V. NSAIDs should be used with caution.
A. High-dose, long-term NSAID use should be avoided.
B. When used chronically, NSAIDs should be used as needed,
rather than daily or around the clock.
C. Short-acting NSAIDs may be preferable to avoid dose
accumulation.
D. NSAIDs should be avoided in patients with abnormal
renal function.
E. NSAIDs should be avoided in patients with a history of
peptic ulcer disease.
F. NSAIDs should be avoided in patients with a bleeding
diathesis.
G. The use of more than one NSAID at a time should be
avoided.
H. Ceiling dose limitations should be anticipated (i.e.,
maximum dose may be unattainable because of toxicity or
may be accompanied by lack of efficacy).
VI. Opioid analgesic drugs may be helpful for relieving
moderate
to severe pain, especially nociceptive pain.
A. Opioids for episodic (i.e., chronic recurrent or
noncontinuous) pain should be prescribed as needed,
rather than around the clock.
B. Long-acting or sustained-release analgesic preparations
should be used only for continuous pain.
1. Breakthrough pain should be identified and treated
by the use of fast-onset, short-acting
preparations. Breakthrough pain includes the
following three types:
a. End-of-dose failure is the result of
decreased blood levels of analgesic with
concomitant increase in pain before the next
scheduled dose.
b. Incident pain is usually caused by activity
that can be anticipated and pretreated.
c. Spontaneous pain, common with neuropathic
pain, is often fleeting and difficult to
predict.
2. Titration should be conducted carefully.
a. Titration should be based on the persistent
need for and use of medications for
breakthrough pain.
b. Titration should be based on the
pharmacokinetics and pharmacodynamics of
specific drugs in the older person and the
propensity for drug accumulation.
c. The potential adverse effects of opioid
analgesic medication should be anticipated
and prevented or treated promptly.
3. Constipation should be prevented.
a. A prophylactic bowel regimen should be
initiated with commencement of analgesic
therapy.
b. Bulking agents should be avoided.
c. Adequate fluid intake should be encouraged.
d. Exercise, ambulation, and physical activities
should be encouraged.
e. Bowel function should be evaluated with every
follow-up visit.
f. Rectal examination and disimpaction should
occur before use of motility agents.
g. An osmotic, stimulant, or motility agent
should be prescribed, if necessary, to
provide regular bowel evacuation.
h. Motility agents should not be used if signs
or symptoms of obstruction are present.
i. If fecal impaction is present, it should be
relieved by enema or manual removal.
4. Mild sedation and impaired cognitive performance
should be anticipated when opioid analgesic drugs
are initiated. Until tolerance for these effects
has developed:
a. Patients should be instructed not to drive.
b. Patients and caregivers should be cautioned
about the potential for falls and accidents.
c. Monitoring for profound sedation,
unconsciousness, or respiratory depression
(defined as a respiratory rate of < 8 per
minute or oxygen saturation of < 90%) should
occur during rapid, high-dose escalations.
Naloxone should be used carefully to avoid
abrupt reversal of pain and autonomic crisis.
5. Severe nausea may need to be treated with
anti-emetic medications, as needed.
a. Mild nausea usually resolves spontaneously in
a few days.
b. If nausea persists, a trial of an alternative
opioid may be appropriate.
c. Anti-emetic drugs should be chosen from those
with the lowest side-effect profiles in older
persons.
6. Severe pruritus may be treated with antihistamine
medications.
7. Myoclonus may be relieved by the use of an
alternate opioid drug or clonazepam in severe
cases.
VII. Fixed-dose combinations (e.g., acetaminophen and
opioid) may
be used for mild to moderate pain.
A. Maximum recommended dose should not be exceeded to
minimize toxicity of acetaminophen or NSAID.
B. Ceiling effect should be anticipated (i.e., maximum
dose may be reached without full efficacy because of
limits imposed by toxicity of acetaminophen or an
NSAID).
VIII. Patients taking analgesic medications should be
monitored
closely.
A. Patients should be re-evaluated frequently for drug
efficacy and side effects during initiation, titration,
or any change in dose of analgesic medications.
B. Patients should be re-evaluated on a regular basis for
drug effectiveness and side effects throughout
long-term analgesic drug maintenance.
1. Patients on long-term opioid therapy should be
evaluated periodically for inappropriate or even
dangerous drug-use patterns.
a. The clinician should watch for indications of
the use of medications prescribed for other
persons or of illicit drug use (the latter
being very rare in this population).
b. The clinician should ask about prescriptions
for opioids from other physicians.
c. The clinician should watch for signs of
narcotic use for inappropriate indications
(e.g., anxiety, depression).
d. Requests for early refills should include
evaluation of tolerance, progressive disease,
or inappropriate behavioral factors.
e. These evaluations need to take place with the
same medical equanimity accompanying similar
evaluations for long-term management of other
potentially risky medications (i.e.,
antihypertensive medications) in order not to
burden the patient with excessive worry or
unnecessary fears, or to promote
"opiophobia."
2. Patients on long-term NSAIDs should be
periodically monitored for gastrointestinal blood
loss, renal insufficiency, and other drug-drug or
drug-disease interactions.
IX. Non-opioid analgesic medications may be appropriate for
some
patients with neuropathic pain and some other chronic pain
syndromes.
A. Carbamazepine is the medication of choice for
trigeminal neuralgia.
B. Agents with the lowest side-effect profiles should be
chosen preferentially.
C. Agents may be used alone but often are more helpful
when used in combination and to augment other pain
management strategies.
D. Therapy should begin with the lowest possible doses and
increased slowly because of the potential for toxicity
of many agents.
E. Patients should be monitored closely for side effects.
F. Clinical endpoints should be decreased pain, increased
function, improvements in mood and sleep, not decreased
drug dose.
NONPHARMACOLOGIC STRATEGIES FOR PAIN MANAGEMENT IN OLDER
PERSONS
I. All patients with diminished quality of life as a result
of
chronic pain are candidates for nonpharmacologic pain
management strategies.
II. Patient education should be provided for all patients
with
chronic pain.
A. Content should include information about the known
cause(s) of pain, methods of pain assessment and
measurement, goals of treatment, treatment options,
expectations of pain management, analgesic drug use for
pain management (prescription and over-the-counter
medications), and self-help techniques, such as the use
of heat, cold, massage, relaxation, and distraction.
B. Educational content should be reinforced during every
patient encounter.
C. Specific patient education should be provided before
special treatments or procedures.
III. Nonpharmacologic interventions can be used alone or in
combination with pharmacologic strategies for chronic pain
management.
IV. Cognitive-behavioral therapies should be a part of the
care
of older patients troubled by chronic pain.
A. Cognitive-behavioral therapy should be applied as a
structured program that includes components of
education, rationale for therapy, coping skills
training, methods to generalize coping skills, and
relapse prevention.
B. Cognitive-behavioral therapy should be conducted by a
professional.
C. Plans for a flare-up should be a part of this therapy
to prevent self-defeating behavior during episodes of
pain exacerbation.
V. Exercise should be a part of the care of all older
patients
troubled by chronic pain.
A. Initial training should be conducted over 8 to 12 weeks
and should be supervised by a trained professional with
knowledge of the special needs of older adults.
B. Exercise should be tailored to the needs and
preferences of the patient in consultation with the
primary clinician.
C. Moderate levels of exercise conditioning (aerobic or
resistance training) should be maintained indefinitely.
VI. A trial of physical or occupational therapy is
appropriate
for the rehabilitation of impaired range of motion,
specific
muscle weakness, or other physical impairments associated
with chronic pain.
VII. Traditional insight-oriented psychotherapy should not
be
used alone for the management of chronic pain.
VIII. Other nonpharmacologic therapies may be helpful for
some
patients with chronic pain.
A. Chiropractic, acupuncture, or transcutaneous nerve
stimulation may be helpful for some patients, but they
are expensive and have not been shown to have greater
benefit than placebo controls in the management of
chronic pain. These interventions should be provided
only by professionals.
B. Self-administered heat, cold, and massage and the use
of liniments and other topical agents may be helpful
for some patients.
1. Initial instruction and demonstration should be
provided by a trained clinician.
2. Precautions against thermal injury should be
provided, especially for patients with sensory
disturbances (e.g., diabetic patients) or with
cognitive impairment.
3. Patients should be cautioned about the toxicity of
or possible reactions to liniments and other
topical agents.
RECOMMENDATION FOR HEALTH SYSTEMS THAT CARE FOR OLDER
PERSONS
I. Health care facilities should support policies and
procedures for routine screening, assessment, and treatment
of chronic pain among all older patients. Health
organizations should include pain management as a major
domain in the development of clinical pathways.
II. Healthcare facilities (ambulatory care facilities,
hospitals, nursing homes, and home-care agencies) should
periodically conduct quality assurance or quality
improvement (QA or QI) activities in pain management.
A. QA or QI activities should include appropriate
structure and process indicators of pain assessment and
treatment activities.
B. Benchmarks for quality improvement should be
established internally and should include quantifiable
pain outcomes, including (but not limited to) patient
satisfaction.
III. Healthcare financing systems (third-party payers,
managed
care organizations, and publicly financed programs) should
extend resources for chronic pain management.
A. Present diagnosis-driven reimbursement systems should
be revised to improve incentives for pain management
and symptom control.
1. Effective pharmacologic and nonpharmacologic
strategies for pain management should be provided.
2. Cost-containment strategies must not result in the
inaccessibility of effective treatment or needless
suffering.
B. Reimbursement should be appropriate for the increased
time and resources often necessary for the care of
frail, dependent, and disabled older patients in all
settings.
IV. Health systems (integrated networks and community
health
planners) should ensure accessibility to specialty pain
services.
V. Specialty pain services should be accredited and adhere
to
guidelines defined by quality review organizations.
VI. Pain-management education for all health care
professionals
should be improved at all levels.
A. Professional health school curricula should provide
substantial training and experience in chronic pain
management in older adults.
1. Curricula should adhere to curriculum guidelines
established by the International Association for
the Study of Pain (IASP).
2. Trainees should demonstrate proficiency in pain
assessment and management.
B. Health systems should provide continuing education in
pain assessment and management to health professionals
at all levels.
C. Accreditation bodies should include pain management
curriculum content as evaluation criteria.
D. Pain management should be included in consumer
information services.
VII. Programs and regulations designed to decrease illicit
drug
use should be revised to eliminate barriers to chronic pain
management for the older patient.
A. State medical license boards should publish
professional standards or guidelines for prescribing
controlled substances for pain, including professional
standards for chronic use, expectations for medical
record documentation, and standards for professional
conduct review.
B. State medical license boards must eliminate clinicians'
trepidation over conduct review that has become a major
barrier to the prescription of effective medications.
C. Law and drug enforcement agencies should recognize
their role in facilitating and providing easy access to
the legitimate use of controlled substances for
patients in pain.
D. Law and drug enforcement agencies should publish
information for clinicians and the public regarding
legal and illegal prescribing, dispensing, storage,
disposal, and use of controlled substances for pain
management.
CLINICAL ALGORITHM(S):
None provided
DEVELOPER(S):
American Geriatrics Society (AGS)
COMMITTEE:
American Geriatrics Society (AGS) Panel on Chronic Pain in
Older
Persons
GROUP COMPOSITION:
Members: Bruce A. Ferrell, MD (Chairman); Laurence A.
Bradley,
PhD; Leo M. Cooney, Jr., MD; Walter H. Ettinger, Jr., MD,
MBA;
Perry G. Fine, MD; Keela Herr, PhD, RN, CS; Benny Katz,
MBBS,
DRACP, PhD; Paul R. Katz, MD; D. Joanne Lynn, MD, MA, MS;
Janice
B. Schwartz; Patricia Connelly.
ENDORSER(S):
Not stated
GUIDELINE STATUS:
This is the current release of the guideline.
An update is not in progress at this time.
GUIDELINE AVAILABILITY:
Electronic copies: An executive summary is available from
the
American Geriatrics Society (AGS) Web site.
Print copies: Available from the American Geriatrics
Society, 770
Lexington Avenue, Suite 300, New York, NY 10021.
COMPANION DOCUMENTS:
None available
PATIENT RESOURCES:
Not stated
NGC STATUS:
This summary was completed by ECRI on July 26, 1999. The
information was verified by the guideline developer as of
August
13, 1999.
COPYRIGHT STATEMENT:
This NGC summary is based on the original guideline, which
is
copyrighted by the American Geriatrics Society (AGS).
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Brief Summary
TITLE:
Complex regional pain syndrome (CRPS).
SOURCE(S):
Olympia (WA): Washington State Department of Labor and
Industries; 1999 Jun. 72-80 [1 references]
ADAPTATION:
Not applicable: Guideline was not adapted from another
source.
RELEASE DATE:
1999
MAJOR RECOMMENDATIONS:
I. Overview of Complex Regional Pain Syndrome (CRPS)
Complex regional pain syndromes are painful conditions that
usually affect the distal part of an upper or lower
extremity and are associated with characteristic clinical
phenomena (noted below). There are two subtypes - CRPS Type
I and CRPS Type II.
The term "complex regional pain syndrome" was
introduced to
replace the terms "reflect sympathetic dystrophy."
CRPS
Type
I used to be called reflex sympathetic dystrophy. CRPS Type
II used to be called causalgia. The terminology was changed
because the pathophysiology of CRPS is not known with
certainty. It was determined that a descriptive term such
as
CRPS ws preferable to terms "reflect sympathetic
dystrophy"
which carries with it the assumption that the sympathetic
nervous system is important in the pathophysiology of the
painful condition.
The terms CRPS Type I and CRPS Type II are meant as
descriptors of certain chronic pain syndromes. They do not
embody any assumptions about pathophysiology. For the most
part the clinical phenomena characteristics of CRPS Type I
are the same as seen in CRPS Type II. The central
difference
between Type I and Type II is that, by definition, Type II
occurs following a known peripheral nerve injury, whereas
Type I occurs in the absence of any known nerve injury.
If a physician believes the CRPS condition is related to an
accepted occupational injury, written documentation of the
relationship (on a more probable than not basis) to the
original condition should be provided. Treatment for CRPS
will only be authorized if the relationship to an accepted
injury is established.
II. Key Issues in Making a Diagnosis
A. CRPS is a syndrome - patient's symptoms and signs match
criteria
B. CRPS is Uncommon - Most patients with widespread pain
in an extremity do NOT have CRPS. Avoid the mistake of
diagnosing CRPS primarily because a patient has
widespread extremity pain that does not fit an obvious
anatomic pattern. In many instances, there is no
diagnostic label that adequately describes the
patient's clinical findings. It is often more
appropriate to describe a patient as having "regional
pain of undetermined origin" than to diagnose CRPS.
C. Is CRPS a Disease? - Many clinicians believe that CRPS
can best be construed as a "reaction pattern" to
injury
or to excessive activity restrictions (including
immobilization) following injury. From this
perspective, CRPS may be a complication of an injury or
be iatrogenically induced but it is not an independent
disease process.
D. Type I CRPS vs. Type II CRPS - In a patient with
clinical findings of CRPS, the distinction between Type
I and Type II CRPS depends on the physician's
assessment of the nature of the injury underlying the
CRPS. In many situations, the distinction is obvious -
if CRPS onsets following an ankle sprain or a fracture
of the hand, it is Type I CRPS. If CRPS onsets
following a gunshot wound that severely injures the
median nerve, it is Type II CRPS. In ambiguous
situations (for example, CRPS in the context of a
possible lumbar radiculopathy), the physician should be
conservative in diagnosing Type II CRPS. This diagnosis
should be made only when there is known nerve injury
with definable loss of sensory and/or motor function.
Chronic Regional Pain Syndrome (CRPS) Conservative
Treatment
Guideline
Labor and Industries Criteria Number 13
EXAMINATION FINDINGS AND DIAGNOSTIC
TEST RESULTS CONSERVATIVE CARE
At least four of the following must be Early aggressive
care is
present encouraged. Emphasis should
be on
in order for a diagnosis of CRPS to be improved functioning
of the
made: symptomatic limb.
FIRST SIX WEEKS OF CARE:
* Sympathetic blocks,
maximum
EXAMINATION FINDINGS: of five. Each block
should be
followed immediately by
1. Temperature / color change physical / occupational
2. Edema therapy.
3. Trophic skin, hair, nail growth * Physical /
occupational
abnormalities therapy should be
focused on
4. Impaired motor function increasing functional
level
5. Hyperpathia / allodynia (see Table 2).
6. Sudomotor changes * Other treatment, e.g.,
medication at MD's
discretion
as long as it promotes
improved function.
AFTER THE 1ST SIX WEEKS OF
CARE:
* Strongly consider
psychiatric
or psychological
consultation
if disability has
extended
DIAGNOSTIC TEST RESULTS: beyond 3 months
* Continued physical /
7. Three phase bone scan that is occupational therapy
based on
abnormal in pattern characteristic documented progress
towards
for CRPS. This test is not needed goals established during
if 4 or more of the above first 6 weeks
(referenced
examination findings are present. above).
* Sympathetic blocks only
if
response to previous
blocks
has been positive,
maximum of
3** every six weeks for
a
maximum of 12 weeks.
SURGICAL INTERVENTIONS **A maximum of 11 blocks can
be
(SYMPATHETECTOMY) FOR TREATMENT OF THISdelivered over the
total 18
week
CONDITION IS NOT COVERED period
PROTOCOL FOR PHYSICAL THERAPY / OCCUPATIONAL THERAPY FOR
CRPS
1. Evaluation should
A. Include a date of onset of original injury
(helpful in determining if early or late stage)
and a date of onset of the CRPS symptoms.
B. Establish a baseline for strength and motion.
C. Establish a baseline for weight bearing for lower
extremity
D. If lower extremity, evaluate distance able to walk
and need for assistive device.
E. If upper extremity, establish a baseline for grip
strength, pinch strength and shoulder range of
motion.
2. Set specific functional goals for treatment related to
affected extremity
3. All treatment programs should include a core of:
A. A progressive active exercise program, including a
monitored home exercise program.
B. Progressive weight bearing for the lower extremity
(if involved).
C. Progressive improvement of grip strength, pinch
strength, ans shoulder range of motion of the
upper extremity (if involved).
D. A desensitization program.
4. For specific cases, additional treatment options may be
indicated to enhance effectiveness of the above core
elements. Documentation should reflect reasons for
these additional treatment options.
5. Documentation should include:
A. At least every two weeks, assessment of progress
towards goals.
B. Response to treatment used in addition to core
elements (listed above in section 3).
C. Evidence of motivation and participation in home
exercise program, i.e., diary or quota system.
CLINICAL ALGORITHM(S):
An algorithm is provided for chronic regional pain syndrome
(CRPS) clinical findings and conservative treatment.
DEVELOPER(S):
Washington State Medical Association - Medical Specialty
Society
Washington State Department of Labor and Industries -
State/Local
Government Agency [U.S.]
Washington State Physical Therapy Association -
Professional
Association
Washington State Occupational Therapy Association -
Professional
Association
COMMITTEE:
Washington State Medical Association (WSMA) Industrial
Insurance/Rehabilitation Committee, Washington State
Department
of Labor and Industries (L&I)
GROUP COMPOSITION:
The individual names of the Washington State Medical
Association
(WSMA) Industrial Insurance Advisory Committee are not
provided
in the original guideline document.
Medical Director, Washington State Department of Labor and
Industries (L&I): Gary Franklin, M.D.
ENDORSER(S):
Not stated
GUIDELINE STATUS:
This is the current release of the guideline.
An update is not in progress at this time.
GUIDELINE AVAILABILITY:
Electronic copies: The complete compilation of guidelines
can be
downloaded (Adobe Acrobat required) from the Washington
State
Department of Labor and Industries Office of the Medical
Director
Web site.
Print copies: L&I Warehouse, Department of Labor and
Industries,
P.O. Box 44843, Olympia, Washington 98504-4843.
COMPANION DOCUMENTS:
This guideline is one of 16 guidelines published in the
following
monograph:
* Medical treatment guidelines. Washington State Department
of
Labor and Industries, 1999 Jun. 88 p.
Also included in this monograph:
* Franklin G, Plaeger-Brockway R; Grannemann TW (editor).
Review, regulate, or reform? What works to control workers'
compensation medical costs? In: Medical treatment
guidelines. Washington State Department of Labor and
Industries, 1999 Jun. p. 3-19.
The complete monograph can be downloaded (Adobe Acrobat
required)
from the Washington State Department of Labor and
Industries
Office of the Medical Director Web site. Print copies are
available from L&I Warehouse, Department of Labor and
Industries,
P.O. Box 44843, Olympia, Washington 98504-4843.
PATIENT RESOURCES:
Not stated
NGC STATUS:
This summary was completed by ECRI on July 24, 1999. The
information was verified by the guideline developer on
October
17, 1999.
COPYRIGHT STATEMENT:
This NGC summary is based on the original guideline, which
may be
subject to the guideline developer's copyright
restrictions.
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{10} CONGESTIVE HEART FAILURE - 22 Feb 2000 (PRIVATE) 567
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------------------------------------------------------------------------
Brief Summary
TITLE:
Guidelines for the evaluation of management of heart
failure:
report of the American College of Cardiology/American Heart
Association Task Force on Practice Guidelines (Committee on
Evaluation and Management of Heart Failure).
SOURCE(S):
J Am Coll Cardiol 1995 Nov 1;26(5):1376-98 [112 references]
Circulation 1995 Nov 1;92(9):2764-84 [112 references]
ADAPTATION:
Not applicable: Guideline was not adapted from another
source.
RELEASE DATE:
1995 Nov 1
MAJOR RECOMMENDATIONS:
Initial Diagnostic Evaluation of Acute Pulmonary Edema
Class I, Usually indicated, always acceptable
1. Focused history/physical examination
2. Twelve-lead ECG
3. Continuous ECG monitoring
4. Blood-serum studies: complete blood count (CBC);
electrolytes, blood urea nitrogen (BUN), creatinine and
cardiac enzyme levels
5. Digital pulse oximetry/arterial blood gases
6. Chest radiograph
7. Transthoracic Doppler-two-dimensional echocardiography
8. Cardiac catheterization/coronary arteriography for
suspected
coronary artery disease (1) if acute intervention for
myocardial injury/infarction is anticipated; (2) to
determine the cause(s) for refractory acute pulmonary edema
Class II, Acceptable, but of uncertain efficacy and may be
controversial
1. Indwelling arterial cannula
2. Transesophageal echocardiography
3. Tabulation of fluid volume intake and urine output
Class III, Generally not indicated
Extensive evaluation (e.g., cardiac catheterization and
coronary
arteriography) in a patient with a concomitant terminal
illness
or who would not be considered a candidate for the
necessary
major cardiovascular intervention.
Therapeutic Management of Acute Pulmonary Edema
Class I, Usually indicated, always acceptable
1. Oxygen therapy
2. Nitroglycerin, sublingually or intravenously
3. Intravenous administration of a diuretic (e.g.,
furosemide)
4. Morphine sulfate
5. Administration of cardiovascular support drugs to attain
and
stabilize clinical-hemodynamic status (e.g., intravenous
infusion of nitroprusside, dobutamine, dopamine)
6. Thrombolytic therapy or urgent revascularization
(angioplasty or coronary artery bypass surgery) for acute
myocardial injury/infarction
7. Intubation and mechanical ventilation for severe hypoxia
that does not respond rapidly to therapy and for
respiratory
acidosis
8. Definitive correction of the underlying cause (e.g.,
mitral
valve replacement or repair of acute, severe mitral
regurgitation) when indicated and clinically feasible
Initial Diagnostic Evaluation of Cardiogenic Shock/Near
Shock
Class I, Usually indicated, always acceptable
1. Focused history-physical examination
2. Twelve-lead ECG (plus occasional right-sided leads)
3. Continuous ECG monitoring
4. Blood-serum studies: complete blood count, platelet
count,
clotting studies, electrolytes, BUN, creatinine, glucose
and
cardiac and liver enzymes
5. Arterial blood gases and lactate concentration
6. Chest radiograph
7. Transthoracic Doppler-two-dimensional echocardiography
8. Indwelling arterial cannula for continuous monitoring of
systemic blood pressure and for arterial blood gas sampling
9. Tabulation of fluid volume intake, urine output and
other
fluid volume loss
10. Cardiac catheterization/coronary arteriography if acute
revascularization for acute myocardial injury/infarction is
anticipated
Class II, Acceptable, but of uncertain efficacy and may be
controversial
Transesophageal echocardiography
Class III, Generally not indicated
Extensive evaluation in a patient with a concomitant
terminal
illness or who is not a candidate for cardiovascular
intervention
Therapeutic Management of Cardiogenic Shock/Near Shock
Class I, Usually indicated, always acceptable
1. Oxygen therapy
2. In the absence of obvious intravascular volume overload,
brisk intravenous administration of fluid volume
3. In the presence of intravascular volume overload or
after
adequate intravenous fluid volume therapy, intravenous
administration of cardiovascular support drugs (e.g.,
dopamine, dobutamine, norepinephrine) to attain and
maintain
stable clinical-hemodynamic status
4. Urgent coronary artery revascularization for acute
myocardial injury/infarction, if readily available
Class II, Acceptable, but of uncertain efficacy and may be
controversial
1. Thrombolytic therapy in the setting of acute myocardial
injury/infarction if a cardiac catheterization/coronary
arteriography/revascularization procedure is not readily
available
2. Ventricular assist device in patients who respond
inadequately to the aforementioned interventions and who
are
reasonable candidates for heart transplantation
Class III, Generally not indicated
Extensive evaluation and major intervention in patients
with a
concomitant terminal illness, those afflicted with an
irreversible underlying cause or those who are not
candidates for
corrective intervention or heart transplantation
Recommendations for Intra-aortic Balloon Counterpulsation
in
Heart Failure
Class I, Usually indicated, always acceptable
1. Cardiogenic shock, pulmonary edema and other acute heart
failure conditions not responding to the proper
administration of fluid volume or pharmacologic therapy, or
both, in patients with potentially reversible heart failure
or as a bridge to heart transplantation
2. Acute heart failure accompanied by refractory ischemia,
in
preparation for cardiac catheterization/coronary
arteriography and definitive intervention
3. Acute heart failure complicated by significant mitral
regurgitation or rupture of the ventricular septum; to
obtain hemodynamic stabilization for definitive diagnostic
studies or intervention, or both
Class II, Acceptable, but of uncertain efficacy and may be
controversial
Progressive, chronic heart failure if necessary to allow
for a
proper diagnostic approach, time to consider treatment
options
and definitive intervention (e.g., cardiac surgery, heart
transplantation).
Class III, Generally not indicated
1. Significant aortic insufficiency
2. Aortic dissection
3. Patients unresponsive to therapy in whom the cause is
known
to be uncorrectable or irreversible and who are not
candidates for transplantation
4. Patients in the end stage of a terminal illness
5. Bleeding diathesis or severe thrombocytopenia
Recommendations for Placement of Pulmonary Artery Balloon
Catheter in Heart Failure
Class I, Usually indicated, always acceptable
1. Cardiogenic shock or near shock that does not respond
promptly to the proper administration of fluid volume
2. Acute pulmonary edema that does not respond to
appropriate
intervention or is complicated by systemic hypotension or
shock/near shock
3. As a diagnostic tool to resolve any uncertainty of
whether
pulmonary edema is cardiogenic or noncardiogenic in origin
Class II, Acceptable, but of uncertain efficacy and may be
controversial
1. Assessment of the status of intravascular volume,
ventricular filling pressures, and overall cardiac function
in a patient whose decompensated chronic heart failure is
not responding appropriately to standard therapy
2. Evaluation of overall cardiac-hemodynamic status and
exclusion of left heart failure in a patient with
decompensated chronic lung disease
3. As a diagnostic tool to assess the origin and clinical
and
hemodynamic significance of a new systolic murmur in acute
heart failure
Class III, Generally not indicated
As a routine approach to the assessment, diagnosis or
treatment
of heart failure
Recommended Routine Diagnostic Studies for Adult Patients
With
Chronic Heart Failure or Stabilized Acute Heart Failure Not
Previously Performed
Class I, Usually indicated, always acceptable
1. CBC and urinalysis
2. Blood-serum: electrolytes, BUN, creatinine, glucose,
phosphorus, magnesium, calcium and albumin levels
3. Thyroid-stimulating hormone levels in patients with
atrial
fibrillation and unexplained heart failure
4. Chest radiograph and ECG
5. Transthoracic Doppler-two-dimensional echocardiography
6. Noninvasive stress testing to detect ischemia in
patients
without angina but with a high probability of coronary
artery disease who would be candidates for
revascularization
7. Noninvasive testing to detect ischemia and assess
myocardial
viability or coronary arteriography in patients with a
previous infarction but with no angina who would be
candidates for revascularization
8. Cardiac catheterization/coronary arteriography in
patients
with angina or large areas of ischemic or hibernating
myocardium; also in patients at risk for coronary artery
disease who are to undergo surgical correction of
noncoronary cardiac lesions
Class II, Acceptable, but of uncertain efficacy and may be
controversial
1. Serum iron and ferritin
2. Noninvasive stress testing to detect ischemia in all
patients with unexplained heart failure who are potential
candidates for revascularization
3. Coronary arteriography in all patients with unexplained
heart failure who are potential candidates for
revascularization
4. Endomyocardial biopsy in patients (a) with recent onset
of
rapidly deteriorating cardiac function or other clinical
indications of myocarditis; (b) receiving chemotherapy with
adriamycin or similar myocardial toxic agents; (c) with a
systemic disease and possible cardiac involvement
(hemochromatosis, sarcoid, amyloid, Loeffler's
endocarditis,
endomyocardial fibroelastosis)
5. Thyroid-stimulating hormone levels in patients with
sinus
rhythm and unexplained heart failure
Class III, Generally not indicated
1. Repeat cardiac catheterization/coronary arteriography or
stress testing in patients in whom coronary artery disease
as a cause of left ventricular dysfunction has been
excluded
previously and no objective evidence of intercurrent
ischemia or infarction has occurred
2. Endomyocardial biopsy in the routine evaluation of
patients
with chronic heart failure
3. Multiple echocardiographic or radionuclide studies in
the
routine follow-up of patients with heart failure responding
to therapy
4. Routine Holter monitoring or signal-averaged
electrocardiography
5. Cardiac catheterization/coronary arteriography in
patients
who are not candidates for revascularization, valve surgery
or heart transplantation
Recommendations for Assessment of Functional Capacity in
Heart
Failure
Class I, Usually indicated, always acceptable
1. Patient interview or questionnaire at each clinic visit
2. Exercise testing, usually with respiratory gas analysis,
to
determine potential candidacy for heart transplantation
Class II, Acceptable, but of uncertain efficacy and may be
controversial
1. Exercise testing to more definitively assess functional
capacity and symptomatic limitations in patients in whom a
disparity exists between symptoms expressed and clinical
assessment
2. Exercise testing to address specific clinical questions
and
issues. Examples include ventricular rate changes and
control during atrial fibrillation or after pacemaker
placement, blood pressure control in a patient with heart
failure with a history of hypertension, exercise-induced
arrhythmias, quantitative evaluation of degree of
disability
and assessing a change in functional capacity or response
to
therapy
Class III, Generally not indicated
Exercise testing as a routine, serially performed procedure
to
follow chronic ventricular dysfunction that is clinically
stable
unless used to assess candidacy for transplantation
Pharmacologic Treatment of Left Ventricular Systolic
Dysfunction
Class I, Usually indicated, always acceptable
1. ACE inhibitors for all patients with significantly
reduced
left ventricular ejection fraction unless contraindicated
2. Hydralazine and isosorbide dinitrate in patients who
cannot
take ACE inhibitors
3. Digoxin in patients with heart failure due to systolic
dysfunction not adequately responsive to ACE inhibitors and
diuretic drugs
4. Digoxin in patients with atrial fibrillation and rapid
ventricular rates
5. Diuretic drugs for patients with fluid overload
6. Anticoagulation in patients with atrial fibrillation, or
a
previous history of systemic or pulmonary embolism
7. ß-blockers for high risk patients after an acute
myocardial
infarction
Class II, Acceptable, but of uncertain efficacy and may be
controversial
1. Digoxin for all patients with heart failure due to left
ventricular systolic dysfunction
2. Addition of hydralazine and isosorbide dinitrate for
patients who do not respond adequately to ACE inhibitors
3. ß-blockers for patients with dilated cardiomyopathy
4. Anticoagulation in patients in sinus rhythm with a very
low
ejection fraction or intracardiac thrombi
5. Outpatient low dose dobutamine infusion for refractory
heart
failure
Class III, Generally not indicated
1. Calcium channel blockers in the absence of coexistent
angina
or hypertension
2. Treatment of asymptomatic ventricular arrhythmias
Pharmacologic Treatment of Left Ventricular Diastolic
Dysfunction
Class I, Usually indicated, always acceptable
1. Diuretic drugs
2. Nitrates
3. Drugs suppressing AV conduction to control ventricular
rate
in patients with atrial fibrillation
4. Anticoagulation in patients with atrial fibrillation or
previous systemic or pulmonary embolization
Class II, Acceptable, but of uncertain efficacy and may be
controversial
1. Calcium channel blockers
2. ß-blockers
3. ACE inhibitors
4. Anticoagulation in patients with intracardiac thrombus
Class III, Generally not indicated
1. Drugs with positive inotropic effect in the absence of
systolic dysfunction
2. Treatment of asymptomatic arrhythmias
Recommendations for Hospital Admission of Patients With
Heart
Failure
Class I, Usually indicated, always acceptable
1. Patients experiencing moderate to severe heart failure
for
the first time
2. Patients with recurrent heart failure complicated by
acutely
threatening events or clinical situations (e.g., recent
myocardial ischemia/infarction, acute pulmonary edema,
hypotension, pulmonary or systemic embolus, symptomatic
arrhythmias or other severe medical illnesses)
Class II, Acceptable, but of uncertain efficacy and may be
controversial
1. Mild to moderate decompensation of chronic heart failure
2. Patients experiencing mild heart failure for the first
time
Diagnostic Evaluation of Acute Heart Failure in the Fetus,
Infant, and Child (Follow general principles for adults)
Class I, Usually indicated, always acceptable
1. Physical examination, including blood pressure
measurement
in all extremities
2. CBC and urinalysis
3. Blood-serum: glucose, calcium, electrolytes, creatinine
4. Electrocardiogram, chest radiograph, transthoracic
Doppler-two-dimensional echocardiogram
Medical Treatment of Acute Heart Failure in the Fetus,
Infant,
and Child
Class I, Usually indicated, always acceptable
1. General: intravenous inotropes (excluding digoxin),
intravenous diuretic
2. Systemic outflow obstruction: prostaglandin E1,
artificial
ventilation without supplemental oxygen
Class II, Acceptable, but of uncertain efficacy and may be
controversial
General: digoxin
Class III, Generally not indicated
Oxygen administration until a definitive diagnosis has been
established
Diagnostic Evaluation of Subacute or Chronic Heart Failure
in the
Fetus, Infant and Child (Follow general principles for
adults)
Class I, Usually indicated, always acceptable
1. General: electrocardiogram, chest radiograph,
transthoracic
Doppler-two-dimensional echocardiogram (if not previously
performed)
2. General: cardiac catheterization/coronary arteriography
to
determine coronary anatomy if not established by
echocardiogram
3. General: Holter monitor if no other cause for failure is
found
4. General: tests for carnitine, selenium deficiency
5. Fetus: repeated echocardiogram for paroxysmal arrhythmia
if
there is evidence of hydrops fetalis
Class II, Acceptable, but of uncertain efficacy and may be
controversial
General: myocardial biopsy
Medical Treatment of Subacute or Chronic Heart Failure in
the
Fetus, Infant and Child (Follow general principles for
adults)
Class I, Usually indicated, always acceptable
1. General: diuretic
2. Congestive cardiomyopathy: digoxin, ACE inhibitor
3. Fetus: digoxin, specific antiarrhythmic treatment
Class II, Acceptable, but of uncertain efficacy and may be
controversial
1. Congestive cardiomyopathy: platelet antagonists
2. Left to right shunt: digoxin, ACE inhibitor
3. Eisenmenger's syndrome: digoxin, phlebotomy
Class III, Generally not indicated
Eisenmenger's syndrome: systemic vasodilator
CLINICAL ALGORITHM(S):
None provided
DEVELOPER(S):
American College of Cardiology (ACC) - Medical Specialty
Society
American Heart Association (AHA) - Professional Association
COMMITTEE:
Committee to Develop Guidelines on the Evaluation and
Management
of Heart Failure
GROUP COMPOSITION:
Committee: 14 members. Degrees and affiliations: 11 with
MD,
FACC; 1 with MD, MPH, FACC; 1 with MD, ChB, DPhil, FACC; I
with
MB, MRCP, FACC
Names of Committee Members: John F. Williams, Jr, MD, FACC,
Chair; Michael R. Bristow, MD, FACC; Michael B. Fowler, MB,
MRCP,
FACC; Gary S. Francis, MD, FACC; Arthur Garson, Jr, MD,
MPH,
FACC; Bernard J. Gersh, MD, ChB, DPhil, FACC; Donald F.
Hammer,
MD, FACC; Mark A. Hlatky, MD, FACC; Carl V. Leier, MD,
FACC;
Milton Packer, MD, FACC; Bertram Pitt, MD, FACC; Daniel J.
Ullyot, MD, FACC; Laura F. Wexler, MD, FACC; William L.
Winters,
Jr, MD, FACC
ENDORSER(S):
Not stated
GUIDELINE STATUS:
This is the current release of the guideline. These
guidelines
were reviewed 2 years after publication and will be
reviewed
yearly thereafter and considered current unless the task
force
revises or withdraws them from distribution.
GUIDELINE AVAILABILITY:
Electronic copies: Available from the American College of
Cardiology (ACC) and the American Heart Association (AHA).
Print copies: Available from Educational Services, American
College of Cardiology, 9111 Old Georgetown Road, Bethesda,
Maryland 20814-1699 and from the American Heart
Association,
Office of Scientific Affairs, 7272 Greenville Avenue,
Dallas, TX
75231-4596
COMPANION DOCUMENTS:
None available
PATIENT RESOURCES:
Not stated
NGC STATUS:
This summary was completed by ECRI on June 30, 1998. The
information was verified by the guideline developer on
December
1, 1998.
COPYRIGHT STATEMENT:
This NGC summary is based on the original guideline, which
is
subject to the guideline developer's copyright restrictions
as
follows:
Copyright to the original guideline is owned by the
American
College of Cardiology (ACC) and the American Heart
Association
(AHA). NGC users are free to download a single copy for
personal
use. Reproduction without permission of the ACC/AHA is
prohibited. Permissions requests should be directed to
Grace
Ronan at the ACC, 9111 Old Georgetown Rd, Bethesda, MD
20814-1699; telephone, (301) 493-2363; fax, (301) 897-9745.
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{12} CONJUNCTIVITIS - 22 Feb 2000
(PRIVATE) 460 Lines
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------------------------------------------------------------------------
Brief Summary
TITLE:
Care of the patient with conjunctivitis.
SOURCE(S):
2nd ed. St. Louis (MO): American Optometric Association;
1995. 54
p. (Optometric clinical practice guideline; no. 11) [54
references]
ADAPTATION:
Not applicable: Guideline was not adapted from another
source.
RELEASE DATE:
1995 (reviewed 1999)
MAJOR RECOMMENDATIONS:
A. Diagnosis of Conjunctivitis
A detailed examination should be performed on patients
presenting with acute or chronic conjunctivitis. Additional
testing to diagnose routine cases of conjunctivitis is
generally not necessary. A comprehensive eye examination
with dilation of the pupil should be performed in those
patients with conjunctival hyperemia accompanied by
proptosis, optic nerve dysfunction, decreased visual
acuity,
diplopia, or evidence of anterior chamber inflammation. In
addition, visual field testing may be indicated for these
patients.
1. Patient History
A careful and detailed patient history is often the
most important step in evaluating patients with
conjunctivitis. The diversity of etiologies for
conjunctivitis makes a good patient history important
in establishing a differential diagnosis. The patient
history includes the chief complaint, ocular history,
general health history and review of systems, social
history, and family ocular and medical history.
2. Ocular Examination
The ocular examination may include, but is not limited
to, the following procedures:
* Visual acuity
* Neuro-ophthalmic screening
* External examination
* Biomicroscopy
* Supplemental testing
* Cultures, smears, and scrapings
* Immunoassay
* Conjunctival biopsy
B. Management of Conjunctivitis
1. Available Treatment Options
a. Allergic Conjunctivitis
Treatment of allergic conjunctivitis is based upon
identification and elimination of specific
antigens, when practical, and upon the use of
medications that decrease or mediate the immune
response. The use of supportive treatment,
including nonpreserved lubricants and cold
compresses, may provide symptomatic relief. A
variety of pharmacologic agents, listed below and
described in greater detail in the guideline
document, may be useful in treating allergic
conjunctivitis:
* Topical steroids
* Topical vasoconstrictor/antihistamines
* Topical antihistamine
* Topical nonsteroidal anti-inflammatory drugs
* Topical mast-cell stabilizers
* Systemic antihistamines
b. Bacterial Conjunctivitis
The ideal method of treating bacterial
conjunctivitis is to identify the causative
organism and initiate the specific antimicrobial
treatment known to be effective against the
offending organism. The below table lists the
commonly available topical antimicrobial drugs,
their spectrum of activity, and drug dosage
recommendations. In the absence of a culture or
smear, the etiologic agent should be considered
with respect to the patient's age, environment,
and related ocular findings. In most cases,
broad-spectrum topical antibiotics are the
treatment of choice. Although most cases of
bacterial conjunctivitis are self-limiting,
treatment with antibiotics can lessen the
patient's symptoms and the duration and chances of
recurrence of the disease.
Hyperacute conjunctivitis requires special
consideration and is discussed in the guideline
document.
c. Viral Conjunctivitis
Supportive therapy for adenoviral infection
includes the time-honored treatment options: cold
compresses, lubricants, and ocular decongestants.
Topical antibiotics are not routinely used unless
there is evidence of secondary bacterial
infection.
The treatment of herpes simplex conjunctivitis may
include the use of antiviral agents such as
trifluridine, although there is no evidence that
this therapy results in a lower incidence of
recurrent disease or keratitis. Supportive
therapy, including lubricants and cold compresses,
may be helpful. Topical steroids are specifically
contraindicated.
Herpes zoster ophthalmicus treatment includes the
use of topical antibiotic/steroid combinations to
reduce the risk of secondary bacterial infection
and decrease the inflammatory response. In
contrast to their effect on herpes simplex
infections, topical steroids do not exacerbate
herpes zoster infections.
d. Chlamydial Conjunctivitis
Adult inclusion conjunctivitis is treated
primarily with systemic antibiotics. Topical
therapy alone is inadequate. Appropriate treatment
regimens are described in the guideline document.
Patients' sexual partners should also be evaluated
for the presence of the infection, and treatment
should be initiated as indicated.
e. Contact Lens-Related Conjunctivitis
The primary treatment of contact lens-related
conjunctivitis involves discontinuing contact lens
wear and determining the underlying etiologic
mechanism for the conjunctivitis.
f. Mechanical Conjunctivitis
Removal of the offending trauma-inducing agent
(e.g., misdirected lash, exposed suture) and
subsequent lubrication usually constitute adequate
treatment.
g. Traumatic Conjunctivitis
The treatment of traumatic conjunctivitis depends
upon the nature of the trauma.
h. Toxic Conjunctivitis
Most cases of toxic conjunctivitis result from
overuse of topical medications and/or cosmetics.
Treatment of toxic conjunctivitis from overuse of
topical preparations should be to stop all topical
medications initially, when possible, and use
preservative-free topical lubricants 4 to 8 times
a day for 3 to 5 days. Patients who show no sign
of clinical improvement after this treatment
should be re-evaluated for another underlying
cause.
i. Neonatal Conjunctivitis
Neonatal conjunctivitis should be comanaged in
conjunction with a pediatric infectious disease
specialist. Immediately upon diagnosis, treatment
should begin. Antimicrobial therapy should
initially be directed at the organism identified
in conjunctival smears. The guideline document
summarizes the current therapeutic approaches to
the most common causes of neonatal conjunctivitis.
j. Parinaud's Oculoglandular Syndrome
Because the vast majority of cases are
self-limiting, the aim of therapy for Parinaud's
oculoglandular syndrome is symptomatic relief of
preauricular lymphadenopathy. The application of a
mild topical vasoconstrictor/lubricant and warm
soaks of the inflamed preauricular area are
generally sufficient.
k. Phlyctenular Conjunctivitis
The treatment of phlyctenular conjunctivitis is
directed at the underlying mechanism, to eradicate
the sensitizing agent when possible.
l. Secondary Conjunctivitis
Identification and treatment of the underlying
ocular or systemic condition are needed to manage
secondary conjunctivitis. Patient who develop
conjunctivitis as a manifestation of systemic
disease should be evaluated and comanaged with an
appropriate medical specialist.
2. Patient Education
Effective management of conjunctivitis requires
appropriate patient education. Thorough education may
help relieve the patient's anxiety about the condition
and increase his or her compliance with therapy. Good
patient education is also crucial for preventing the
spread of infectious conjunctivitis, which in many
cases is highly contagious.
3. Prognosis and Follow-Up
Follow-up care should be provided at appropriate
intervals to help ensure compliance and continued
effectiveness. The frequency and composition of
evaluation and management visits for conjunctivitis are
summarized in the table below:
Frequency and Composition of Evaluation and Management
Visits for
Conjunctivitis
------------------------------------------------------------------------
Type of Frequency of History Visual Slit Lamp
Ophthalmoscopy Management Plan
Patient Follow-Up Acuity Biomicroscopy
------------------------------------------------------------------------
Allergic * Mild - every 5 Yes Yes Yes As
indicated * Identify/remove
Conjunctivitis to 7 days
allergen
* Moderate -
* Use of
every 3 to 5
nonpreserved
days
lubricants, cold
* Severe - every
compresses,
1 to 3 days
topical
pharmaceuticals,
systemic
antihistamines
* Educate patients
Bacterial * Mild - every 5 Yes Yes Yes As
indicated * Identify organism
Conjunctivitis to 7 days
and specific
* Moderate -
antimicrobial
every 3 to 5
agent
days
* Hyperacute form:
* Severe - every
obtain smears and
1 to 3 days
cultures, do
saline lavage
* Use of topical
and/or systemic
antibiotics
* Obtain
consultation for
evaluation and
treatment of
underlying
systemic condition
* Educate patient
Viral * Mild - every 5 Yes Yes Yes As
indicated * Use of cold
Conjunctivitis to 7 days
compresses,
* Moderate -
lubricants, ocular
every 3 to 5
decongestants
days
* Herpes simplex:
* Severe - every
use of antiviral
1 to 3 days
agent
* Herpes zoster: use
of topical
antibiotic/steroid
combinations
* Educate patient
Chlamydial * Mild - every 5 Yes Yes Yes As
indicated * Use of systemic
Conjunctivitis to 7 days
antibiotics
* Moderate -
* Obtain
every 3 to 5
consultation for
days
evaluation and
* Severe - every
treatment of
1 to 3 days
underlying
systemic condition
* Educate patient
------------------------------------------------------------------------
CLINICAL ALGORITHM(S):
An algorithm is provided for Optometric Management of the
Patient
with Conjunctivitis.
DEVELOPER(S):
American Optometric Association (AOA) - Professional
Association
COMMITTEE:
American Optometric Association Consensus Panel on the Care
of
the Patient with Conjunctivitis
GROUP COMPOSITION:
Members: Christopher J. Quinn, O.D. (Principal Author);
Dennis E.
Mathews, O.D.; Richard F. Noyes, O.D.; Gary E. Oliver,
O.D.; J.
James Thimons, Jr., O.D.; Randall K. Thomas, O.D.
AOA Clinical Guidelines Coordinating Committee Members:
John F.
Amos, O.D., M.S. (Chair); Barry Barresi, O.D., Ph.D.; Kerry
L.
Beebe, O.D.; Jerry Cavallerano, O.D., Ph.D.; John Lahr,
O.D.;
David Mills, O.D.
ENDORSER(S):
Not stated
GUIDELINE STATUS:
This is the current release of the guideline. According to
the
guideline developer, this guideline has been reviewed on a
biannual basis and is considered to be current.
An update is not in progress at this time.
GUIDELINE AVAILABILITY:
Electronic copies: Available from the American Optometric
Association Web site.
Print copies: Available from the American Optometric
Association,
243 N. Lindbergh Blvd., St. Louis, MO 63141-7881.
COMPANION DOCUMENTS:
The following is available:
* Quick reference guide. Conjunctivitis. St. Louis, MO:
American Optometric Association (AOA), 1995.
Print copies: Available from the American Optometric
Association
(AOA), 243 N. Lindbergh Blvd, St. Louis, MO 63141-7881.
PATIENT RESOURCES:
The following is available:
* Answers to your questions about conjunctivitis. St.
Louis,
MO: American Optometric Association. (Patient information
pamphet).
Electronic copies: Available from the American Optometric
Association Web site.
Print copies: Available from the American Optometric
Association,
243 N. Lindbergh Blvd., St. Louis, MO 63141-7881.
Please note: This patient information is intended to
provide
health professionals with information to share with their
patients to help them better understand their health and
their
diagnosed disorders. By providing access to this patient
information, it is not the intention of NGC to provide
specific
medical advice for particular patients. Rather we urge
patients
and their representatives to review this material and then
to
consult with a licensed health professional for evaluation
of
treatment options suitable for them as well as for
diagnosis and
answers to their personal medical questions. This patient
information has been derived and prepared from a guideline
for
health care professionals included on NGC by the authors or
publishers of that original guideline. The patient
information is
not reviewed by NGC to establish whether or not it
accurately
reflects the original guideline's content.
NGC STATUS:
This summary was completed by ECRI on December 1, 1999. The
information was verified by the guideline developer on
January
31, 2000.
COPYRIGHT STATEMENT:
This NGC summary is based on the original guideline, which
is
subject to the guideline developer's copyright restrictions
as
follows:
Copyright to the original guideline is owned by the
American
Optometric Association (AOA). NGC users are free to
download a
single copy for personal use. Reproduction without
permission of
the AOA is prohibited. Permissions requests should be
directed to
Jeffrey L. Weaver, O.D., Director, Clinical Care Group,
American
Optometric Association, 243 N. Lindbergh Blvd., St. Louis,
MO
63141; (314) 991-4100, ext. 244; fax (314) 991-4101;
e-mail,
ClinicalGuidelines@theAOA.org.
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Date Modified: Sunday, February 06, 2000
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{14} CONSTIPATION - 22 Feb 2000
(PRIVATE) 208 Lines
----------------------------------------------------------------------------
National
Guideline
Clearinghouse
[HOME] [NGC RESOURCES] [HELP] [WHAT'S NEW] [SITE
MAP] [CONTACT NGC] [ABOUT NGC]
Search NGC: Search Help Detailed Search
Browse NGC: Disease/Condition Treatment/Intervention
Organization
Options: Brief Summary Complete Summary
Compare Guidelines: Add to Guideline Collection View
Guideline
Collection
------------------------------------------------------------------------
Brief Summary
TITLE:
Management of constipation.
SOURCE(S):
Iowa City (IA): University of Iowa; 1998 Jun. 49
(Research-based
protocols; no. 1998).[50 references]
ADAPTATION:
Not applicable: Guideline was not adapted from another
source.
RELEASE DATE:
1996 (revised 1998 Jun)
MAJOR RECOMMENDATIONS:
INDIVIDUALS AT RISK FOR CONSTIPATION
Through research reviews, several factors were identified
which
place older adults at risk for constipation. If an
individual is
at risk according to any of the following factors, an
assessment
needs to be made to determine if symptoms of constipation
are
present, and if they are, the interventions described in
this
protocol may be implemented. The risk factors for
constipation
include;
* Age greater 55 years
* Recent abdominal or perianal surgery.
* Limited physical activity, e.g., bedrest, poor mobility
secondary to chronic disability
* Inadequate diet, low fiber less than 15 grams of dietary
fiber per day
* Use of drugs known to be associated with increased risk
of
constipation
* Chronic constipation history
* Laxative abuse history
* Comorbidities known to be associated with constipation
ASSESSMENT CRITERIA
The following assessment criteria indicate patients/clients
who
are likely to benefit most from the use of this
research-based
protocol:
* Patients/clients greater than 55 years of age
* Patients/clients who have less than three bowel movements
per week and/or experience straining at stool more than 25%
of the time
The first step of management of constipation is to identify
and
assess older adults who are at high risk for constipation.
Once the presence of constipation has been established, the
individual should be assessed for rectal impaction by
digital
exam. If stool is present, disimpaction is necessary prior
to
initiating the following interventions.
Fluid intake
Fluid intake of at least 1.5 liters per day is recommended
to
avoid constipation.
Water is preferred although other fluids such as juices are
equally beneficial.
Coffee, tea, and alcohol should be avoided due to their
diuretic
properties.
Diet
Recommendations for dietary fiber intake vary from 25 to 30
grams
per day when fluid intake is at least 1500 milliliters per
day.
A diet high in fiber is not recommended for individuals who
are
immobile or who do not consume at least 1500 milliliters of
fluids per day.
Physical Activity
Walking 15-20 minutes one or twice a day or more as
tolerated is
recommended for those who are fully mobile.
Ambulating at least 50 feet twice a day is recommended for
individuals with limited mobility.
For individuals who are unable to walk or are restricted to
bedrest, chair or bed exercises, such as pelvic tilt, low
trunk
rotation, and single leg lifts, are recommended. The
exercises
should be performed for 15 to 20 minutes at least twice a
day.
Toileting
Toileting is recommended 5 to 15 minutes after meals and as
needed, especially after breakfast when the gastrocolic
reflex is
strongest.
Laxatives
Laxative use may be considered at any time if there is no
bowel
movement for more than three days.
For chronic constipation, constipation of longer than six
month
duration, laxative use is advocated only as supplement tot
he
above regimen of adequate fluid intake, high fiber diet,
exercise, and toileting routine and when there is no bowel
movement for more than three days.
It also advocated that all laxative use be either decreased
or
eliminated when initiating the fluid, fiber, exercise, and
toileting regimen.
When laxative treatment is necessary, a prioritized
approach to
instituting the various categories of laxatives is
advocated.
Each category of laxative treatment should be trialed for
at
least a month before progressing to the next level. A
stepwise
progression of laxative treatment is recommended. First,
bulk
forming laxatives should be trailed. Thereafter stool
softeners,
osmotics, stimulants, suppositories, and lastly enemas
should be
trialed.
Stool softeners are recommended for situations where
straining
should be avoided.
CLINICAL ALGORITHM(S):
None provided
DEVELOPER(S):
University of Iowa Gerontological Nursing Interventions
Research
Center - Academic Institution
COMMITTEE:
Not applicable
GROUP COMPOSITION:
Authors: Marcia Hert, BSN, RN, CRNO; Jennifer Huseboe, RN,
BSN.
Series Editor: Marita G. Titler, PhD, RN, FAAN.
Content Expert: Jacqueline Stolley, PhD, RNCS
ENDORSER(S):
Not stated
GUIDELINE STATUS:
This is the current release of the guideline.
An update is not in progress at this time.
GUIDELINE AVAILABILITY:
Electronic copies: Not available at this time
Print copies: Available from the University of Iowa
Gerontological Nursing Interventions Research Center,
Department
of Nursing-RDDC, University of Iowa Hospitals and Clinics,
200
Hawkins Drive T152 GH, Iowa City, IA 52242-1009. For more
information, please see the University of Iowa
Gerontological
Nursing Interventions Research Center Web site.
COMPANION DOCUMENTS:
None available
PATIENT RESOURCES:
Not stated
NGC STATUS:
This summary was completed by ECRI on March 1, 1999. The
information was verified by the guideline developer on May
5,
1999.
COPYRIGHT STATEMENT:
This summary is based on content contained in the original
guideline, which is subject to terms as specified by the
guideline developer. These summaries may be downloaded from
the
NGC Web site and/or transferred to an electronic storage
and
retrieval system solely for the personal use of the
individual
downloading and transferring the material. Permission for
all
other uses must be obtained from the guideline developer by
contacting the University of Iowa Gerontological Nursing
Intervention Research Core.
Return to top
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[Contact NGC] [Site Map]
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-----------------------------------------------------------------
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© 2000 National Guideline Clearinghouse
Date Modified: Thursday, June 10, 1999
[PAGE]
@1323
================================================================================
{44} COPD (MAMC) - 22 Feb 2000 (PRIVATE)
65 Lines
----------------------------------------------------------------------------
Department of Pharmacy
[Mamclogo.gif (11446 bytes)]
Treatment Guideline for COPD
1. Establish diagnosis: history of cigarette smoking at
least 20 pack years
with obstruction on pulmonary function testing that does
not correct to
normal with bronchodilators.
2. Encourage, cajole and convince patient to stop smoking!
Can refer for
smoking cessation.
3. If still symptomatic and not hypoxic. (Hypoxic patients
should be
treated with oxygen.)
*Ipratropium (Atrovent®) MDI
2 puffs QID ® 6 puffs QID
|
STILL SYMPTOMATIC
Switch to Combivent 2 QID may
increase to 4 puffs QID
|
STILL SYMPTOMATIC
add Theo 24® with goal of plasma level 5-15meq/ml or
switch MDI to nebulized Ipratropium and Albuterol or both
|
STILL SYMPTOMATIC
Initiate a trial of prednisone 40mg QD for 2-3 weeks with
pre/post
bronchodilator spirometry before and after. If FEV1
improves by 20% then
add inhaled steroid and taper prednisone to lowest dose
that maintains
improvement.
4. Other therapies to consider include:
a) vaccination for pneuococcal pneumonia and influenza
b) pulmonary rehabilitation and nutritional supplementation
for
malnourished patients
c) *Patients with fixed obstruction and chronic stable
dyspnea
are best treated with Ipatropium. Patients with partially
reversible obstruction and frequent episodes of acute
dyspnea or
wheezing may respond better to Albuterol (Proventil®) 2
puffs q4
hours ---> 4 puffs q4 hours.
Pharmacy Home Page MAMC Home Page
------------------------------------------------------------------------
Send mail to Pharmacy Pagemaster with questions or comments
about this web
site.
Copyright © 1998
Last modified: January 04, 2000
[PAGE]
@1323
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{69} DELACRUZ,ZENAIDA - 22 Feb 2000 (PRIVATE) 9 Lines
----------------------------------------------------------------------------
Ms. DeLaCruz was seen today at Adult Primary Care (MAMC)
and recommended to
take medications and not to work until 28 February 2000, if
she is improved
by then.
For any questions, please call me at 253-968-3528.
Stephen Whitlock Smith, MD
024-38-5114
Internal Medicine, MAMC
[PAGE]
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{45} DEPRESSION (MAMC) - 22 Feb
2000 (PRIVATE) 151 Lines
----------------------------------------------------------------------------
I. TITLE: MADIGAN ARMY MEDICAL CENTER CLINICAL STANDARD FOR
MANAGEMENT OF
DEPRESSION IN ADULTS-- PRIMARY CARE SETTING
II. INDICATIONS FOR THE STANDARD: Depression is one of the
most common
psychiatric disorders seen in a Primary Care setting,
according to the
Agency for Health Care Policy and Research. Major
depressive disorder is a
syndrome consisting of a constellation of signs and
symptoms that are not
normal reactions to lifes stress. Depression often goes
untreated, both
because of lack of recognition of the disorder on the part
of health care
professionals, and because of failure to appreciate the
potential benefits
of treatment to interpersonal functioning and vocational
adjustment. In
this age of health care reform, Primary Care providers may
be expected to
provide psychiatric/mental health care to a greater extent
than they have
in the past. Early diagnosis of depression in a Primary
Care setting, using
this clinical pathway, will make treatment available at the
very first
outpatient visit, will avoid delays in treatment related to
referrals to
specialty care, will lower the cost of care by
standardizing medications
and avoiding inpatient admissions, and will ultimately
increase patient
satisfaction.
III. METRICS WHICH WILL BE USED TO MONITOR ADHERENCE TO THE
PRACTICE
RECOMMENDATIONS: Record review will reflect concurrence
with each of the
following metrics:
1. A history consistent with depression (DSM IV
criteria) is recorded. This history will include the
description of sleep, appetite, mood, and suicidal
ideation. (See VII, A., Clinical Practice Guideline.
Number 5)
2. Referral to Behavioral Health is documented when
patient reports suicidal ideation. (See VII, A.,
Clinical Practice Guideline. Number 5)
3. Referral to Behavioral Health is documented after
failure of 2nd medication trial (medications
ineffective or had significant side effects). (See VII,
A., Clinical Practice Guideline. Number 5)The patient
was given instruction on anticipated results and side
effects of medication and where/when to return to his
or her provider for worsening symptoms. (See VII, B.,
Major Depression Guideline)
IV. DATE: Completed 21 July 1998.
V. AUTHORS: Point of Contact (POC): COL Russell Hicks,
Staff Psychiatrist,
ccmail: COL Russell Hicks
phone: 968-1170 (DSN) 782-1170
FAX: 968- 2763
LTC Stephen Vance, Staff Psychiatrist 968-2275
LTC Janis Tyrell-Smith, Psychiatric Clinical Nurse
Specialist 968-2063/3070
Mary Brencick, MSW, Wellness Program, 968-4846
Kathleen A. Kutscher, MSW, CSW, Mental Health Utilization
Manager 968-1552
Ann Lancaster, RN, CHN, Health Promotions Coordinator
968-4388
Marion Christiansen, RN, Clinical Pathway Coordinator, QSD
968-0663
VI. AREAS OF DISAGREEMENT: None
VII. PUBLISHED STANDARDS OF CARE RELATING TO CURRENT
STANDARD: This
standard for Depression was developed using the following
references:
A. Clinical practice guideline. Number 5. Depression in
primary
care, volumes 1 and 2. US Department of Health and Human
Services, Agency for Health Care Policy and Research.
Washington,
DC: US Government Printing Office, 1993, publication no.
93-0550,
93-0551.
B. Major Depression Guideline. George Tipton, MD. Clinical
Guidelines For Primary Care Providers. Supplement to
Federal
Practitioner. Vol. 15. NO. 35. Part 3. March 1998.
C. Behavioral Health Treatment Redesign in Managed Care
Settings.
Bologna, Nancy C., et. al. Clinical Psychology: Science and
Practice. Vol. 5. Number 1, Spring 1998.
D. Primary Care Diagnosis and Pharmacologic Treatment of
Depression in Adults. Lesseig, Delores Z., Nurse
Practitioner.
October 1996.
VIII. CLINICAL PRACTICE RECOMMENDATIONS : Please refer to
the attached
documents:
#1-Clinical Pathway-Depression in the Adult Primary Care
Setting
#2-Overview of Treatment for Depression
#3-Screening Tool-PRIME-MD (Primary Care Evaluation of
Mental
Disorders)
#4-Suicide Risk Assessment guide
#5-Antidepressant Medication Dosing Chart
#6-Providers Guide to Behavioral Science Services at MAMC
IX. IMPACT TO THE INSTITUTION: This clinical standard
impacts all providers
who care for adult patients with depression. This includes
all of the
Primary Care portals (Family Practice Clinic, Soldier Care
Clinic, Adult
Primary Care Clinic, McChord Clinic), MAMC Behavioral
Science Services, and
MAMC Pharmacy Department.
X. LINKS WITHIN THE LMAMC INTRANET: This standard is linked
to the
Clinical Pathway for Depression and to the referral
guideline for
Depression. A brief reminder about the depression pathway
should be placed
in CHCS when a provider prescribes an antidepressant
medication. This
statement will refer providers to the depression clinical
pathway. When
MAMC evolves to an automated out patient record, the
pathway should be
automated to facilitate the documentation of the patients
course per this
standard.
XI. METHODS OF PROVIDER EDUCATION: Inservices will be given
to all primary
care providers and Behavioral Science Services to present
the guidelines
and emphasize its use. For this pathway to be effective and
universally
implemented staff physicians must be aware of the content
and emphasize its
use.
Make copies of the pathway for Depression readily available
at appropriate
patient care sites, and encourage providers to place a copy
of this pathway
in the patients outpatient record. The pathway can become a
part of the
clinic note for each visit.
List the pathway for Depression on the MAMC Intranet as
well as on the MAMC
Internet site.
Publish the Depression pathway to providers at our Regional
care facilities
for reference.
Have a reminder concerning the Depression pathway appear on
the CHCS screen
when antidepressant medications are ordered.
XII. REVISION FREQUENCY: Pathway revisions deemed necessary
by the
Behavioral Science Services or by Primary Care providers
will be made
whenever a need is determined. These revisions will be
forwarded to the
Clinical Standards Committee for approval. At a minimum,
this pathway will
be reviewed annually if no interim revisions are made.
[PAGE]
@1323
================================================================================
{17} DIABETES MELLITUS - 22 Feb
2000 (PRIVATE) 204 Lines
----------------------------------------------------------------------------
National
Guideline
Clearinghouse
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MAP] [CONTACT NGC] [ABOUT NGC]
Search NGC: Search Help Detailed Search
Browse NGC: Disease/Condition Treatment/Intervention
Organization
Options: Brief Summary Complete Summary
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Guideline
Collection
------------------------------------------------------------------------
Brief Summary
TITLE:
Management of diabetes mellitus.
SOURCE(S):
Ann Arbor (MI): University of Michigan Health System; 1998.
12 [7
references]
ADAPTATION:
Not applicable: Guideline was not adapted from another
source.
RELEASE DATE:
1996 May (revised 1998 Apr)
MAJOR RECOMMENDATIONS:
Note from NGC: The following key points summarize the
content of
the guideline. Refer to the full text for additional
information,
including dosing and cost considerations for oral agents
for the
management of type 2 diabetes and self-management topics.
Diabetes diagnosis and screening: Recently, the American
Diabetes
Association recommended new standards for the diagnosis of
diabetes. A fasting glucose level greater than or equal to
126
mg/dl (7.0 mmol) confirmed on a separate day is now the
preferred
diagnostic criterion for diabetes. As before, diabetes may
also
be diagnosed on the basis of symptoms (polydipsia,
polyuria,
unintentional weight loss) and elevated glucose level (>
200
mg/dl) confirmed on a separate day (fasting glucose > 126
mg/dl).
The oral glucose tolerance test is generally not
recommended for
diagnosis of diabetes in nonpregnant adults. Use of
glycosylated
hemoglobin (or hemoglobin A1c) to screen for diabetes is
controversial due to lower sensitivity and lack of
standardization of the assay.
Key aspects of care: Routine screening and prevention
efforts for
cardiovascular risk factors (hypertension, hyperlipidemia,
tobacco use) and for microvascular disease (retinopathy,
nephropathy, neuropathy) are recommended to be performed in
the
following time frames. Management of risk factors,
complications,
and glycemia is summarized in the referenced figures
(algorithms)
that may be found in the full-text guideline.
Each regular diabetes Every 3 to 6 Annually
visit months
* Diabetes visit every * Hemoglobin * Dilated retinal
3 months for A1c or examination by an
patients on insulin; glycosylated eye care specialist
every 6 months for hemoglobin and treatment of
patients on oral measured and retinopathy. [A**]
agents or diet only. glycemic * Urine protein and,
* Weight checked. control if normal, screen
* Blood pressure optimized. for
measured and [A**] microalbuminuria.
controlled. [A*] ACE inhibitor for
* Diabetic foot microalbuminuria or
examination proteinuria. [A**]
performed areas of * Monofilament
concern discussed. testing of feet
[A**] [A**]
* Smoking cessation * Lipids measured and
counseling provided controlled. [A*,
for patients with B**]
tobacco dependence. * Smoking status
[B**] assessed.
* Very important * Other important
self-management self-management
actions reviewed and actions reviewed
reinforced: and reinforced:
* active - hypo and
responsibility for hyperglycemia
own care
- diabetes
- progress identification
toward goal for
hemoglobin A1c -
or glycosylated complications
Hgb level screening
- blood glucose - foot care
monitoring, if
on insulin - injection
sites
- regular
exercise
- medication
compliance
- meal plan
- stress and
coping
mechanisms
- family
planning/birth
control
- preconception
counseling/care
[B**]
Special Circumstance: Pregnancy. Preconception counseling
and
glycemic control in women with diabetes mellitus results in
optimal maternal and fetal outcomes [evidence: B**]. Before
pregnancy, diabetic women should be started on insulin
therapy
and have their oral hypoglycemic agents and ACE inhibitors
stopped.
* Definitions
Levels of evidence for the most significant
recommendations:
A. Randomized controlled trials
B. Controlled trials, no randomization
C. Observational trials
D. Opinion of expert panel
CLINICAL ALGORITHM(S):
Algorithms are provided for:
* Prevention, screening, and treatment of cardiovascular
risk
factors in patients with diabetes mellitus: hypertension,
hyperlipidemia, smoking
* Prevention, screening and treatment of microvascular
complications in patients with diabetes mellitus:
retinopathy, nephropathy, neuropathy
* Monitoring glycemic control in patients with diabetes
mellitus
DEVELOPER(S):
University of Michigan Health Systems - Academic
Institution
COMMITTEE:
Diabetes Mellitus Guideline Team
GROUP COMPOSITION:
Team Leaders: Deryth Stevens, MD; Sandeep Vijan, MD.
Team Members: Martha Funnell, MS, RN; Douglas Green, MD;
Van
Harrison, PhD; William Herman, MD; Roland Hiss, MD;
Catherine
Martin, MS, RN; Evelyn Piehl, MS, RN; Barbara Ratliff, RN;
Connie
Standiford, MD.
ENDORSER(S):
Not stated
GUIDELINE STATUS:
This is the current release of the guideline. It is an
update of
a previously issued version.
An update is not in progress at this time.
GUIDELINE AVAILABILITY:
Print copies: Available from the University of Michigan
Health
System, Office of Clinical Affairs, The University of
Michigan
Hospitals, C-201 Med Inn, Box 0826, Ann Arbor, Michigan
49109-0826. Telephone: (734) 763-0555; Fax (734) 936-9406.
COMPANION DOCUMENTS:
None available
PATIENT RESOURCES:
Not stated
NGC STATUS:
This summary was completed by ECRI on May 20, 1999. The
information was verified by the guideline developer on June
17,
1999.
COPYRIGHT STATEMENT:
This NGC summary is based on the original guideline, which
is
copyrighted by the University of Michigan Health Systems
(UMHS).
Return to top
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Date Modified: Friday, September 03, 1999
[PAGE]
@1323
================================================================================
{15} DIABETIC FOOT CARE - 22 Feb
2000 (PRIVATE) 217 Lines
----------------------------------------------------------------------------
National
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Clearinghouse
[HOME] [NGC RESOURCES] [HELP] [WHAT'S NEW] [SITE
MAP] [CONTACT NGC] [ABOUT NGC]
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Organization
Options: Brief Summary Complete Summary Full Text
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Guideline
Collection
------------------------------------------------------------------------
Brief Summary
TITLE:
Preventive foot care in patients with diabetes.
SOURCE(S):
Diabetes Care 1999 Jan;22(Suppl 1):S54-S55 [1 references]
ADAPTATION:
Not applicable: Guideline was not adapted from another
source.
RELEASE DATE:
1999 Jan
MAJOR RECOMMENDATIONS:
RISK IDENTIFICATION
Risk identification is fundamental for effective
preventive management of the foot in people with
diabetes. The risk of ulcers or amputations is
increased in people who have had diabetes >10 years,
are male, have poor glucose control, or have
cardiovascular, retinal, or renal complications. The
following four foot-related risk conditions are
associated with an increased risk of amputation:
* Peripheral neuropathy
* Altered biomechanics
* Evidence of increased pressure (callus, erythema,
hemorrhage under a callus)
* Limited joint mobility, bony deformity, or severe
nail pathology (thick nails)
* Peripheral vascular disease, and
* A history of ulcers or amputation.
FOOT EXAM
* All individuals with diabetes should receive a
thorough foot examination at least once a year to
identify high-risk foot conditions. This
examination should include an assessment of
protective sensation, foot structure and
biomechanics, vascular status, and skin integrity.
People with one or more high-risk foot conditions
should be evaluated more frequently for the
development of additional risk factors. People
with neuropathy should have a visual inspection of
their feet at every visit with a health care
professional.
* Evaluation of neurological status in the low-risk
foot should include a quantitative somatosensory
threshold test, using either the Semmes-Weinstein
monofilament or vibratory sensation. Initial
screening for peripheral vascular disease should
include a history for claudication and an
assessment of the pedal pulses. The skin should be
assessed for integrity, especially between the
toes and under the metatarsal heads. The presence
of erythema, warmth, or callus formation may
indicate areas of tissue damage with impending
breakdown. Bony deformities, limitation in joint
mobility, and problems with gait and balance
should be assessed.
PREVENTION OF HIGH-RISK CONDITIONS
The development of neuropathy, an important predictor
of ulcers and amputation, can be delayed significantly
by maintaining glycemic levels to as near normal as
possible. Smoking cessation should be encouraged to
reduce the risk of vascular disease complications.
MANAGEMENT OF HIGH-RISK CONDITIONS
* People with neuropathy or evidence of increased
plantar pressure may be adequately managed with
well-cushioned walking shoes or athletic shoes.
Patients should be educated on the implications of
sensory loss and the ways to substitute other
sensory modalities (hand palpation, visual
inspection) for surveillance of early problems.
* People with evidence of increased plantar pressure
(e.g., erythema, warmth, callus, or measured
pressure) should use footwear that cushions and
redistributes the pressure. Callus can be debrided
with a scalpel or pumice stone. People with bony
deformities (e.g., hammertoes, bunions) may need
extra-wide shoes or depth shoes. People with
extreme bony deformities (e.g., Charcot foot) that
cannot be accommodated with commercial therapeutic
footwear, may need custom-molded shoes.
* People with symptoms of claudication should
receive further vascular assessment. Exercise
therapy and surgical options may be considered.
* People with a history of ulcers should be
evaluated for the underlying pathology that led to
the ulceration and be managed accordingly. Minor
skin conditions such as dryness and tinea pedis
should be treated to prevent the development of
more serious conditions.
PATIENT EDUCATION
Patients with diabetes and high-risk foot conditions
should be educated regarding their risk factors and
appropriate management, considering the following:
* Assessment of a person's current knowledge and
care practices
* Implications of the loss of protective sensation,
the importance of foot monitoring on a daily
basis, the proper care of the foot, including nail
and skin care, and the selection of appropriate
footwear.
* Patients with neuropathy should be advised to
break in new shoes gradually to minimize the
formation of blisters and ulcers.
* Patients with visual difficulties, physical
constraints preventing movement, or cognitive
problems that impair their ability to assess the
condition of the foot and to institute appropriate
responses will need other people, such as family
members, to assist in their care.
* Patients at low risk may benefit from education on
foot care and footwear.
PROVIDER EDUCATION
All health care providers of people with diabetes
should be able to conduct a simple screening exam of
the neurological, vascular, dermatological, and
musculoskeletal systems. Additional expertise in
patient education, footwear modifications, nail and
callus care, and surgical management of the foot may be
needed.
CLINICAL ALGORITHM(S):
None provided
DEVELOPER(S):
American Diabetes Association (ADA) - Professional
Association
COMMITTEE:
Professional Practice Committee
GROUP COMPOSITION:
Authors of Position Statement, Initial Draft: Jennifer A.
Mayfield, MD, MPH (chair); Gayle E. Reiber, PhD, MPH; Lee
J.
Sanders, DPM; Dennis Janisse, CPed; and Leonard M. Pogach,
MD.
ENDORSER(S):
American Podiatric Medical Association - Medical Specialty
Society
GUIDELINE STATUS:
The guideline was originally approved in August 1998.
ADA position statements are reissued annually.
An update of the current guideline is not in progress at
this
time.
GUIDELINE AVAILABILITY:
Electronic copies: Available from the American Diabetes
Association (ADA) Web site.
Print copies: Available from ADA, 1600 Duke Street,
Alexandria,
VA 22314.
COMPANION DOCUMENTS:
The following is available:
* Mayfield JA, Reiber GE, Sanders LJ, Janisse D, Pogach LM:
Preventive foot care in people with diabetes (Technical
Review). Diabetes Care 1998;21:2161-77.
Print copies: Available from ADA, 1600 Duke Street,
Alexandria,
VA 22314.
PATIENT RESOURCES:
Not stated
NGC STATUS:
Not stated
COPYRIGHT STATEMENT:
This NGC summary is based on the original guideline, which
is
copyrighted by the American Diabetes Association (ADA).
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{18} DYSPEPSIA - 22 Feb 2000 (PRIVATE) 165
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------------------------------------------------------------------------
Brief Summary
TITLE:
Evaluation of dyspepsia.
SOURCE(S):
Gastroenterology 1998 Mar;114(3):579-81 [189 references]
ADAPTATION:
Not applicable: Guideline was not adapted from another
source.
RELEASE DATE:
1997 Nov 8
MAJOR RECOMMENDATIONS:
Management:
Referral for early upper endoscopy is always indicated in
older
patients presenting with new-onset dyspepsia. This is
because the
incidence of gastric cancer in the United States and other
Western countries increases with advancing age; a threshold
of 45
years is recommended. However, in populations where the
age-specific incidence of gastric cancer is greater in
younger
age groups, a lower age threshold should be applied.
Patients
with alarm symptoms (e.g., weight loss, recurrent vomiting,
dysphagia, evidence of bleeding, or anemia) should be
referred
for prompt endoscopy. Patients whose symptoms have failed
to
respond to empiric therapeutic approaches described below
also
should undergo endoscopy.
If endoscopy has been competently performed once, there is
no
indication to repeat it unless new alarm symptoms have
developed
that require investigation. After endoscopy, treatment
should be
targeted at the underlying diagnosis, but the majority of
patients will be labeled as having functional (or nonulcer)
dyspepsia; these patients may respond to reassurance and
explanation followed, if necessary, by a course of
antisecretory
or prokinetic therapy. Although the role of H. pylori in
functional dyspepsia remains uncertain, in those who have
documented infection, eradication therapy is reasonable
after
fully explaining the risks and limitations. In patients
with
persistent symptoms, other treatments that may be
considered
include behavioral therapy, psychotherapy, or
antidepressant
therapy, but these approaches are not of established value.
In younger patients with no alarm features who have not
been
investigated previously, it is recommended that a locally
validated noninvasive H. pylori test (e.g., serology or
urea
breath test) is undertaken to determine if the patient is
infected. A breath test is more costly but has greater
accuracy
for documenting current H. pylori infection. If there is
documented H. pylori infection, then an empiric trial of
anti-H.
pylori therapy is recommended. The rationale is that ulcer
disease will heal and the ulcer diathesis will be
abolished. A
follow-up visit is recommended within 4-8 weeks. If
symptoms fail
to respond or rapidly recur or alarm features develop, then
prompt upper endoscopy is indicated. It is unlikely that an
early
(and hence curable) gastric cancer would progress to
advanced
cancer within 1-2 months of presentation; hence, follow-up
within
this time period is recommended.
A trial of noninvasive testing followed by empiric therapy
for H.
pylori assumes that background prevalence of infection is
not
universally high and gastric cancer is not common. In
regions
where there is a high background incidence of gastric
cancer, a
strategy of H. pylori testing and endoscopy of those who
test
positive for the infection (to definitely exclude
malignancy) may
be preferable to a test and treat strategy, although data
are
unavailable.
In younger patients with no alarm features who are H.
pylori
negative, it is recommended that a trial of antisecretory
therapy
(e.g., H2-blocker or proton pump inhibitor) or a prokinetic
(e.g., cisapride) be prescribed for 1 month. If this fails
to
relieve symptoms, therapy may be switched between the
antisecretory and prokinetic classes. If after 8 weeks of
therapy
symptoms persist or rapidly recur on stopping treatment,
then
endoscopy is recommended.
CLINICAL ALGORITHM(S):
A clinical algorithm is provided for the management of
patients
presenting with dyspepsia who have not been previously
investigated.
DEVELOPER(S):
American Gastroenterological Association (AGA) - Medical
Specialty Society
COMMITTEE:
American Gastroenterological Association Clinical and
Practice
Economics Committee
GROUP COMPOSITION:
Committee Members: Nicholas J. Talley; Marc D. Silverstein;
Lars
Agreus; Amnon Sonnenberg; Gerald Holtmann
ENDORSER(S):
Not stated
GUIDELINE STATUS:
This is the current release of the guideline.
An update is not in progress at this time.
GUIDELINE AVAILABILITY:
Electronic copies: Available from the American
Gastroenterological Association (AGA) Web site at
http://www.gastrojournal.org/cgi/content/full/114/3/579
Print copies: Available from AGA, 7910 Woodmont Avenue, 7th
Floor, Bethesda, MD 20814-3015.
COMPANION DOCUMENTS:
The following is available:
Talley NJ, Silverstein MD, Agreus L, Nyren O, Sonnenberg A,
Holtmann G. AGA technical review: evaluation of dyspepsia.
Gastroenterology 1998 Mar;114(3):582-595 [160 references].
Print copies: Available from AGA, 7910 Woodmont Avenue, 7th
Floor, Bethesda, MD 20814-3015.
PATIENT RESOURCES:
Not stated
NGC STATUS:
This summary was completed by ECRI on September 1, 1998. It
was
verified by the guideline developer on December 1, 1998.
COPYRIGHT STATEMENT:
This NGC summary is based on the original guideline, which
is
subject to the guideline developer's copyright
restrictions.
Please contact the Public Policy Coordinator, American
Gastroenterological Association, 7910 Woodmont Ave, 7th
Floor,
Bethesda, MD 20814; telephone, (301) 654-2055; fax, (301)
654-5970.
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{19} ELDERS WITH GENETIC CONDITIONS
- 22 Feb 2000 (PRIVATE)
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------------------------------------------------------------------------
Brief Summary
TITLE:
Identification, referral, and support of elders with
genetic
conditions.
SOURCE(S):
Iowa City (IA): University of Iowa Gerontological Nursing
Interventions Research Center ; 1999. 31 p. [11 references]
ADAPTATION:
Not applicable: Guideline was not adapted from another
source.
RELEASE DATE:
1999
MAJOR RECOMMENDATIONS:
I. Identify
Identification of individuals or families experiencing or
at
risk for a genetic condition is an important contribution
of
gerontological nurses. Assessment of the family health
history, family knowledge and readiness to learn, and
family
goals and desired outcomes are important elements of
screening for genetic risks and initiating appropriate
interventions.
Comprehensive Family Health History
The family health history is obtained by interview in order
to construct a picture of family health for 3 to 4
generations when possible. Family histories are best
recorded as pedigrees. Pedigrees use a standardized set of
symbols to show relationships between individuals as well
as
their health status.
Indications for referral for specialized genetic counseling
services include:
o family history of a condition with a known genetic
component, such as Huntington disease or Alzheimer
disease.
o presence of a condition that follows a recognizable
pattern of inheritance (e.g. autosomal dominant or
recessive, X-linked dominant or recessive).
o new diagnosis or family history of an earlier than
expected onset in common illnesses, such as breast,
ovarian, prostate, or colon cancer; cardiovascular
disease, and Alzheimer's disease.
o requests for information regarding genetic testing or
gene therapy options.
Genetics Psychosocial Assessment
A second important element of an assessment for
genetics-related health needs is the determination of an
individual or family's current level of knowledge,
readiness
to learn, coping strategies, and communication styles.
Establish Mutual Goals
A third element of assessment for genetics-related health
needs is discussion with the individual, family, or
community regarding their goals in order to determine
mutual
genetics-related health outcomes.
II. Refer
Once the identification of a client who is experiencing or
at risk for experiencing a genetic condition is made,
gerontological nurses may find it necessary to refer their
clients to other providers in order to assure the accuracy
of diagnosis as well as to provide specialty genetics or
mental health services.
Referral for Confirmation of Diagnosis
Accurate genetic counseling is dependent upon accurate
diagnoses. Individuals or families may need referral to
their primary care provider or specialist for a
comprehensive evaluation of the condition of concern.
Referral for Specialized Genetic Services
Individuals or families meeting the criteria for referral
for specialized genetic services can be referred to genetic
specialists for further evaluation. A number of strategies
can be used to locate genetic specialists in your area,
including:
o Contact the genetics division of a regional tertiary
care facility.
o Contact the State Department of Public Health for
information about outreach genetic services.
o Visit the follow Web sites for information about
contacting genetic specialists:
+ the International Society of Nurses in Genetics
Web site, www.nursing.creighton.edu/isong;
+ the the National Society of Genetic Counselors Web
site, www.nsgc.org
Once the referral is initiated, clients may be asked to
release medical records to the genetic specialists prior to
their evaluation. Following the evaluation, the referring
provider will receive a summary letter of the visit
including information provided to the client regarding the
known inheritance of the condition as well as
recommendations for follow-up care.
Referral for Specialty Mental Health Services
Individuals or families who demonstrate ongoing difficulty
in processing and/or coping with genetic information may
require referral to specialty mental health services if
their counseling needs are beyond the skills of the primary
care provider or genetics specialist providers.
III. Support
The third key element of the gerontological nurse's role in
caring for individuals affected by genetic conditions is
the
provision of ongoing support. This support may take the
form
of a general advocacy role or through more specific
interventions such as reinforcement of specialty
recommendations, teaching, psychosocial counseling, and
follow-up assessments and goal setting.
Advocacy
Gerontological nurses are in important positions to
advocate
for their clients in relationship to genetics by assuring
that clients are referred for comprehensive services; by
assuring that clients are fully informed regarding genetic
information, genetic testing, and genotype-based therapies;
and by assuring that their client's genetic information,
like other health information, remains confidential.
Reinforce specialty interventions
Gerontological nurses can review and clarify information
and
recommendations provided by the genetic specialist
providers
with their clients. Facilitation or implementation of
specialist recommendations may be another important
activity
for gerontological nurses related to genetics services.
Teaching
In addition to clarifying information provided by other
specialty providers, teaching related to a health condition
or disease process, therapeutic options, and availability
of
resources is another potential nursing intervention for
gerontological nurses supporting persons with or at risk
for
genetic conditions.
Psychosocial counseling
Individuals and families provided with new information
about
the genetics of a health condition may be faced with unique
challenges as they synthesize the meaning of this
information for their health and life planning. In
addition,
individuals who have sought specific genetic information
through genetic testing are faced with both benefits and
burdens of this information. Consequently, gerontological
nurses can provide supportive psychosocial interventions
such as coping enhancement, decision-making support, and
family integrity promotion as clients sort through the
meaning of genetic information for themselves and their
families.
Ongoing assessment and goal setting
The chronic nature of many health conditions of elders as
well as the lasting and multigenerational nature of genetic
information necessitates that gerontological nurses
maintain
continuing contact with clients for assessment of outcomes
and modification of the care plan based upon mutual
goal-setting.
Identification, referral, and support are three important
general
nursing genetics interventions appropriate for all
gerontological
nurses. However, nurses who consistently work with clients
experiencing known genetic conditions (such as Huntington's
disease and Alzheimer's disease) may benefit from formal
continuing education or advanced academic preparation in
genetics
nursing in order to provide basic and advanced genetics
nursing
interventions.
CLINICAL ALGORITHM(S):
None provided
DEVELOPER(S):
University of Iowa Gerontological Nursing Interventions
Research
Center - Academic Institution
COMMITTEE:
University of Iowa Gerontological Nursing Interventions
Research
Center Research Dissemination Core
GROUP COMPOSITION:
Author: Debra L. Schutte, MSN, RN.
Series Editor: Marita G. Titler, PhD, RN, FAAN.
ENDORSER(S):
Not stated
GUIDELINE STATUS:
This is the current release of the guideline.
An update is not in progress at this time.
GUIDELINE AVAILABILITY:
Electronic copies: Not available at this time
Print copies: Available from the University of Iowa
Gerontological Nursing Interventions Research Center,
Department
of Nursing-RDDC, University of Iowa Hospitals and Clinics,
200
Hawkins Drive T152 GH, Iowa City, IA 52242-1009. For more
information, please see the University of Iowa
Gerontological
Nursing Interventions Research Center Web site.
COMPANION DOCUMENTS:
None available
PATIENT RESOURCES:
None available
NGC STATUS:
This summary was completed by ECRI on November 19, 1999.
The
information was verified by the guideline developer as of
January
20, 2000.
COPYRIGHT STATEMENT:
This summary is based on content contained in the original
guideline, which is subject to terms as specified by the
guideline developer. These summaries may be downloaded from
the
NGC Web site and/or transferred to an electronic storage
and
retrieval system solely for the personal use of the
individual
downloading and transferring the material. Permission for
all
other uses must be obtained from the guideline developer by
contacting the University of Iowa Gerontological Nursing
Intervention Research Core.
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{20} FIBROMYALGIA - 22 Feb 2000
(PRIVATE) 256 Lines
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------------------------------------------------------------------------
Brief Summary
TITLE:
Fibromyalgia.
SOURCE(S):
Olympia (WA): Washington State Department of Labor and
Industries; 1999 Jun. 81-5 [1 references]
ADAPTATION:
Not applicable: Guideline was not adapted from another
source.
RELEASE DATE:
1999
MAJOR RECOMMENDATIONS:
Fibromyalgia is a complex pain disorder that raises many
questions for providers, particularly as to whether this
condition is related to the industrial insurance system.
Is fibromyalgia accepted as an industrial injury or
occupational
disease?
Based on a lack of scientific evidence, the Washington
Department
of Labor and Industries does not generally recognize
fibromyalgia
as an industrial injury, or occupational disease, or an
aggravation to a pre-existing condition.
The worker's health care provider may submit additional
information, described below, that the provider believes
rebuts,
or challenges, this general policy for an individual
worker.
If a provider asserts a worker's fibromyalgia is related to
the
industrial injury or occupational exposure, what type of
documentation should be submitted to support this
contention?
1. Case-specific information linking the injury to the
occurrence of fibromyalgia
Case-specific information might include, but is not limited
to:
* Evidence of a temporal relationship to the worker's
industrial injury or occupational exposure (e.g., the
injury precedes all symptoms of fibromyalgia or
symptoms of potentially crossover disorders such as
chronic fatigue syndrome)
* Documentation that the worker's diagnosis of
fibromyalgia meets the American College of
Rheumatology's 1990 Criteria for the Classification of
Fibromyalgia (see attachment in the guideline document)
* A biological and clinically justifiable rationale for
the relationship between the industrial injury and the
occurrence of fibromyalgia. The biological rationale
should include a discussion based on accepted
principles of biological sciences (anatomy, physiology,
biochemistry, etc. . .) as to how the industrial injury
caused the condition.
2. Scientific studies that address the relationship between
individual injuries and the occurrence of fibromyalgia
The provider is encouraged to submit published scientific
studies supporting the contention of causality. In 1996,
and
again in 1997 and 1998, the department reviewed the
existing
scientific literature on this subject and found
insufficient
medical data to establish a causal relationship between a
traumatic injury or occupational exposure and the
development of fibromyalgia. Therefore, it is particularly
important that the provider point out any new studies or
new
analyses of old studies that he or she feels supports a
different conclusion regarding causality.
Effective January 1, 1999 State Fund claim managers will
automatically request this information from the attending
physician whenever fibromyalgia is contended on a claim.
Information submitted by the provider to support the causal
relationship will be reviewed by department medical staff
before
a claim adjudication decision is made.
Will the department or self-insurer pay for short-term
treatment
of fibromyalgia?
Temporary treatment as an aid to recovery
In general, fibromyalgia is not an accepted condition and
treatment is not allowed. However, if fibromyalgia is
directly
retarding recovery of the accepted industrial injury or
occupational disease, the department or self-insurer may
authorize temporary treatment. Temporary treatment can be
authorized when all of the following conditions are met:
* The accepted industrial injury is not stable,
* Fibromyalgia is directly retarding recovery of the
accepted
industrial injury or occupational disease, and
* The required documentation is submitted (see
authorization
and documentation requirements below)
Treatment as an aid to recovery will be authorized for no
longer
than 90 calendar days. If the worker has reached maximum
recovery
from the accepted industrial injury or occupational disease
prior
to the 90-day period, the fibromyalgia treatment will be
terminated at that time.
What are the authorization requirements?
The provider must obtain prior authorization to treat
fibromyalgia as an aid to recovery. The department or
self-insurer will not pay for treatment for fibromyalgia as
an
unrelated condition unless specifically authorized.
To request prior authorization, the provider must submit
the
following in writing to the department of self-insured:
* Adequate documentation that the worker's diagnosis of
fibromyalgia meets the American College of Rheumatology's
1990 Criteria for the Classification of Fibromyalgia (see
attachment in the guideline document),
* An explanation of how fibromyalgia, as an unrelated
condition, is affecting the accepted industrial condition,
and
* A treatment plan.
Note: The State Fund's Provider Toll Free staff will not be
able
to authorize these services.
What type of treatment may be allowed for the temporary
treatment
of fibromyalgia?
The department or self-insured employer is most likely to
approve
treatment plans that include conservative, non-invasive
treatment
that the scientific literature has shown to be effective in
the
short term. Such treatment includes, but may not be limited
to:
* Physical therapy,
* Low dose tricyclic anti-depressants
* Muscle relaxants on a time-limited basis, or
* Spinal manipulations
The department or self-insured employer will not approve
invasive
therapies or treatments whose effectiveness has not been
documented for even the short-term. The following types of
treatment will not be approved for the treatment of
fibromyalgia:
* Trigger point injections,
* Methotrexate,
* Opioids, or
* Non-steroidal anti-inflammatory drugs (NSAIDs)
Note: Fibromyalgia may coexist with other conditions for
which
such therapies may be indicated.
What are the documentation requirements?
When treating an unrelated condition, the attending
physician
must submit a report every 30 days outlining the effect of
the
treatment on both the unrelated and the accepted industrial
conditions.
CLINICAL ALGORITHM(S):
None provided
DEVELOPER(S):
Washington State Medical Association - Medical Specialty
Society
Washington State Department of Labor and Industries -
State/Local
Government Agency [U.S.]
COMMITTEE:
Washington State Medical Association (WSMA) Industrial
Insurance
Advisory Committee, Washington State Department of Labor
and
Industries (L&I)
GROUP COMPOSITION:
The individual names of the Washington State Medical
Association
(WSMA) Industrial Insurance Advisory Committee are not
provided
in the original guideline document.
Medical Director, Washington State Department of Labor and
Industries (L&I): Gary Franklin, M.D.
ENDORSER(S):
Not stated
GUIDELINE STATUS:
This is the current release of the guideline.
An update is not in progress at this time.
GUIDELINE AVAILABILITY:
Electronic copies: The complete compilation of guidelines
can be
downloaded (Adobe Acrobat required) from the Washington
State
Department of Labor and Industries Office of the Medical
Director
Web site.
Print copies: L&I Warehouse, Department of Labor and
Industries,
P.O. Box 44843, Olympia, Washington 98504-4843.
COMPANION DOCUMENTS:
This guideline is one of 16 guidelines published in the
following
monograph:
* Medical treatment guidelines. Washington State Department
of
Labor and Industries, 1999 Jun. 88 p.
Also included in this monograph:
* Franklin G, Plaeger-Brockway R; Grannemann TW (editor).
Review, regulate, or reform? What works to control workers'
compensation medical costs? In: Medical treatment
guidelines. Washington State Department of Labor and
Industries, 1999 Jun. p. 3-19.
The complete monograph can be downloaded (Adobe Acrobat
required)
from the Washington State Department of Labor and
Industries
Office of the Medical Director Web site. Print copies are
available from L&I Warehouse, Department of Labor and
Industries,
P.O. Box 44843, Olympia, Washington 98504-4843.
PATIENT RESOURCES:
Not stated
NGC STATUS:
This summary was completed by ECRI on July 24, 1999. The
information was verified by the guideline developer on
October
17, 1999.
COPYRIGHT STATEMENT:
This NGC summary is based on the original guideline, which
may be
subject to the guideline developer's copyright
restrictions.
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{46} GASTROESOPHAGEAL
REFLUX (MAMC) - 22 Feb 2000 (PRIVATE)
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Department of Pharmacy
[Mamclogo.gif (11446 bytes)]
GERD Prescribing Guidelines
[wpe14.jpg (44220 bytes)]
[wpe1D.jpg (21472 bytes)]
DIAGNOSIS DEFINITIONS -
GASTOESOPHAGEAL REFLUX
DISEASE:
Defined by a typical history
of mid-epigastric or
retrosternal burning, usually
relieved promptly with
antacids and made worse by
lying down and eating certain
foods, especially fatty
foods.
DYSPEPSIA:
Episodic or persistent
abdominal symptoms, often
related to meals, which
patients or physicians
believe to be due to
disorders of the proximal
digestive tract. This usually
manifests as an epigastric
discomfort, accompanied by
fullness, burning,belching,
bloating, nausea, vomiting,
fatty food intolerance or
difficulty completing a meal;
bowel habits usually remain
unaltered. (See Referral
Guidelines for same.)
LIFESTYLE MODIFICATIONS FOR
PATIENTS WITH GERD:
Decrease or eliminate intake
of fatty or spicy foods,
alcohol, coffee (caffeinated
or decaffeinated), chocolate,
peppermint, and citrus juice.
Eat smaller meals. Do not eat
3 hours before bedtime. Stay
upright 2 hours after meals.
If overweight, lose weight
and achieve ideal body
weight. Stop smoking
cigarettes. Avoid bending or
stooping, if associated with
symptoms. Avoid tight
clothing over the abdominal
area. Try lozenges or chewing
gum to stimulate saliva
secretion. Avoid aspirin and
other arthritis medications
unless prescribed by a
physician. Elevate the head
of the bed 6 - 8 inches.
Pharmacy Home Page MAMC Home Page
------------------------------------------------------------------------
Send mail to Pharmacy Pagemaster with questions or comments
about this web
site.
Copyright © 1998
Last modified: January 04, 2000
I. TITLE: MADIGAN ARMY MEDICAL CENTER CLINICAL STANDARD FOR
ADULT
GASTROESOPHAGEAL REFLUX (GERD):
This standard is to complement the GERD pharmacy guideline
and GERD
referral guideline that are available for GERD.
II. INDICATIONS FOR THE STANDARD:
About 10% of the adult U.S. population have daily symptoms
of GERD, a third
to half have intermittent symptoms. Pharmacological therapy
with
medications for GERD accounts for 7.5% of the pharmacy
budget (based on FEB
1998 data). More money is spent on omeprazole than any
other single agent
on the formulary. This standard should improve care
quality, decrease
overall costs, improve referral efficiency and bring a
consistent pattern
of care for this entity when the patient is treated in
several centers.
III. METRICS WHICH WILL BE USED TO MONITOR ADHERANCE TO THE
PRACTICE
RECOMMENDATIONS:
Record or a chart summary sheet will reflect concurrence
with each of the
five subsequent metrics:
A history consistent with GERD is recorded. This history
will include the
description of a mid-epigastric or retrosternal burning
pain, that is
aggravated by recumbence or bending and consumption of
certain foods
(especially by large and/or fatty meals) and, if attempted,
relieved by
antacids [1].
The patient was given instruction in lifestyle modification
and "First
Line" pharmaceutical management as treatment for GERD. This
instruction
will include information about dietary changes, smoking
cessation, weight
loss, and the elevation of the head of the bed. The patient
record will
reflect that a trial of antacids and/or alginic acid
(gaviscon) as "First
Line" pharmacological management (prescribing guideline)
has occurred
(patients may have done so prior to seeking medical
attention) [1].
A Trial of "Second Line" therapy with an H2-blocker
will be
carried out
after lifestyle modifications fail and prior to treatment
with omeprazole
(prescribing guideline) [1].
If the treatment in number 3. was effective in controlling
symptoms then a
trial off of the H2-blocker will be attempted [1].
A treatment failure of lifestyle changes, antacids, and
H2-blocker OR
evidence of atypical or complicated disease including
hoarseness, chest
pain, cough, asthma, anemia, dysphagia, odynophagia, or
esophagitis on EGD
will be documented prior to prescribing omeprazole
(prescribing guideline)
OR referral to GI (referral may be made if patient has > 5
year history of
GERD referral guideline) [1].
References:
a. Arch Intern Med. 1995;155:2165-2173. [See section VII
for reference
pertaining to all five metrics of management.]
IV. DATE: Completed 16 April 1998
V. AUTHORS:
LTC Robert Sudduth, Gastroenterology Service, Dept of
Medicine, MAJ Robert
Gibbons, General Internal Medicine Service, Dept of
Medicine, with
contributions from Pharmacy and Therapeutics committee.
Point of Contact: MAJ Robert Gibbons
phone: 968-0842
FAX: 968-2972
VI. AREAS OF DISAGREEMENT: The GERD pharmacy guideline and
the GERD
referral guideline were reviewed and are in agreement. The
treatment
recommendations from Foundation Health differ some: less
emphasis on
diagnosis add follow-up via telephone in 2 weeks after
starting treatment
use of escalated doses of H2-blockers and omeprazole
without GI evaluation
consideration of complicated GERD is later "in the
algorithm"
VII. PUBLISHED STANDARDS OF CARE RELATING TO CURRENT
STANDARD:
KR DeVault, DO Castell, for the Practice Parameters
Committee of the
American College of Gastroenterology. Guidelines for the
Diagnosis and
Treatment of Gastroesophageal Reflux Disease. Arch Intern
Med.
1995;155:2165-2173.
VIII. CLINICAL PRACTICE RECOMMENDATIONS:
The current clinical standard reflects adherence to the
GERD referral
guideline and GERD prescribing guideline as indicated in
the metrics.
IX. IMPACT TO THE INSTITUTION:
This clinical standard will impact all clinics involved in
the care of
adult patients, most especially those involved in primary
care.
X. LINKS WITHIN THE MAMC INTRANET:
This standard will be linked to the GERD pharmacy guideline
and GERD
referral guideline.
XI. METHODS OF PROVIDER EDUCATION:
Department Chiefs will notify their departments of the
standard.
Adult ambulatory medical education should emphasize the use
of the
guidelines.
Automated reminders may be sent via CHCS when providers
order
pharmaceuticals for the treatment of GERD.
XII. REVISION FREQUENCY:
Annual review of the standard will be made by the point of
contact with
oversight from the Pharmacy and Therapeutics committee and
clinical staff
on the Gastroenterology Service. Revisions may be needed
when changes occur
in the pharmaceutical costs to MAMC. Such changes can be
made in
prescribing guidelines by the pharmacy.
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(PRIVATE) 60 Lines
----------------------------------------------------------------------------
Department of Pharmacy
[Mamclogo.gif (11446 bytes)]
Helicobacter Pylori Prescribing Guidelines
Adult ANTIBIOTICS for Helicobacter pylori are indicated
when associated
with
PEPTIC ULCER DISEASE COMPARISON of THERAPIES for
Helicobacter pylori
Regimen Duration * Cost
Tetracycline 500mg QID 14 days $ 0.98
Metronidazole 250mg TID " $ 0.99
Bismuth subsalicylate 2 tabs QID " $ 8.52
Ranitidine 150mg BID 4 weeks $ 2.95
(with above) $13.44
Metronidazole 500mg BID 7 days $ 0.50
Omeprazole 20mg BID " $24.50
Clarithromycin 250mg BID " $21.72
$46.72
Amoxicillin 1gm BID 7 days $ 2.86
Omeprazole 20mg BID " $49.01
Clarithromycin 500mg BID " $43.45
$95.32
Last Update - 13 May 99
NOTE:
1. Treatment is indicated in the following situations:
a. Active ulcer, H. pylori positive.
b. Ulcer patients in remission and on chronic
H2-blockers to prevent ulcer recurrence. Test for H.
pylori antibodies first. May d/c H2 blockers after
therapy.
c. Dyspeptic patients that have gotten better after a
two week empiric trial of H2-blockers and have then had
a positive H. pylori antibody (see also dyspepsia
referral guideline). Refer dyspeptic patients to GI
that are not better after a two week trial of H2's.
Those that are better but H.pylori negative should
complete 8 weeks of H2's and then be observed.
2. Start Ranitidine in the first regimen above
concomitantly with
antibiotics, but after antibiotics in the other two
regimens.
3. Ulcer patients in remission don't need the ranitidine
component of therapy.
Pharmacy Home Page MAMC Home Page
-----------------------------------------------------------------
Send mail to Pharmacy Pagemaster with questions or comments
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Copyright © 1999
Last modified: January 04, 2000
hypertension (mamc)
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National
Guideline
Clearinghouse
[HOME] [NGC RESOURCES] [HELP] [WHAT'S NEW] [SITE
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------------------------------------------------------------------------
Brief Summary
TITLE:
Sixth report of the Joint National Committee on Prevention,
Detection, Evaluation, and Treatment of High Blood
Pressure.
SOURCE(S):
Hypertension 1994 Mar;23(3):275-85 [49 references]
Bethesda (MD): U.S. Department of Health and Human
Services,
Public Health Service, National Institutes of Health,
National
Heart, Lung and Blood Institute; 1997 Nov. 33 [254
references]
ADAPTATION:
Not applicable: Guideline was not adapted from another
source.
RELEASE DATE:
1997 Nov
MAJOR RECOMMENDATIONS:
BLOOD PRESSURE MEASUREMENT AND CLINICAL EVALUATION
Classification
Although classification of adult blood pressure is somewhat
arbitrary, it is useful to clinicians who must make
treatment
decisions based on a constellation of factors including the
actual level of blood pressure. A classification of blood
pressure for adults (aged 18 years and older) is provided
in the
following table:
Classification of Blood Pressure for Adults Aged 18 Years
and Older*
Blood Pressure, mm Hg
Category Systolic Diastolic
Optimal** <120 and <80
Normal <130 and <85
High-normal 130-139 or 85-89
Hypertension***
Stage 1 140-159 or 85-89
Stage 2 160-179 or 100-109
Stage 3 > 180 or N > 110
* Not taking antihypertensive drugs and not acutely
ill. When systolic and diastolic blood pressures fall
into different categories, the high category should be
selected to classify the individual's blood pressure
status. In addition to classifying stages of
hypertension on the basis of average blood pressure
levels, clinicians should specify presence or absence
of target organ disease and additional risk factors.
This specificity is important for risk classification
and treatment.
** Optimal blood pressure with respect to
cardiovascular risk is less than 120/80 mm Hg. However,
unusually low readings should be evaluated for clinical
significance.
*** Based on the average of 2 or more readings taken at
each of 2 or more visits after an initial screening.
Detection and Confirmation
Hypertension detection begins with proper blood pressure
measurements, which should be obtained at each health care
encounter. The following techniques are recommended:
* Patients should be seated in a chair with their backs
supported and their arms bared and supported at heart
level.
Patients should refrain from smoking or ingesting caffeine
during the 30 minutes preceding the measurement.
* Under special circumstances, measuring blood pressure in
the
supine and standing positions may be indicated.
* Measurement should begin after at least 5 minutes of
rest.
The appropriate cuff size must be used to ensure accurate
measurement. The bladder within the cuff should encircle at
least 80% of the arm. Many adults will require a large
adult
cuff.
* Measurements should be taken preferably with a mercury
sphygmomanometer; otherwise, a recently calibrated aneroid
manometer or a validated electronic device can be used.
* Both SBP and DBP should be recorded. The first appearance
of
sound (phase 1) is used to define SBP. The disappearance of
sound (phase 5) is used to define DBP.
* Two or more readings separated by 2 minutes should be
averaged. If the first 2 readings differ by more than 5 mm
Hg, additional readings should be obtained and averaged.
* Clinicians should explain to patients the meaning of
their
blood pressure readings and advice them of the need for
periodic remeasurement. The following table provides
follow-up recommendations based on the initial set of blood
pressure measurements:
Recommendations for Follow-up Based on Initial Blood
Pressure
Measurements for Adults
Initial Blood
Pressure, mm Hg*
Systolic Diastolic Follow-up Recommended**
<130 <85 Recheck in 2 y
130-139 85-89 Recheck in 1 y***
140-159 90-99 Confirm within 2 mo***
160-179 100-109 Evaluate or refer to source of care
within 1 mo
>180 >110 Evaluate or refer to source of care
immediately or within 1 week
depending on clinical situation
* If systolic and diastolic categories are different,
follow recommendations for shorter follow-up (eg,
160/86 mm Hg should be evaluated or referred to source
of care within 1month).
**Modify the scheduling of follow-up according to
reliable information about post blood pressure
measurement , other cardiovascular risk factors, or
target organ disease.
***Provide advice about lifestyle modifications (see
Section 3 in text).
Evaluation
Evaluation of patients with documented hypertension has 3
objectives:
1. to identify known causes of high blood pressure;
2. to assess the presence or absence of target organ damage
and
cardiovascular disease, the extent of the disease, and the
response to therapy; and
3. to identify other cardiovascular risk factor or
concomitant
disorders that may define prognosis and guide treatment.
Data for evaluation are acquired through medical history,
physical examination, laboratory tests, and other
diagnostic
procedures.
Medical History. A medical history should include the
following:
known duration and levels of elevated blood pressure;
patient
history or symptoms of CHD, heart failure, cerebrovascular
disease, peripheral vascular disease, renal disease,
diabetes
mellitus, dyslipidemia, other comorbid conditions, gout, or
sexual dysfunction; family history of high blood pressure,
premature CHD, stroke, diabetes, dyslipidemia, or renal
disease;
symptoms suggesting causes of hypertension; history of
recent
changes in weight, leisure-time physical activity, and
smoking or
other tobacco use; dietary assessment including intake of
sodium,
alcohol, saturated fat, and caffeine; history of all
prescribed
and over-the-counter medications, herbal remedies, and
illicit
drugs, some of which may raise blood pressure or interfere
with
the effectiveness of antihypertensive drugs (see Section
4);
results and adverse effects of previous antihypertensive
therapy;
and psychosocial and environmental factors (eg, family
situation,
employment status and working conditions, education level)
that
may influence hypertension control.
Physical Examination. The initial physical examination
should
include the following: 2 or more blood pressure
measurements
separated by 2 minutes with the patient either suppine or
seated
and after standing for at least 2 minutes in accordance
with the
recommended techniques mentioned earlier; verification in
the
contralateral arm (if values are different, the high value
should
be used); measurement of height, weight, and waist
circumference
(see Section 3); funduscopic examination for hypertensive
retinopathy (ie, arteriolar narrowing, focal arteriolar
constructions, arteriovenous crossing changes, hemorrhages
and
exudates, disc edema); examination of the neck for carotid
bruits, distended veins, or an enlarged thyroid gland;
examination of the heart for abnormalities in rate and
rhythm,
increased size, precordial heave, clicks, murmurs, and
third and
fourth heart sounds; examination of the lungs for rales and
evidence for bronchospasm; examination of the abdomen for
bruits,
enlarged kidneys, masses, and abnormal aortic pulsation;
examination of the extremities for diminished or absent
peripheral arterial pulsations, bruits, and edema; and
neurological assessment.
Laboratory Tests and Other Diagnostic Procedures. Routine
laboratory tests recommended before initiating therapy are
tests
to determine the presence of target organ damage and other
risk
factors. These routine tests include urinalysis, complete
blood
cell count, blood chemistry (potassium, sodium, creatinine,
fasting glucose, total cholesterol, and high-density
lipoprotein
cholesterol, and 12-lead electrocardiogram.
Optional tests include creatinine clearance,
microalbuminuria,
24-hour urinary protein, blood calcium, uric acid, fasting
triglycerides, low-density lipoprotein cholesterol,
glycosolated
hemoglobin, thyroid-stimulating hormone (thyrotropin, and
limited
echocardiography (see Section 4) (to determine the presence
of
LVH). More complete assessment of cardiac anatomy and
function by
standard echocardiography, examination of structural
alternations
in arteries by utlrasonography, measurement of ankle/arm
index,
and plasma renin activity/urinary sodium determination may
be
useful in assessing cardiovascular status in selected
patients.
Identifiable Causes of Hypertension
Additional diagnostic procedures may be indicated to seek
causes
of hypertension, particularly in patients
1. whose age, history, physical examination, severity of
hypertension, or initial laboratory findings suggest such
causes;
2. whose blood pressures are responding poorly to drug
therapy;
3. with well controlled hypertension whose blood pressures
begin to increase;
4. with stage 3 hypertension; and
5. with sudden onset of hypertension.
Risk Stratification
The risk for cardiovascular disease in patients with
hypertension
is determined not only by the level of blood pressure but
also by
the presence or absence of target organ damage or other
risk
factors such as smoking, dyslipidemia, and diabetes, as
shown in
the following table:
Components of Cardiovascular Risk Stratification in
Patients With
Hypertension*
Major Risk Factors
Smoking
Dyslipidemia
Diabetes mellitus
Age >60 y
Sex (men and postmenopausal women)
Family history of cardiovascular disease:
Women <65 y or men <55 y
Target Organ Damage/Clinical
Cardiovascular Disease
Heart diseases
Left ventricular hypertrophy
Angina or prior myocardial infarction
Prior coronary revascularization
Heart failure
Stroke or transient ischemic attack
Nephropathy
Peripheral arterial disease
Retainopathy
Based on this assessment and the level of blood pressure,
the
patient's risk group can be determined, as shown in the
following
table:
Risk Stratification and Treatment*
Risk Group A Risk Group B Risk Group C
(No Risk (At Least 1 Risk (TOD/CCD and/or
Factors; No Factor, Not Diabetes, With
Blood Pressure TOD/CCD***) Including or Without
Stages (mm Hg) Diabetes; No Other Risk
TOD/CCD) Factors)
High-normal Life style Lifestyle Drug therapy
(130-139/85-89) modification modification
Drug therapy
Stage 1 Lifestyle Lifestyle
(140-159/90-99) modification (up modification***
to 12 mo)
(up to 6 mo)
Stages 2 and 3 Drug therapy
(>160/> 100) Drug therapy
Drug therapy
* Note: For example, a patient with diabetes and a blood
pressure of 142/94 mm Hg plus left ventricular hypertrophy
should be classified as having stage 1 hypertension with
target organ disease (left ventricular hypertrophy) and
with
another major risk factor (diabetes). This patient would be
categorized as "Stage 1, Risk group C," and
recommended for
immediate initiation of pharmacologic treatment. Lifestyle
modification should be adjunctive therapy for all patients
recommended for pharmacologic therapy.
** TOD/CCD indicated target organ disease/clinical
cardiovascular disease (see Table 4).
*** For patients with multiple risk factors, clinicians
should consider drugs as initial therapy plus lifestyle
modifications.
^^ For those with heart failure, renal insufficiency, or
diabetes.
PREVENTION AND TREATMENT OF HIGH BOOD PRESSURE
Lifestyle Modifications
Lifestyle modifications can have a major protective effect
against high blood pressure and cardiovascular disease:
* Lose weight if overweight
* Limit alcohol intake to no more than 1 oz (30 mL) of
ethanol
(eg, 24 oz [720 mL] of beer, 10 oz
* [300 mL] of wine, or 2 oz [60 mL] of 100-proof whiskey)
per
day or 0.5 oz (15 mL of ethanol per
* day for women and lighter-weight people
* Increase aerobic physical activity (30-45 min most days
of
the week)
* Reduce sodium intake to no more than 100 mmol/d (2.4 g of
sodium or 6 g of sodium chloride)
* Maintain adequate intake of dietary potassium
(approximately
90 mmol/d)
* Maintain adequate intake of dietary calcium and magnesium
for general health
* Stop smoking and reduce intake of dietary saturated fat
and
cholesterol for overall cardiovascular health
Pharmacologic Treatment
The decision to initiate pharmacologic treatment requires
consideration of several factors: the degree of blood
pressure
elevation, the presence of target organ damage, and the
presence
of clinical cardiovascular disease or other risk factors.
Initial Drug Therapy.
When the decision has been made to begin antihypertensive
therapy
and if there are no indication for another type of drug, a
diuretic or b -blocker should be chosen because numerous
RCTs
have shown a reduction in morbidity and morality with these
agents.
There are compelling indications for specific agents in
certain
clinical conditions, based on outcomes data from RCTs. Some
of
these include ACE inhibitors in diabetes mellitus (type 1)
with
proteinuria; ACE inhibitors and diuretics in heart failure,
and
beta-blockers (non-ISA) in myocardial infarction. In other
situations where outcomes data are not yet available, there
are
indications for other agents and the choice should be
individualized, using the agent that most closely fits the
patient's needs. Other treatment recommendations contained
in the
guideline include:
* In older persons, diuretics are preferred and long-acting
dihydropyridine calcium antagonists may be considered.
* Specific therapy for patients with LVH, coronary artery
disease, and heart failure are outlined.
* Patients with renal insufficiency with greater than 1 g/d
of
proteinuria should be treated to a therapy blood pressure
goal of 125/75 mm Hg; those with less proteinuria should be
treated to a blood pressure goal of 130/85 mm Hg. ACE
inhibitors have additional renoprotective effects over
pother antihypertensive agents.
* Patients with diabetes should be treated to a therapy
blood
pressure goal of below 130/85 mm Hg.
If the response to the initial drug choice is inadequate
after
reaching the full dose, 2 options for subsequent therapy
should
be considered:
1. If the patient is tolerating the first choice well, add
a
second drug from another class.
2. If the patient is having significant adverse effects or
no
response substitute an agent from another class.
If a diuretic is not chosen as the first drug, it is
usually
indicated as a second-step agent because its addition will
enhance the effects of other agents. If addition of a
second
agent controls blood pressure satisfactorily, an attempt to
withdraw the first agent may be considered.
Before proceeding to each successive treatment step,
clinicians
should consider possible reasons for lack of responsiveness
to
therapy, including pseudoresistance, nonadherence to
therapy,
volume overload, drug-related causes, associated
conditions, and
identifiable causes of hypertension.
Strategies for Improving Adherence to Antihypertensive
Therapy:
Various strategies may improve adherence to therapy and
control
of high blood pressure including the following
recommendations:
* Be aware of signs of patient nonadherence to
antihypertensive therapy
* Establish the goal of therapy: to reduce blood pressure
to
nonhypertensive levels with minimal or
* no adverse effects
* Educate patient about the disease, and involve them and
their families in its treatment. Have
* them measure blood pressure at home
* Maintain contact with patients; consider
telecommunication
* Keep care inexpensive and simple
* Encourage lifestyle modifications
* Integrate pill-taking into routine activities of daily
living
* Prescribe medications according to pharmacologic
principles,
favoring long-acting formulations
* Be willing to stop unsuccessful therapy and try a
different
approach
* Anticipate adverse effects, and adjust therapy to
prevent,
minimize, or ameliorate side effects
* Continue to add effective and tolerated drugs, stepwise,
in
sufficient doses to achieve the goal of
* therapy
* Encourage a positive attitude about achieving therapeutic
goals
* Consider using nurse case management
Summary of Other Major Recommendations:
* Strategies for managing hypertensive emergencies and
urgencies are described.
* Racial and ethnic minority populations are growing
segments
of our society. The prevalence of hypertension in these
populations differs across groups, and control rates are
not
as good as in the general population. Clinicians should be
aware of these management challenges, taking social and
cultural factors into account.
* Guidelines are provided for management of children and
women
with hypertension
CLINICAL ALGORITHM(S):
An algorithm is presented for treatment of hypertension.
DEVELOPER(S):
National Heart, Lung, and Blood Institute (U.S.) (NHLBI) -
Federal Government Agency [U.S.]
COMMITTEE:
National High Blood Pressure Education Program (NHBPEP)
Joint National Committee on Prevention, Detection,
Evaluation and
Treatment of High Blood Pressure (JNC IV)
GROUP COMPOSITION:
The NHBPEP Coordinating Committee consists of
representatives
from 38 national professional, public, and voluntary health
organizations and 7 federal agencies.
The preparation of the JNC VI report was coordinated by an
executive committee, composed of the JNC VI chair, the
chairs of
the individual section writing teams, and the chairs of 4
previous JNC reports - a total of 9 individuals.
Contributions
were obtained from multidisciplinary experts from the
fields of
medicine, nursing, nutrition, pharmacy and public health,
whose
submissions were condensed, assembled, reviewed and edited
by the
executive committee. 80 individuals are acknowledged as
contributors.
Names of Executive Committee Chair and Members: Sheldon G.
Sheps,
MD (Chair); Henry R. Black MD; Jerome D. Cohen, MD; Norman
M.
Kaplan, MD; Keith C. Ferdinand, MD; Aram V. Chobanian, MD;
Harriet P. Dustan, MD; Ray W. Gifford, Jr., MD; Marvin
Moser, MD.
ENDORSER(S):
American Academy of Family Physicians (AAFP) - Medical
Specialty
Society
American Academy of Neurology (AAN) - Medical Specialty
Society
American Academy of Ophthalmology - Medical Specialty
Society
American Academy of Physician Assistants (AAPA) -
Professional
Association
American Association of Occupational Health Nurses (AAOHN)
-
Professional Association
American College of Cardiology (ACC) - Medical Specialty
Society
American Pharmaceutical Association - Professional
Association
American Podiatric Medical Association - Medical Specialty
Society
American College of Physicians (ACP) - Medical Specialty
Society
American Heart Association (AHA) - Professional Association
American Diabetes Association (ADA) - Professional
Association
American Dietetic Association (ADA) - Professional
Association
American Society of Health-System Pharmacists (ASHP) -
Professional Association
American Osteopathic Association - Professional Association
American Nurses Association (ANA) - Professional
Association
American Optometric Association (AOA) - Professional
Association
American Medical Association (AMA) - Medical Specialty
Society
National Medical Association - Professional Association
American Dental Association (ADA) - Professional
Association
National High Blood Pressure Education Program
American Public Health Association (APHA)
Health Care Financing Administration - Federal Government
Agency
[U.S.]
Health Resources and Services Administration (HRSA) -
Federal
Government Agency [U.S.]
American College of Chest Physicians (ACCP) - Medical
Specialty
Society
American College of Occupational and Environmental Medicine
-
Medical Specialty Society
American College of Preventive Medicine (ACPM) - Medical
Specialty Society
National Stroke Association (NSA) - Professional
Association
National Institute of Diabetes and Digestive and Kidney
Diseases
(U.S.) (NIDDK) - Federal Government Agency [U.S.]
National Kidney Foundation - Disease Specific Society
Society for Nutrition Education - Professional Association
American Academy of Insurance Medicine (AAIM) -
Professional
Association
American Red Cross
American Society of Hypertension - Disease Specific Society
Association of Black Cardiologists - Medical Specialty
Society
Citizens for Public Action on High Blood Pressure and
Cholesterol
Inc - Private Nonprofit Organization
Council on Geriatric Cardiology - Disease Specific Society
International Society on Hypertension in Blacks - Disease
Specific Society
National Black Nurses Association, Inc - Professional
Association
National Hypertension Association, Inc - Disease Specific
Society
National Optometric Association - Professional Association
Department of Veterans Affairs - Federal Government Agency
[U.S.]
National Center for Health Statistics, Centers for Disease
Control and Prevention - Federal Government Agency [U.S.]
NHLBI Ad Hoc Committee on Minority Populations
Agency for Healthcare Research and Quality (AHRQ) - Federal
Government Agency [U.S.]
GUIDELINE STATUS:
This is the current release of the guideline.
This guideline updates the recommendations previously
issued by
the National Heart, Lung, and Blood Institute (NHLBI), the
"Fifth
Report of the Joint National Committee on Prevention,
Detection,
Evaluation, and Treatment of High Blood Pressure," 1992.
An update is not in progress at this time.
GUIDELINE AVAILABILITY:
Electronic copies: Electronic copies can be downloaded from
the
National Heart, Lung, and Blood Institute (NHLBI) Web site.
Print copies: Available from NHLBI Information Center, P.O.
Box
30105, Bethesda, MD 20824-0105; e-mail: nhlbiic@dgsys.com
COMPANION DOCUMENTS:
The following is available:
* JNC VI Guide to Prevention and Treatment of Hypertension
Recommendations. (Quick Reference Card)
Electronic copies: Available from the National Heart, Lung
and
Blood Institute Web site.
Print copies: Available from NHLBI Information Center, P.O.
Box
30105, Bethesda, MD 20824-0105; e-mail: nhlbiic@dgsys.com
PATIENT RESOURCES:
The following is available:
* Preventing high blood pressure. Bethesda, MD: NHLBI,
1997.
Available from the National Heart, Lung and Blood Institute
Web site.
Print copies: Available from NHLBI Information Center, P.O.
Box
30105, Bethesda, MD 20824-0105; e-mail: nhlbiic@dgsys.com
Please note: This patient information is intended to
provide
health professionals with information to share with their
patients to help them better understand their health and
their
diagnosed disorders. By providing access to this patient
information, it is not the intention of NGC to provide
specific
medical advice for particular patients. Rather we urge
patients
and their representatives to review this material and then
to
consult with a licensed health professional for evaluation
of
treatment options suitable for them as well as for
diagnosis and
answers to their personal medical questions. This patient
information has been derived and prepared from a guideline
for
health care professionals included on NGC by the authors or
publishers of that original guideline. The patient
information is
not reviewed by NGC to establish whether or not it
accurately
reflects the original guideline's content.
NGC STATUS:
This summary was completed by ECRI on January 5, 1999. The
information was verified by the guideline developer on
April 30,
1999.
COPYRIGHT STATEMENT:
No copyright restrictions apply.
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Date Modified: Monday, June 14, 1999
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Department of Pharmacy
[Mamclogo.gif (11446 bytes)]
Hypertension Therapy Guidelines
Life-style modifications, including weight reduction,
increased physical
activity, moderation of alcohol intake, and modification of
sodium intake,
especially in elderly and black patients, can be used as
definitive or
adjunctive therapy for hypertension. Hypertension classes
are given the
last Friday of each month from 0930-1200 featuring talks by
nursing,
nutrition, and pharmacy. Patients should call 968-2410 or
968-2415 to
register.
The Sixth Joint National Committee on Detection,
Evaluation, and Treatment
of Hypertension-JNC VI (Arch Intern Med, 12/97) recommends
diuretics or
beta blockers as preferred initial therapy for most
patients. These agents
have demonstrated a reduction in morbidity and mortality
over many years
with many patients.
FIRST LINE AGENTS:
(for most patients):
Diuretic- HCTZ 12.5-25 mg qd or
"Maxzide" ½-1 po qd
Beta Blocker- Atenolol 50-100mg qd or qhs
if fatigue develops
Also Consider:
ACE Inhibitor- Lisinopril or Benazepril 5-40
mg qd
Alpha Blocker- Doxazosin -use ½ tabs, up to
16 mg qd*
Beta Blocker- Metoprolol 25-150 mg po bid
Calcium Channel blockers- Verapamil SR 180 - 240 mg
qd**
Felodipine 2.5-20mg qd
Central Sympatholytic- Clonidine 0.1 - 0.6 mg po bid
* starter pack titrates patient from 1 to 4 mg in five
weeks
** Non-dihydropyridines = verapamil and diltiazem - slow
and protect heart rate
Dihydropyridines = felodipine, nifedipine, and amlodipine
- do not slow heart rate
THIRD LINE AGENTS:
(because of cost, side
effects,and/or efficacy)
Central Sympatholytic- Catapres patch TTS
1-TTS 3 q wk
Methyldopa 250-500 mg
bid
Direct Vasodilator- Hydralazine 25-150 mg
po bid
Minoxidil 2.5-50 mg
bid
reserved for
Calcium Channel Blockers- - Dilacor XR 120-480 mg those
with
qd
angina
Nifedipine SR (Adalat
CC) 30-90 mg qd
Angiotensin II Receptor Valsartan 80-320 mg only if cough
on
Blockers- qd ACEI
Diuretic- Furosemide 20 - 120mg given BID for
bid hypertension
Drug Combinations:
Good:
Diuretic combine well with beta blockers, ACE inhibitors or
Angiotensin II
receptor antagonists. Be aware that the combination of
Maxzide and an ACE
Inhibitor can result in hyperkalemia. Maxzide should be
considered in any
patient on HCTZ who develops hypokalemia.
ACE Inhibitors and Calcium channel blockers also combine
additively.
Sample triple therapy: HCTZ, Lisinopril, and Felodipine -
or -
Atenolol, Doxazosin, and diuretic.
Be Careful Of:
Beta blockers and calcium channel blockers can cause or
exacerbate heart
block. Hypokalemia on HCTZ, hyperkalemia on Maxzide/ACE
inhibitor.
High dose diuretics are generally not more effective than
low dose
diuretics & are more dangerous.
Calcium channel blockers and alpha blockers often cause
hypotension in
combination.
A = ACE Inhibitor B = Beta Blocker C = Calcium Channel
Blocker
C+ = Nondihydropyridine CCB D = Diuretic Al = Alpha Blocker
*indicates first line therapy
Patient Characteristic Consider Think twice before giving:
African American D,C A
Diabetic A*,C
Coronary Artery Disease A, B*, C+ (esp Dilacor XR)
nifedipine, minoxidil
Systolic CHF A, D, B-may help some
patients
Diastolic CHF A, C+
Hyperlipidemia A, Al*, C B, D
Impotence A, Al B, C, D
RAD/COPD C, D B
BPH Al
Gout B,C D
Isolated Systolic
Hypertension B, D*
Migraine Headaches B*, C
Smoker Clonidine patch
Renal Failure Furosemide, metalozone,
metoprolol
Allergy shots/prior
anaphylaxis B
Elderly, prone to
delirium Clonidine
Depression Al, B
DRUG COSTS IN HYPERTENSION THERAPY
DRUG STRENGTH COST DOSAGE
DIURETICS: 25mg $0.003/tab QD
HCTZ 50mg 0.004/tab QD
Potassium Supplement SR 10mEq 0.009/tab QD
HCTZ/Triamterene 50/75mg 0.01/tab QD
BETA BLOCKERS:
10,20,40mg 0.001/tab BID/TID
Propranolol
Propranolol 80mg 0.01/tab QD
Atenolol 25, 50mg 0.02/tab QD
Atenolol 100mg 0.03/tab QD
Metoprolol 50mg 0.03/tab BID
Metoprolol 100mg 0.04/tab BID
Pindolol 5mg 0.04/tab BID
Pindolol 10mg 0.06/tab BID
Labetalol 200mg 0.21/tab BID
1,2mg 0.53/tab QD
ALPHA BLOCKERS:
4mg 0.55/tab QD
Doxazosin
8mg 0.58/tab QD
Terazosin 1,2,5,10mg 0.46
ACE INHIBITORS:
12.5mg 0.01/tab
Captopril
Captopril 25mg 0.02/tab BID/TID
Captopril 50mg 0.03/tab BID/TID
Lisinopril 5mg 0.31/tab QD
Lisinopril 10mg 0.33/tab QD
Lisinopril 20mg 0.35 QD
Benazepril 5,10,20mg 0.25/tab QD
CALCIUM CHANNEL BLOCKERS:
Verapamil SR 180mg 0.18/tab QD
Dilacor XR 240mg 0.11/tab QD
Dilacor XR 180mg 0.54/tab QD
Dilacor XR 240mg 0.58/tab QD
Nifedipine XL 30mg 0.64/cap QD
Nifedipine XL 60mg 1.11/cap QD
Nifedipine XL 90mg 1.19/cap QD
Felodipine 5,10,2.5mg 0.49/cap QD
OTHERS:
0.1,0.2mg 0.006/0.007/tab BID
Clonidine
Clonidine patch TTS1, 0.66 - 1.53/day 1/wk
TTS2, TTS3
Hydralazine 10,25,50mg 0.01/tab TID
Methyldopa 250,500mg 0.02-04/tab BID/TID
Indapamide 1.25mg 0.35
------------------------------------------------------------------------
Send mail to Pharmacy Pagemaster with questions or comments
about this web
site.
Copyright © 1998
Last modified: January 04, 2000
[PAGE]
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{23} IMMUNIZATION - 22 Feb 2000
(PRIVATE) 256 Lines
----------------------------------------------------------------------------
National
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Organization
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Guideline
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------------------------------------------------------------------------
Brief Summary
TITLE:
Quality standards for immunization.
SOURCE(S):
Clin Infect Dis 1997 Oct;25(4):782-6 [15 references]
ADAPTATION:
The guideline document is a summary of guidelines already
developed by national organizations, including the Advisory
Committee on Immunization Practices (ACIP) of the Centers
for
Disease Control and Prevention, the American Academy of
Pediatrics (AAP), and the American Academy of Family
Physicians
(AAFP).
RELEASE DATE:
1997
MAJOR RECOMMENDATIONS:
Summary
The IDSA endorses the use of the following immunizations on
the
basis of current immunization recommendations for healthy
infants, children, and adults. Vaccinations for children
include
diphtheria, tetanus, and pertussis (DTP/DTaP); Haemophilus
influenzae type b; hepatitis B; measles, mumps, and rubella
(MMR); poliomyelitis; and varicella. All adults should be
immune
to measles, mumps, rubella, tetanus, and diphtheria, and
those
>65 years of age or in groups at high risk for infection
should
receive pneumococcal vaccine and annual influenza
vaccinations.
Adults susceptible to hepatitis A, hepatitis B, and/or
varicella
should be immunized if they are at risk for exposure to
these
viral agents.
The Standard
Children
The standard is immunization of children and adolescents
according to the current "Recommended Childhood
Immunization
Schedule, United States" approved each year by the Advisory
Committee on Immunization Practices of the Centers for
Disease
Control and Prevention, the American Academy of Pediatrics,
and
the American Academy of Family Physicians. Vaccinations
that
should be given are those against diphtheria, tetanus, and
pertussis (DTP/DTaP); Haemophilus influenzae type b;
hepatitis B;
measles, mumps, and rubella (MMR); poliomyelitis; and
varicella.
The specific target is >90% immunization rates by age 2
years for
the routinely recommended vaccines in the schedule.
Approximately
80% of immunizations recommended for children are scheduled
in
the first 2 years of life. For adolescents, routinely
recommended
vaccines should be given at age 11-12 years, in accordance
with
the recommendations noted previously. Children and
adolescents at
increased risk for influenza, hepatitis A, or invasive
pneumococcal infection should be given appropriate
immunizations.
1999 Childhood Immunization Schedule
Adults
The standard for adult immunizations is based on
recommendations
from the Advisory Committee on Immunization Practices of
the
Centers for Disease Control and Prevention, the American
College
of Physicians, the American Academy of Family Physicians,
and
other national organizations.
Recommendations for immunizations in adults.
Vaccine Recommendation
MMR*þ Two doses for persons born after 1956 who are at
high risk of exposure; one dose for persons born
after 1956 who are at low risk of exposure
Tetanus/diphtheria* Primary series consisting of first
dose, sond dose
after 1 month, and third dose 6-12 months later,
followed by a booster every 10 years or once at
the age of 50 years
Influenza++§ Annual vaccination
Pneumococcal++|| One vaccination, with possible
revaccination after
> 6 years
Hepatitis B#** First dose, followed by second dose 1-2
months
later; third dose 5 months later
Varicella#þþ First dose, followed by second dose 1-2 months
later
Hepatitis A#þþ+ First dose, followed by second dose 6-12
months
later
NOTE. Data are based on recommendations of the Advisory
Committee
on Immunization Practices and the American College of
Physicians.
MMR = measles-mumps-rubella.
* For all adults lacking immunity.
þ Adults born in or before 1956 are considered naturally
immune; adults born after 1956 should receive one dose of
MMR vaccine and some adults, such as college students,
persons working in health care facilities, and
international
travelers, may need two doses.
++ For all adults >65 years of age and for persons with
chronic illnesses.
§ Includes other persons at high risk such as those with
chronic cardiopulmonary disease, chronic metabolic diseases
(including diabetes mellitus), chronic renal dysfunction,
hemoglobinopathies, and immunosuppresion, as well as
residents of long-term-care facilities, providers of home
health care or health care to high-risk persons, and other
individuals who wish to avoid influenza.
|| Includes younger individuals with high-risk conditions
such as cardiopulmonary disease, diabetes, alcoholism,
chronic liver disease, chronic renal failure, or CSF leaks
or immunocompromise due to conditions such as splenic
dysfunction or asplenia, Hodgkin's disease, lymphoma,
multiple myeloma, nephrotic syndrome, and organ
transplantation; revaccination should be considered for
persons at highest risk who received te 14-valent vaccine
or
the 23-valent vaccine >6 years previously.
# For all adults in high risk groups.
** Includes those who are exposed to blood or blood
products
during their work (e.g., health care workers), clients and
staff of institutions for the developmentally disabled,
hemodialysis patients, sexually active homosexual or
bisexual males, injection drug users, recipients of certain
blood products such as factor VII or IX concentrates,
household and sexual contacts of hepatitis B virus (HBV)
carriers, sexually active heterosexual individuals with
multiple partners or a recent episode of a sexually
transmitted disease, inmates of long-term correctional
facilities, individuals from high-risk populations (e.g.,
Pacific Islanders, Alskan natives, and first generation
immigrants and/or refugees from countries where HBV
infection is of high or intermediate endemicity), and
international travelers planning prolonged visits to areas
with high rates of hepatitis B.
þþ Includes susceptible persons who may be increased risk
of
exposure or who have close contact with persons at high
risk
for serious complications from varicella infection
including
health care workers, susceptible family contacts of
immunocompromised individuals, teachers of young children,
day care workers, residents and staff in institutional
settings, college students, inmates and staff of
correctional institutions, military personnel, nonpregnant
women of childbearing age, and international travelers.
þþ+ Includes persons traveling to or working in countries
with high rates of hepatitis A virus (HAV) infections,
persons who live in communities with high rates of HAV
infections (e.g., Native Americans, Alaskan natives, and
Pacific Islanders), homosexual and bisexual males,
injection
drug users, persons with chronic liver disease, and food
handlers (optional).
All adults should be immune to measles, mumps, rubella,
tetanus,
and diphtheria. All adults >65 years of age and those
younger
individuals in high-risk groups should receive the
pneumococcal
vaccine and annual influenza vaccinations. Adults
susceptible to
hepatitis B, varicella, or hepatitis A should be
appropriately
immunized if they are at high risk for exposure or
transmission
of these agents to high-risk persons.
CLINICAL ALGORITHM(S):
None provided
DEVELOPER(S):
Infectious Diseases Society of America (IDSA) - Medical
Specialty
Society
COMMITTEE:
IDSA Practice Guidelines Committee
GROUP COMPOSITION:
Names of Committee Members: Anne A. Gershon, Pierce
Gardner,
Georges Peter, Kristin Nichols, and Walter Orenstein.
ENDORSER(S):
Not stated
GUIDELINE STATUS:
This is the current release of the guideline.
GUIDELINE AVAILABILITY:
Electronic copies: Available from the Infectious Diseases
Society
of America (IDSA) Web site.
Print copies: Available from IDSA, 99 Canal Center Plaza,
Suite
210, Alexandria, VA 22314.
COMPANION DOCUMENTS:
The following are available:
1. Gross PA, Barrett TL, Dellinger EP, Krause PJ, Martone
WJ,
McGowan JE Jr, Sweet RL, Wenzel RP. Purpose of quality
standards for infectious diseases. Infectious Diseases
Society of America. Clin Infect Dis 1994 Mar;18(3):421.
Electronic copies: Available from the IDSA Web site.
2. Gross PA. Practice guidelines for infectious diseases:
Rationale for a work in progress. Clin Infect Dis. 1998
May;26(5):1037-41.
Print copies: Available from IDSA, 99 Canal Center Plaza,
Suite
210, Alexandria, VA 22314.
PATIENT RESOURCES:
Not stated
NGC STATUS:
This summary was completed by ECRI on January 15, 1999. The
information was verified by the guideline developer as of
March
22, 1999.
COPYRIGHT STATEMENT:
This NGC summary is based on the original guideline, which
is
subject to the guideline developer's copyright
restrictions.
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Date Modified: Monday, June 14, 1999
[PAGE]
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{49} KNEE (MAMC) - 22 Feb 2000 (PRIVATE)
103 Lines
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I. TITLE: The Clinical Standard at Madigan Army Medical
Center for use of
Magnetic Resonance Imaging (MRI) and Arthroscopy of the
Knee with Chronic
and Acute Injuries
II. INDICATIONS FOR THE STANDARD: Standardizing diagnosis
tools for
patients with knee injuries will improve the utilization of
MRI and
orthopedics consultation. The present literature
demonstrates that MRI may
be a useful diagnostic tool for acute knee injuries when
examination is
complicated by pain or swelling. Unstable knee injuries
appear best
diagnosed using orthopedic examination..
III. METRICS WHICH WILL BE USED TO EVALUATE COMPLIANCE WITH
THE PRACTICE
RECOMMENDATIONS:
a. All patients will have documented acceptable knee
examination
(Hoppenfield Text and pictures for examination) to include
plain
radiography results prior to referral to orthopedics or
MRI.
b. All patients with unstable knees (Traumatic Knee Pain
Referral
Guideline, MAMC, 1 Sept 1998) will have documentation of
referral to the
orthopedics sports clinic (usually Monday AM) but they do
not require a
Magnetic Resonance Imaging (MRI).
c. All patients with stable knees will have documentation
of physical
therapy attempt, re-examination, and non-use/use of MRI(
Anterior Chronic
Knee Pain Referral Guideline MAMC, 1 Sept 1998).
IV. DATE: 1 Nov 98
V. AUTHORS: Drs Patrick St Pierre, Michael Johnson, Kelly
Dawson, Richard
Jordan, Rush Youngberg, Ann Marie Bianchi, Nelson Hagar,
and Dianna
Choolijian. POC: Dr St Pierre, (968-3178).
VI. AREAS OF DISAGREEMENT: Include the mandatory use of the
MRI in acute,
chronic, unstable, and multiple site knee injuries of the
knee. Further,
correlation of the physical examination of the injured knee
with findings
at MRI as compared to operative findings at arthroscopy,
are variable.
VII. PUBLISHED STANDARDS OF CARE RELATIVE TO CURRENT
STANDARD: Present
protocol for both acute traumatic and chronic knee
injuries, with physical
examination Physical Examination of Spine and Extremities
by Stanley
Hoppenfeld and Richard Huton, chapter 7, pages 171-196,
1976, Prentice
Hall: ISBN:0838578535 (Hoppenfield text), are in the MAMC
Orthopedic
Referral Guidelines (1 Sept 98) ( Referral Guideline
Chronic & Traumatic ,
MAMC, 1 Sept 1998) and the 1997 InterQual Criteria for
ICD-9-CMs relative
to MRI and Arthroscopy for knee injuries/pain.
VIII CLINICAL PRACTICE RECOMMENDATIONS:
All patients with Traumatic and Anterior knee injuries
(Hyperlink to
Referral Guidelines) should have a thorough knee
examination (Hoppenfield
text). Once the examination has been performed, patient
care will proceed
as follows:
1) Unstable knees: Patients with an unstable knee on
examination will be
referred to orthopedics sports clinic (Monday AM) and a
physical therapy
consult will be completed. Patients with unstable knees do
not require MRI
prior to referral to orthopedics.
2) Stable knees: Patients with a stable knee injury will be
referred to
physical therapy for six to eight weeks of therapy.
a. If there is no improvement in six to eight weeks, the
patient will be
referred to orthopedics for further workup only if they
have mechanical
symptoms of pain with palpable click, persistent effusion,
and thigh
atrophy. Otherwise, physical therapy is to continue for
another six to
eight weeks.
b. In a patient with a stable knee, an MRI should be
considered at six to
eight weeks for persistent pain without physical findings
(effusion/atrophy/palpable click). MRI is especially useful
in patients
with questionable diagnosis, conflicting diagnosis,
possible multiple
injury sites, and conflicting physical findings.
c. Patients with compromised knee or range of motion should
be referred to
orthopedics immediately (ASAP) to evaluate for a displaced
bucket handle
meniscal tear.
IX. IMPACT STATEMENT TO INSTITUTION: This new Clinical
Practice
Recommendation will standardize examination of patients
with an acute and
chronically painful knee. This ought to decrease
inappropriate MRI use and
orthopedic referral.
X. PROPOSED LINKS WITHIN THE MAMC INTRANET: To the MAMC
Orthopedic Referral
Guidelines (1 Sept 98) ( Referral Guideline, MAMC, 1 Sept
98 and the 1997
InterQual Criteria for ICD-9-CMs ) relative to MRI and
Arthroscopy for
knee injuries/pain.
XI. METHODS OF PROVIDER EDUCATION: Dr St Pierre has
volunteered to perform
in-service on how to perform an appropriate knee
examination as well as
produce a video to distribute to all areas for review.
XII. REVISION FREQUENCY: Re-evaluation of the use of MRI
and arthroscopy in
knee injury/pain in six months after initiation of the
Practice
Recommendation and annually thereafter. Further education
based on review
of practice.
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Feb 2000 (PRIVATE) 124 Lines
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I. TITLE: MADIGAN ARMY MEDICAL CENTER CLINICAL STANDARD FOR
LOW BACK PAIN
IN ADULTS
II. INDICATIONS FOR THE STANDARD: Low back problems in
adults rank high
among the reasons for physician office visits and are
costly in terms of
medical treatment, time lost from work, and diminished
quality of life.
Acute low back problems are defined as activity intolerance
due to lower
back or back-related leg symptoms of less than 3 months
duration. This
clinical standard for Low Back Pain in Adults outlines the
new paradigm
shift away from care focused exclusively on pain but toward
helping
patients improve activity tolerance. The standard provides
Primary Care
Managers with a plan to determine non-serious versus
serious spinal
pathology causing limitations due to low back symptoms.
III. METRICS WHICH WILL USED TO MONITOR ADHERANCE TO THE
PRACTICE
RECOMMENDALTIONS:
1. Documentation of initial history(algorithum page 1)
includes
description of mechanism of injury.
2. Documentation of physical examination (algorithum page
1)
includes palpation of the lumbar back.
3. Documentation of Referral to Physical Therapy
(Algorithum Page
3) at 2 weeks if patient not improving.
IV. DATE: Completed 7 October 98
V. AUTHORS: Daniel Newman, MD; MAJ Stephen Bolt, MD; COL
Shashi Kumar, MD;
LCDR Clayton Turner, MD; COL Joseph Dettori; LTC Karen
Cozean.
POC: Dr. Daniel Newman, staff, Internal Medicine
Phone: 968-0678 Fax: 968-2972
Ccmail: MAMC, Department of Medicine (MCHJ-M)
VI. AREAS OF DISAGREEMENT: No areas of significant
disagreement were noted
by the committee.
VII. PUBLISHED STANDARDS OF CARE RELATING TO CURRENT
STANDARD:
1. Adult Patients With Low Back Pain/Sciatica (ACUTE),
American Academy of Orthopedic Surgeons and North
American Spine Society, published 1997.
2. Health Care Guideline: Adult Low Back Pain,
Institute for Clinical Systems Integration, October,
1997.
3. National Low Back Pain Clinical Guidelines, The
Royal College of General Practitioners, published 1997.
4. Clinical Practice Guideline: Number 14. Acute Low
Back Problems in Adults. Rockville Md., U.S. Dept. of
Health and Human Services, Public Health Service,
Agency for Health Care Policy and Research. AHCPR
Publication No. 95-0642. December 1994.
VIII. CLINICAL PRACTICE RECOMMENDATION: Please refer to the
attached
treatment algorithm on Low Back Pain, to be used as the
standard of care.
IX. IMPACT STATEMENT TO THE INSTITUTION: This standard of
care will impact
all providers who care for adult patients with back pain:
all Primary Care
managers, Orthopedists, Neurologists, Neurosurgeons,
Radiologists, Physical
Therapists, Physical Medicine and Rehabilitation , nursing
personnel,
laboratory personnel, and Pharmacy personnel. It will
impact physical
therapy with an initial increase in referrals, balanced
later by a decrease
in chronic low back pain patients referred. It may impact
family practice
or other providers privileged to perform osteopathic
manipulation, with an
increase in patients receiving osteopathic manipulation.
X. LINKS WITHIN THE MAMC INTRANET: The Low Back Pain in
Adults clinical
standard will be published on the MAMC Intranet on the
Clinical Standards
Webpage. It will be hypertexted to the related Referral
Guidelines on the
Intranet, and referenced on the CHCS bulletin board within
the appropriate
Referral Guidelines (Currently related referral guidelines
are: Low Back
Pain (mechanical, adult), and Low Back Pain (with
neurological symptoms). A
unified Low Back Pain, Acute referral guideline is
currently undergoing
ratification) . Electronic notice of the approved Low Back
Pain clinical
standard will be sent to all providers using current
electronic mail
systems on CHCS and CC: Mail.
XI. METHODS OF PROVIDER EDUCATION:
Department Chiefs will notify their departments of the
standard
and emphasize the use of the guideline.
Inservices will be given by the authors to all primary care
providers encompassing the care standard for low back pain
and
the referral guidelines to specialty care.
The treatment algorithm for Low Back Pain will be listed on
the
MAMC intranet site.
Copies of the practice recommendation for treatment of low
back
pain will be made available at appropriate patient care
sites.
Publish the practice recommendation to providers at our
Regional
care facilities for reference.
Send automated reminders via CHCS when providers order
pharmaceuticals for the treatment of low back pain.
XII. REVISION FREQUENCY: This standard of care for Low Back
Pain will be
reviewed by the Clinical Standards Committee annually.
Revisions deemed
necessary by the authors, based on data such as updated
treatment
guidelines or outcomes of metric audits, will be
incorporated into the care
standard for low back pain, and will be forwarded to the
Clinical Standards
Committee for approval on an annual basis or earlier if the
need is
determined.
[PAGE]
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{24} LOW VISION - 22 Feb 2000 (PRIVATE)
176 Lines
----------------------------------------------------------------------------
National
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Clearinghouse
[HOME] [NGC RESOURCES] [HELP] [WHAT'S NEW] [SITE
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Browse NGC: Disease/Condition Treatment/Intervention
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------------------------------------------------------------------------
Brief Summary
TITLE:
Care of the patient with low vision.
SOURCE(S):
St. Louis (MO): American Optometric Association; 1997. 72
p.
(Optometric clinical practice guideline; no. 14) [111
references]
ADAPTATION:
Not applicable: Guideline was not adapted from another
source.
RELEASE DATE:
1997 (reviewed 1999)
MAJOR RECOMMENDATIONS:
Potential Components of the Comprehensive Examination of
the
Patient with Low Vision
A. Patient History
1. Nature of the presenting problem, including diagnosis,
visual difficulties, and chief complaint
2. Visual and ocular history, including family ocular
history
3. General health history, pertinent review of systems,
family medical history
4. Medication usage and medication allergies
5. Social history
6. Vocational, educational, and avocational vision
requirements (i.e., needs assessment)
B. Visual Acuity
1. Distance visual acuity testing
2. Near visual acuity testing
C. Refraction
1. Objective refraction
2. Subjective refraction
3. Assessment of present spectacles and low vision devices
D. Ocular Motility and Binocular Vision Assessment
1. Gross assessment of ocular alignment
2. Sensorimotor testing
3. Amsler grid testing, monocular and binocular
4. Contrast sensitivity testing, monocular and binocular
5. Effects of lenses, prisms, or occlusion on visual
functioning
E. Visual Field Assessment
1. Confrontation visual field testing
2. Amsler grid assessment, monocular and binocular
3. Tangent screen testing
4. Goldmann bowl perimetry or equivalent kinetic testing
5. Automated static perimetry
F. Ocular Health Assessment
1. External examination
2. Biomicroscopy
3. Tonometry
4. Central and peripheral fundus examination
G. Supplemental Testing
1. Contrast sensitivity
2. Glare testing
3. Color vision
4. Visually evoked potential
5. Electroretinogram
6. Electro-oculogram
Management of Visual Impairment
Management strategies for the following types of visual
impairment are discussed in the guideline document:
* Reduced visual acuity
* Central visual field defects
* Peripheral visual field defects
* Reduced contrast sensitivity and glare sensitivity
CLINICAL ALGORITHM(S):
An algorithm is provided for Optometric Management of the
Patient
with Low Vision.
DEVELOPER(S):
American Optometric Association (AOA) - Professional
Association
COMMITTEE:
American Optometric Association Consensus Panel on Care of
the
Patient with Low Vision
GROUP COMPOSITION:
Members: Kathleen E. Fraser, O.D. (Principal Author); Roy
Gordon
Cole, O.D.; Eleanor E. Faye, M.D.; Paul B. Freeman, O.D.;
Gregory
L. Goodrich, Ph.D.; Joan A. Stelmack, O.D.; Stanley F.
Wainapel,
M.D., M.P.H.
AOA Clinical Guidelines Coordinating Committee Members:
John F.
Amos, O.D., M.S., (Chair); Kerry L. Beebe, O.D.; Jerry
Cavallerano, O.D., Ph.D.; John Lahr, O.D.; Richard L.
Wallingford, Jr., O.D.
ENDORSER(S):
Not stated
GUIDELINE STATUS:
This is the current release of the guideline. According to
the
guideline developer, this guideline has been reviewed on a
biannual basis and is considered to be current.
An update is not in progress at this time.
GUIDELINE AVAILABILITY:
Electronic copies: Available from the American Optometric
Association Web site.
Print copies: Available from the American Optometric
Association,
243 N. Lindbergh Blvd., St. Louis, MO 63141-7881.
COMPANION DOCUMENTS:
The following is available:
* Quick reference guide. Low vision. St. Louis, MO:
American
Optometric Association, 1997.
Print copies: Available from the American Optometric
Association
(AOA), 243 N. Lindbergh Blvd, St. Louis, MO 63141-7881.
PATIENT RESOURCES:
None available
NGC STATUS:
This summary was completed by ECRI on December 1, 1999. The
information was verified by the guideline developer on
January
31, 2000.
COPYRIGHT STATEMENT:
This NGC summary is based on the original guideline, which
is
subject to the guideline developer's copyright restrictions
as
follows:
Copyright to the original guideline is owned by the
American
Optometric Association (AOA). NGC users are free to
download a
single copy for personal use. Reproduction without
permission of
the AOA is prohibited. Permissions requests should be
directed to
Jeffrey L. Weaver, O.D., Director, Clinical Care Group,
American
Optometric Association, 243 N. Lindbergh Blvd., St. Louis,
MO
63141; (314) 991-4100, ext. 244; fax (314) 991-4101;
e-mail,
ClinicalGuidelines@theAOA.org.
Return to top
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Date Modified: Sunday, February 06, 2000
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{51} METFORMIN (MAMC) - 22 Feb 2000
(PRIVATE) 96 Lines
----------------------------------------------------------------------------
Department of Pharmacy
[Mamclogo.gif (11446 bytes)]
Metformin Prescribing Guidelines
Appropriate Use: Metformin is approved by the FDA for first
line treatment
of Maturity Onset Diabetes Mellitus (NIDDM) used after diet
alone fails. It
is also approved for use in combination with sulfonylureas.
It is more
expensive ($1.50/day maximum dose) than glyburide
($0.28/day maximum dose)
and therefore should ordinarily be used after both diet and
sulfonylurea
therapy has failed. The combination of sulfonylureas and
metformin is
clearly more potent than either agent alone. Thus the usual
algorithm is:
1. Diet
2. Diet plus sulfonylurea (non obese) or metformin as
monotherapy in the obese patient, based on... BMI > 27
BMI = wt in kg (height in M2)
3. Diet plus sulfonylurea plus metformin.
4. Diet plus insulin
Success is defined as an FBS < 115 at any given step
and failure as FBS > 140 with intermediate values
leaving room for individualization of therapy.
Dosage: Tablets come in 500mg and 850mg. GI intolerance is
common. Doses
should be adjusted weekly in increments until an effective
level is reached
or the maximum dose (2500mg) is reached. e.g.
Week One Week Two Week Three Week Four Week Five
Option 500mg
#1 BID 1000mg AM 1000mg AM 1000mg AM
500mg PM 1000mg PM 500mg
Midday
1000mg PM
Or
Option
#2 850mg QD 850mg BID 850mg TID
Much of the improvement comes within the first few days
but may continue for several months.
Contraindications: Biguanides are known to cause lactic
acidosis
in patients with a predisposing risk factor. The actual
incidence
for metformin is, however, quite low and when it has
occurred has
frequently been in patients with risk factors.
1. Renal impairment (delayed excretion of metformin,
acidosis). Serum Creatinine >1.3mg/dl for women,
>1.4mg/dl for men.
2. Excess alcohol use.
3. Shock: CHF, sepsis, myocardial infarcts,
dehydration.
4. Acidosis.
5. Major surgery.
6. Hypoxia, COPD, pneumonia, asthma.
7. Use of iodinated contrast material (stop metformin
before study).
8. Stop in-hospitalized patients and substitute insulin
until discharge.
9. Cirrhosis.
Advantages:
1. Different mechanism of action than sulfonylureas,
decreases hepatic gluconeogenesis, accelerates glucose
transport.
2. No hypoglycemia when used alone.
3. Tends to lower lipid levels when used alone.
4. Tendency to cause mild weight loss in contrast to
sulfonylureas and insulin.
5. Preservation of lean body mass.
Pharmacy Home Page MAMC Home Page
------------------------------------------------------------------------
Send mail to Pharmacy Pagemaster with questions or comments
about this web
site.
Copyright © 1998
Last modified: January 04, 2000
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{26} MUSCULOSKELETAL CONDITIONS - 22 Feb 2000 (PRIVATE) 375
Lines
----------------------------------------------------------------------------
National
Guideline
Clearinghouse
[HOME] [NGC RESOURCES] [HELP] [WHAT'S NEW] [SITE
MAP] [CONTACT NGC] [ABOUT NGC]
Search NGC: Search Help Detailed Search
Browse NGC: Disease/Condition Treatment/Intervention
Organization
Options: Brief Summary Complete Summary Full Text
Compare Guidelines: Add to Guideline Collection View
Guideline
Collection
------------------------------------------------------------------------
Brief Summary
TITLE:
Guidelines for the initial evaluation of the adult patient
with
acute musculoskeletal symptoms.
SOURCE(S):
Arthritis Rheum 1996 Jan;39(1):1-8 [41 references]
ADAPTATION:
Not applicable: Guideline was not adapted from another
source.
RELEASE DATE:
1995 Oct 10
MAJOR RECOMMENDATIONS:
The most useful information in evaluating musculoskeletal
pain
comes from the history and physical examination, with
reassessment as necessary. When the diagnosis and proper
management are obscure, selective ordering of tests and/or
consultation may be the most cost-effective approach.
Specific recommendations, excerpted by NGC:
History
Musculoskeletal emergencies may present with acute symptoms
and
must be excluded. These conditions include infection (for
example, septic arthritis, subacute bacterial endocarditis
and
sepsis, osteomyelitis, necrotizing faciitis), systemic
vasculitis, acute myelopathy or spinal cord compression,
fracture, deep vein thrombosis, and anterior compartment
syndrome
or tumor.
"Red flags" suggesting the need for urgent evaluation
and
management of the patient with musculoskeletal symptoms are
summarized in the following table:
Feature Differential diagnosis
History of significant trauma Soft tissue injury, internal
derangement, or fracture
Hot, swollen joint Infection, systemic rheumatic
disease, gout, pseudogout
Constitutional signs and symptoms Infection, sepsis,
systemic
(e.g., fever, weight loss, rheumatic disease
malaise)
Weakness
* Focal Focal nerve lesion (compartment
syndrome, entrapment neuropathy,
mononeuritis multiplex, motor
neuron disease, radiculopathy*)
* Diffuse Myositis, metabolic myopathy,
paraneoplastic syndrome,
degenerative neuromuscular
disorder, toxin, myelopathy,*
transverse myelitis
Neurogenic pain (burning, numbness, paresthesia)
* Asymmetric Radiculopathy,* reflex sympathetic
dystrophy, entrapment neuropathy
* Symmetric Myelopathy,* peripheral neuropathy
Claudication pain pattern Peripheral vascular disease,
giant
cell arteritis (jaw pain), lumbar
spinal stenosis
* Radiculopathy and myelopathy may be due to infectious,
neoplastic, or mechanical processes.
After excluding musculoskeletal emergencies, an orderly
evaluation will sort out the major diagnostic
possibilities.
Diagnostically useful clinical features in the initial
evaluation
of the patient with acute musculoskeletal symptoms are
summarized
in the following table:
Tendinitis/bursitis Noninflammatory Systemic
joint problems* rheumatic
disease+
Symptoms
* AM stiffness Focal, brief Focal, brief Significant,
prolonged
* Constitutional Absent Absent Present
symptoms
* Peak period or With use After prolonged After
discomfort use prolonged
inactivity
Locking or Unusual, except Implies loose Uncommon
instability rotator cuff tear, body, internal
trigger finger derangement, or
weakness
* Symmetry Uncommon Occasional Common
Signs
* Tenderness Focal, Unusual Over entire
periarticular, or exposed
tender points joint spaces
(fibromyalgia)
* Inflammation Over tendon or Unusual Common
(fluid, pain bursa
warmth,
erythema)
* Instability Uncommon Occasional Uncommon
* Multisystem No No Often
disease
* For example, osteoarthritis or internal derangement.
+ For example, rheumatoid arthritis (RA) and systemic lupus
erythematosus (SLE)
Physical examination
Guided by the history, the physical examination helps to
distinguish between mechanical problems, soft tissue
disease, and
noninflammatory and inflammatory joint disease. A major
goal of
the examination is to detect warmth over a joint, joint
effusion,
and pain on joint motion. These are the hallmarks of
synovitis.
Limitations in range of motion and instability are also
important
to assess.
Clincal syndromes:
Some distinct symptom patterns are useful in sorting out
musculoskeletal symptoms and suggesting the diagnostic
possibilities.
Monarthralgia or oligoarthralgia. Joint symptoms of one and
up to
a few joints may be due to trauma, infection,
crystal-induced
inflammation (gout, pseudogout), or primary inflammatory
arthritis (including spondylarthropathies and atypical
presentation of RA). In acute monarthritis, it is essential
that
infection of a joint be diagnosed or excluded, and this can
only
be done by joint aspiration and synovial fluid culture.
Chronic
monarticular symptoms with little or no effusion are
usually from
OA. Tendinitis and bursitis generally involve one joint
region,
and the physical examination is usually diagnostic.
Polyarthralgia or polyarthritis. A careful history and
complete
physical examination are essential to the evaluation of
polyarthritis because the differential diagnosis is
extensive.
The presence of prolonged morning stiffness, systemic
symptoms,
Raynaud's phenomenon, rash, or sicca symptoms, and
manifestations
of other organ involvement suggest a systemic rheumatic
disease.
The specific evaluation is guided by the clinical
manifestations
and should screen organ systems which can be involved
without
overt signs, such as the lung, heart, liver, kidney, and
bowel,
for potential involvement. Precise diagnosis and effective
management require close followup as well as consultation
and are
beyond the scope of this guideline. If the history and
physical
examination do not provide a diagnosis, symptomatic
management
and reassessment over several weeks is more productive
initially
than is laboratory testing or diagnostic imaging.
Myalgia. This symptom may be secondary to a localized
problem
(trauma or overuse) or a systemic disorder (acute or
chronic
infection, toxic or metabolic disorders) or, less commonly,
it
may reflect a primary muscle disease. In otherwise healthy
patients, the findings of normal strength and multiple
tender
points in characteristic locations should raise the
possibility
of fibromyalgia. Proximal weakness and elevated creatine
phosphokinase enzyme levels suggest inflammatory myopathy.
A
patient 50 years or older with myalgias of the shoulder and
hip
girdle and normal strength should be evaluated for
polymyalgia
rheumatica, including measurement of the erythrocyte
sedimentation rate (ESR).
Laboratory Studies
In the initial evaluation of acute joint symptoms,
diagnostic
testing for rheumatic disease should be undertaken only
after a
careful history and physical examination, and is
unnecessary when
a mechanical problem or extraarticular source is diagnosed.
The Westergren ESR is elevated in infection, inflammatory
states,
and malignancy and is not, by itself, diagnostic of a
specific
disease. Although the ESR is diagnostically nonspecific, in
the
setting of polyarthralgia and an equivocal joint
examination, an
elevated ESR suggests that an inflammatory arthritis is
more
likely. The ESR is almost always markedly elevated and,
therefore, diagnostically useful in patients with giant
cell
arteritis and polymyalgia rheumatica.
Serum RF should be ordered when there is at least a
moderate
suspicion of RA: symmetric, small joint, polyarticular
joint pain
with inflammatory symptoms or signs. The diagnosis should
never
be based solely on the results of RF testing. The higher
the RF
titer, the more likely a positive RF is related to RA.
ANA tests should not be ordered in patients with focal
problems
(e.g., back pain, localized tendinitis) who do not have
systemic
symptoms. Nearly all patients with SLE show ANA positivity
on
human cell line substrates (HEp-2 cells), but positive test
results without SLE are common when few manifestations of
SLE are
present. While a patient with a positive ANA with few or no
compatible clinical features is unlikely to have SLE, the
higher
the titer, the more likely the result is related to SLE or
other
ANA-associated disease. A positive ANA can be further
subclassified by the pattern and the specific autoantibody
detected (anti-double-stranded DNA, anti-Ro, anti-La,
anti-Scl-70, anti-RNP, anti-Sm, etc.) and can be useful in
suggesting a specific rheumatic disease, but should not be
ordered routinely
Panels of tests: A variety of serologic and biochemical
tests
have been bundled into ``arthritis panels,'' which
increases the
frequency of finding positive results unrelated to
rheumatic
disease. This may confuse the situation and lead to
unnecessary
or inappropriate further testing or treatment; therefore,
panels
are not recommended.
Polarized microscopy: Definitive diagnosis of gout is based
on
the demonstration of monosodium urate crystals by polarized
microscopy of synovial fluid. However, a compelling
clinical
presentation, such as recurrent, acute, self-limited
podagra, may
be sufficient.
Synovial fluid analysis is indicated in evaluating an acute
monarthritis or in the febrile patient with established
arthritis
with an acute flare, to rule out septic arthritis. Analysis
of
synovial fluid by polarized light microscopy must be
performed
promptly by someone competent in the technique, since
studies
show considerable variation in laboratory accuracy. Any
inflammatory fluid without an explanation, particularly
when
fever is present, should be assumed to be infected until
proven
otherwise by appropriate culture.
Imaging Studies
Imaging studies are indicated when the examination cannot
localize the anatomic structure that is causing symptoms,
especially after significant trauma, when there is loss of
joint
function (e.g., unable to bear weight), when pain continues
despite conservative management, when a fracture or bone
infection is suspected, or when there is a history of
malignancy.
Plain radiographs will be unrevealing or unhelpful (and are
therefore not indicated) for most patients with acute and
new
symptoms of RA, SLE, gout, mechanical back pain, or
tendinitis/bursitis. Radiographs may confirm the diagnosis
of OA
and assess its severity, but normal findings on radiographs
do
not rule out the presence of OA. More specialized imaging
such as
MRI or radionuclide bone scanning is useful when specific
disorders are suspected and the management would be altered
according to the findings. These studies should be reserved
for
patients in whom specific disorders are suspected, when the
diagnosis cannot be made in a less costly manner, and only
after
a thorough history and physical examination.
Referral criteria
To increase the likelihood of an optimal outcome,
consultation is
recommended in patients who have the following conditions:
* Suspected septic arthritis
* Undiagnosed multisystem or systemic rheumatic disease
* Acute myelopathy or mononeuritis multiplex
* Undiagnosed synovitis, in whom arthrocentesis or synovial
biopsy may be needed
* Musculoskeletal pain undiagnosed after 6 weeks
* Unexplained immunochemical test abnormalities suggestive
of
an underlying rheumatic disease
* Musculoskeletal pain not adequately controlled with
therapy
* Musculoskeletal pain associated with severe or
progressive
loss of function or work productivity
* Conditions for which treatment with steroids or
immunosuppressive drugs is considered
* Systemic rheumatic disease in a pregnant or postpartum
patient
* Dysfunction out of proportion to objective findings
* Suspected acute tendon/muscle rupture
* Acute internal derangement with severe pain, poor
function,
or instability
* End-stage joint disease
CLINICAL ALGORITHM(S):
Algorithms are provided for:
1. an initial approach to the patient with symptoms in one
or a
few joints and
2. an initial approach to the patient with polyarticular
joint
symptoms.
DEVELOPER(S):
American College of Rheumatology (ACR) - Medical Specialty
Society
COMMITTEE:
Ad Hoc Committee on Clinical Guidelines
GROUP COMPOSITION:
Names of Committee Members: Robert H. Shmerling, MD
(co-chairman); Howard A. Fuchs, MD (co-chairman);
Christopher D.
Lorish, PhD; Lisa A. Nichols, MSN, RN, FNP-C; Alison J.
Partridge, LICSW; Robert B. Brigham; Jorge
Sanchez-Guerrero, MD,
MSc; R. A. Sands, MD; Matthew H. Liang, MD, MPH
(ex-officio).
ENDORSER(S):
Not stated
GUIDELINE STATUS:
This is the current release of the guideline.
An update is not in progress at this time.
GUIDELINE AVAILABILITY:
Electronic copies: Available from the American College of
Rheumatology (ACR) Web site.
Print copies: Available from the American College of
Rheumatology, 1800 Century Place, Suite 250, Atlanta, GA
30345.
COMPANION DOCUMENTS:
None available
PATIENT RESOURCES:
Not stated
NGC STATUS:
This summary was completed by ECRI on January 15, 1999. The
information was verified by the guideline developer as of
March
5, 1999.
COPYRIGHT STATEMENT:
This NGC summary is based on the original guideline, which
is
subject to the guideline developer's copyright
restrictions.
The guideline is copyrighted by the American College of
Rheumatology. Reproduction is prohibited. For multiple
copies,
contact the American College of Rheumatology at 404-633-377
or
acr@rheumatology.org
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Date Modified: Tuesday, June 08, 1999
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================================================================================
{25} MYOCARDIAL
ISCHEMIA - 22 Feb 2000 (PRIVATE) 224 Lines
----------------------------------------------------------------------------
National
Guideline
Clearinghouse
[HOME] [NGC RESOURCES] [HELP] [WHAT'S NEW] [SITE
MAP] [CONTACT NGC] [ABOUT NGC]
Search NGC: Search Help Detailed Search
Browse NGC: Disease/Condition Treatment/Intervention
Organization
Options: Brief Summary Complete Summary Full Text
Compare Guidelines: Add to Guideline Collection View
Guideline
Collection
------------------------------------------------------------------------
Brief Summary
TITLE:
Coronary artery disease with myocardial infarction.
SOURCE(S):
Ann Intern Med 1997 Apr 1;126(7):561-82 [280 references]
Ann Intern Med 1997 Apr 1;126(7):556-60 [11 references]
ADAPTATION:
Not applicable: Guideline was not adapted from another
source.
RELEASE DATE:
1996 Apr 22
MAJOR RECOMMENDATIONS:
Strength of Evidence Grades Used in Major Recommendations:
A: Supported by data from large, randomized clinical
trials.
B: Supported by well-designed clinical studies.
C: Supported by a synthesis of small observational reports.
D: Supported by consensus and practice norms without
empirical
documentation.
The strength-of-evidence grade is given in parentheses
after each
position.
Acute Evaluation Phase:
1. The initial clinical history, physical examination, and
electrocardiogram provide critical information for risk
stratification of a patient who may be having an acute
infarction. Important predictors of outcome include age,
hemodynamics (systolic blood pressure and heart rate) at
time of presentation, evidence of congestive heart failure
on physical examination, location of the infarction, and
history of previous infarction. (A)
2. Although the acute use of such specialized technologies
as
echocardiography and perfusion imaging may provide
additional information in specific clinical situations,
their incremental value in the acute evaluation of patients
who may have an infarction has not been proven. Thus, we
cannot currently recommend their routine use. (C)
3. Rapid triage of reperfusion candidates and patients in
cardiogenic shock is necessary to optimize myocardial
salvage and, ultimately, the number of lives saved. (A)
Cardiac Care Unit Phase:
1. Patients with clear evidence of myocardial damage should
be
admitted to an intensive care setting in which staff are
trained to interpret hemodynamic and electrocardiographic
data and provide rapid therapy, such as defibrillation, if
needed. (B)
2. Patients receiving thrombolytic therapy should be
monitored
for clinical signs of reperfusion. Those who do not have
reperfusion have a higher risk for death or complications
after infarction (B) and may benefit from "rescue"
reperfusion therapy. (B)
3. Patients who do not have complications within 24 hours
after
infarction can be moved to a less intensive, but monitored,
medical setting. (B)
Hospital Phase:
1. The optimal duration of continuous rhythm monitoring is
unknown, but this monitoring should continue for at least
24
hours after transfer from an intensive care unit (C).
2. Patients who have recurrent ischemia, high-grade
arrhythmia,
or congestive heart failure after infarction are at high
risk for death, complications, or both (B) and may benefit
from cardiac catheterization (D).
3. Patients who have no complications should be considered
for
early discharge from the hospital. In many clinical
settings, these patients may be discharged safely after 4
to
5 days of hospitalization (B).
Predischarge Phase:
1. Left ventricular function should be assessed in all
patients
who have an infarction (A). This assessment can be done
accurately on the basis of clinical factors alone in at
least 40% of patients (B).
2. Specialized methods, such as Holter monitoring,
signal-averaged electrocardiography, heart rate variability
assessment, and programmed electrical stimulation studies,
can detect patients at increased risk for sudden cardiac
death (B). However, because abnormal results on these tests
have not been shown to alter patient management, they are
not currently recommended for routine care after an
infarction (B).
3. Patients who have markers for residual ischemia on
noninvasive stress testing are at increased risk for later
infarction or death (B).
4. Adding radionuclide ventriculography, perfusion imaging,
or
echocardiography to electrocardiographic stress testing
increases the sensitivity of electrocardiographic stress
testing for the prediction of future cardiac events but
decreases the overall specificity of this testing. The
incremental value of additional imaging has not been shown
to be worth the increased cost (C).
5. Among patients who have uncomplicated infarctions, those
with significant left ventricular dysfunction are more
likely to have multivessel disease and to incur a long-term
survival advantage from coronary revascularization (A).
Thus, they may benefit from routine cardiac
catheterization.
6. Patients who have uncomplicated infarctions and
preserved
left ventricular function are at low risk (mortality rate,
<3% over the first year after infarction); thus,
noninvasive
tests can be used safely for risk stratification (B).
7. Screening and intervention for the purposes of secondary
prevention, including education about smoking cessation;
therapy for hyperlipidemia, hypertension, or diabetes; and
cardiac rehabilitation, can significantly improve long-term
prognosis and should be part of routine care after an
infarction (A). Additional life-prolonging medical
therapies
(with aspirin, beta-blockers, and angiotensin-converting
enzyme inhibitors for patients with significant ventricular
dysfunction) should also be instituted in patients who have
no clinical contraindications to these therapies (A).
CLINICAL ALGORITHM(S):
Algorithms are provided for risk stratification after
myocardial
infarction and predischarge evaluation.
DEVELOPER(S):
American College of Physicians (ACP) - Medical Specialty
Society
COMMITTEE:
Clinical Efficacy Assessment Subcommittee, Health and
Public
Policy Committee
GROUP COMPOSITION:
Authors: Eric D. Peterson, MD; Leslee J. Shaw, Ph.D.;
Robert M.
Califf, MD
Names of Committee Members: George E. Thibault, MD, Chair;
John
R. Feussner, MD, Co-Chair; Anne-Marie J. Audet, MD;
Gottlieb C.
Friesinger Jr, MD; Daniel L. Kent, MD; Keith I. Marton, MD;
Valerie Anne Palda, MD; John J. Whyte, MD; Preston L.
Winters, MD
ENDORSER(S):
American College of Physicians Board of Regents
GUIDELINE STATUS:
This is the current release of the guideline.
An update is not in progress at this time.
GUIDELINE AVAILABILITY:
Electronic copies: Available from the American College of
Physicians and American Society of Internal Medicine
(ACP-ASIM)
Web site.
Print copies: Available from ACP-ASIM, 190 N. Independence
Mall
West, Philadelphia, PA 19106-1572.
COMPANION DOCUMENTS:
The statements made by ACP in the guideline document were
developed using the information provided in the following
background paper:
* Peterson ED, Shaw LJ, Califf RM. Risk stratification
after
myocardial infarction Ann Intern Med 1997;126(7):562-82.
Information contained in this background paper is
represented in
the methodology fields of the NGC summary (i.e., Methods to
Collect Evidence; Methods to Analyze the Evidence; Cost
Analysis).
Electronic copies: Available from the American College of
Physicians and American Society of Internal Medicine
(ACP-ASIM)
Web site.
Print copies: Available from ACP-ASIM, 190 N. Independence
Mall
West, Philadelphia, PA 19106-1572.
PATIENT RESOURCES:
None available
NGC STATUS:
This summary was completed by ECRI on September 1, 1998.
The
information was verified by the guideline developer on
December
1, 1998.
COPYRIGHT STATEMENT:
This NGC summary is based on the original guideline, which
is
subject to the guideline developer's copyright
restrictions.
Summaries of ACP-ASIM guidelines may be downloaded from the
NGC
Web site and/or transferred to an electronic storage and
retrieval system solely for the personal use of the
individual
downloading and transferring the material. Permission for
all
other uses must be obtained from ACP-ASIM by contacting the
ACP-ASIM Permissions Coordinator, telephone: (800)
523-1546, ext.
2670.
Return to top
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Date Modified: Wednesday, September 29, 1999
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================================================================================
{52} NONSTEROIDALS (MAMC) - 22
Feb 2000 (PRIVATE) 105 Lines
----------------------------------------------------------------------------
Department of Pharmacy
[Mamclogo.gif (11446 bytes)]
Non-Steroidal Anti-Inflammatory Agent
Prescribing
Guidelines
Factors to consider in the use of these agents include
properties of the
drug as well as properties of the patient. From an efficacy
standpoint, in
general, there are few major differences among the various
NSAIDs, although
there are clear individual variations in response. Of
particular note
should be the concern of Gastrointestinal Damage and renal
toxicity.
Patients at increased risk for gastrointestinal toxicity
include:
a. age over 60.
b. history of peptic ulcer disease.
c. concomitant corticosteroid or warfarin use.
d. previous use of H2-blockers, Protien Pump Inhibitors
(PPI's).
e. taking higher doses of NSAIDs.
1. First line agents: Decide whether an NSAID is warranted.
One may benefit
from the analgesic Acetaminophen 650-1000mgs.
* Motrin 400-800mgs tid ($0.01-0.02 per tab)
* Indocin 25-50mgs tid ($0.01-0.02 per tab)
* Naproxen 250-500mgs bid ($0.05-0.07 per tab)
* Salsalate 500mg 2 tabs twice daily ($0.02 per tab)
2. If response after 3-4 weeks is unsatisfactory, utilize a
different first
line drug or the addition of tylenol to these agents may
prove effective.
3. Second line agents: If first line agents are
unsuccessful, consider
second line agents. These are considered second line agents
mainly due to
cost or possible increase in gastrointestinal toxicity.
* Ansaid 100mgs bid ($0.11 per tab)
* Feldene 20mgs daily ($0.03 per tab)
* Clinioril 200mgs bid ($0.07 per tab)
* Tolectin 400mgs tid ($0.10 per tab)
* Meclomen 100mgs qid ($0.09 per tab)
4. Third line agents:
* Voltaren 75mgs bid ($0.25 per day)
* Daypro 600-1200mgs daily (not on formulary) ($0.50-1.00
per day)
* Relafen 500-1000mgs bid (not on formulary) ($1.21-2.42
per day)
* Lodine 200-400mgs tid (not on formulary) ($0.32-0.62 per
day)
5. If patients are considered high risk for
gastrointestinal toxicity (see
prescribing algorithm); then consider whether the patient
truly needs an
NSAID. If so, consider the use of the nonacetylated
salicylate initially.
If salsalate is unsuccessful consider the use of the
prostaglandin E1
analog Misoprostol at 200 micrograms twice daily in
conjunction with a
NSAID. If misoprostol cannot be used, omeprazole may be
used in combination
with the NSAID. A third option is to use a COX II inhibitor
in lieu of
combination therapy.
If the patient has renal compromise, there are no studies
suggesting that
one NSAID is preferred over any other. Salsalate, which is
a nonacetylated
salicylate and poor prostaglandin inhibitor, may have less
effect on
glomerular filtration.
6. Tips to reduce the risk of NSAIDs in the elderly:
- Do not prescribe NSAIDs when they are not necessary.
- Do not continue treatment longer than necessary.
- Start at the lowest dose and follow-up for toxicity and
therapeutic benefit.
- Increase the dose cautiously.
- Never add non-selective NSAIDs into anticoagulant
therapy.
- Beware of high-risk drugs (e.g. corticosteriods) and high
risk
patients with HTN, CHF, or Liver Failure
- Beware of drug interactions (e.g. warfarin, ACE
inhibitors).
7. Patients on chronic NSAID therapy should have close
follow-up as this
class of drugs is associated with more iatrogenic
complications than any
other. The American College of Rheumatology recommends lab
evaluation with
CBC, Urinalysis, creatinine, potassium, and SGOT every 1-3
months initially
and then every 3-12 months after stability. Patients
needing more frequent
evaluations include those with diabetes, renal disease,
polypharmacy or age
over 60.
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{27} OCCULT BLOOD IN THE STOOL - 22
Feb 2000 (PRIVATE) 178
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Organization
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------------------------------------------------------------------------
Brief Summary
TITLE:
Suggested technique for fecal occult blood testing and
interpretation in colorectal cancer screening.
SOURCE(S):
Ann Intern Med 1997 May 15;126(10):808-10
Ann Intern Med 1997 May 15;126(10):811-22 [82 references]
ADAPTATION:
Not applicable: Guideline was not adapted from another
source.
RELEASE DATE:
1996 Oct 26
MAJOR RECOMMENDATIONS:
Relative Contraindications to Screening with Fecal Occult
Blood
Tests
Screening with fecal occult blood tests should not be done
in
persons who are likely to have misleading results, such as
those
with active hemorrhoidal bleeding or symptoms that already
suggest colorectal cancer.
Type of Test and Specimen Collection
The most practical and appropriate technique for screening
with
fecal occult blood tests currently involves a guaiac-based
test.
Two slides should be prepared from each of three
consecutive
bowel movements; the person being screened should be
encouraged
to prepare for stool sampling by abstaining from aspirin in
dosages greater than 325 mg/d, substantial doses of
nonsteroidal
anti-inflammatory drugs, red meat, poultry, fish, some raw
vegetables, and vitamin C. Slides should not be rehydrated
and
should be developed within 7 days of preparation.
Screening Test Frequency
No recommendation is made about the optimal frequency (that
is,
annual or biennial) for screening with fecal occult blood
tests.
Definition and Evaluation of Positive Fecal Occult Blood
Test
Results
A positive result on a fecal occult blood test should be
defined
as positivity in one or more slide windows; this definition
maximizes the sensitivity of the entire screening
procedure. A
positive result should generally lead to a complete
colorectal
examination within 2 to 3 months for neoplasms.
Method of Complete Colorectal Evaluation
The best approach to a complete colorectal evaluation is to
proceed directly to complete colonoscopy, assuming that
high-quality colonoscopy is readily available. A possible
alternative is an examination with flexible sigmoidoscopy
and
high-quality, air-contrast barium enema.
Interpretation of Negative Fecal Occult Blood Test Results
A negative result on a fecal occult blood test cannot rule
out
colorectal cancer. If symptoms that indicate possible
colorectal
cancer develop after a negative screening result, timely
evaluation is warranted. (Such an evaluation of symptoms
would be
considered a diagnostic work-up rather than screening).
Management after a Complete Colorectal Evaluation for a
Positive
Screening Test Result
If Colonoscopy Reveals No Clinically Important Colorectal
Neoplasm
If complete colonoscopy reveals no colorectal neoplasm or
only a
single, small (<1 cm) tubular adenoma, further screening
for
colorectal cancer may reasonably be deferred for 5 or more
years.
If Colonoscopy Detects a High-Risk Lesion
If colonoscopy detects a lesion that is associated with a
high
risk for colorectal cancer, colonoscopic surveillance is
warranted after the lesion is removed.
CLINICAL ALGORITHM(S):
None provided
DEVELOPER(S):
American College of Physicians (ACP) - Medical Specialty
Society
COMMITTEE:
Clinical Efficacy Assessment Subcommittee, Health and
Public
Policy Committee
GROUP COMPOSITION:
Authors: David F. Ransohoff, MD, and Christopher A. Lang,
MD
Clinical Efficacy Assessment Subcommittee: George E.
Thibault,
MD, Chair; John R. Feussner, MD, Co-Chair; Anne-Marie J.
Audet,
MD; Gottlieb C. Friesinger Jr., MD; Daniel L. Kent, MD;
Keith I.
Marton, MD; Valerie Anne Palda, MD; John J. Whyte, MD; and
Preston L. Winters, MD.
ENDORSER(S):
American College of Physicians Board of Regents
GUIDELINE STATUS:
This is the current release of the guideline.
An update is not in progress at this time.
GUIDELINE AVAILABILITY:
Electronic copies: Available from the American College of
Physicians and American Society of Internal Medicine
(ACP-ASIM)
at
http://www.acponline.org/journals/annals/15may97/ppcolo1.htm.
Print copies: Available from the ACP-ASIM, 190 N.
Independence
Mall West, Philadelphia, PA 19106-1572.
COMPANION DOCUMENTS:
The statements made by ACP in the guideline document are
developed using the information provided in the following
background paper:
Ransohoff DF, Lang CA. Screening for colorectal cancer with
the
fecal occult blood test: a background paper Ann Intern Med
1997
May 15; 126(10): 811-822
Electronic copies: Available from the American College of
Physicians and American Society of Internal Medicine
(ACP-ASIM)
at
http://www.acponline.org/journals/annals/15may97/ppcolo2.htm.
Print copies: Available from the ACP-ASIM, 190 N.
Independence
Mall West, Philadelphia, PA 19106-1572.
Information contained in this background paper is
represented in
the methodology field of the NGC summary (i.e., Methods to
Collect Evidence; Methods to Analyze the Evidence; Cost
Analysis).
PATIENT RESOURCES:
Not stated
NGC STATUS:
This summary was completed by ECRI on October 1, 1998. The
information was verified by the guideline developer on
December
1, 1998.
COPYRIGHT STATEMENT:
This NGC summary is based on the original guideline, which
is
subject to the guideline developer's copyright
restrictions.
Summaries of ACP-ASIM guidelines may be downloaded from the
NGC
Web site and/or transferred to an electronic storage and
retrieval system solely for the personal use of the
individual
downloading and transferring the material. Permission for
all
other uses must be obtained from ACP-ASIM by contacting the
ACP-ASIM Permissions Coordinator, telephone: (800)
523-1546, ext.
2670.
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{16} OSTEOARTHRITIS OF THE
KNEE - 22 Feb 2000 (PRIVATE) 158
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------------------------------------------------------------------------
Brief Summary
TITLE:
Guidelines for the medical management of osteoarthritis.
Part II.
Osteoarthritis of the knee.
SOURCE(S):
Arthritis Rheum 1995 Nov;38(11):1541-6 [40 references]
ADAPTATION:
Not applicable: Guideline was not adapted from another
source.
RELEASE DATE:
1995 Jul 8
MAJOR RECOMMENDATIONS:
Excerpted by NGC
The medical management of patients with osteoarthritis (OA)
of
the knee should be individualized and based on numerous
factors,
including the presence of such comorbid conditions as
hypertension, heart disease, peptic ulcer disease, or
kidney
disease, which influence decisions about drug therapy.
Medical management begins with nonpharmacologic therapy.
This
includes patient education, health professional social
support
via telephone contact, weight loss (if overweight),
physical
therapy, occupational therapy, and aerobic exercise
programs
(particularly aquatic). During physical therapy the patient
will
perform range of motion exercises and quadriceps
strengthening
exercises, and receive assistive devices for ambulation.
The
occupational therapist will teach the principles of joint
protection and energy conservation, and will provide
assistive
devices for activities of daily living and instrumental
activities of daily living.
In patients with OA of the knee who have an effusion and
local
signs of inflammation, judicious use of intraarticular
corticosteroid injections is appropriate. When joints are
painful
and swollen, aspiration of fluid, followed by
intraarticular
injection of a corticosteroid is an effective short-term
method
of decreasing pain and increasing quadriceps strength. It
is
generally recommended, although not well supported by
published
data, that injection of corticosteroids in a given joint
not be
performed more than 3-4 times in a given year because of
concern
about the possible development of progressive cartilage
damage
through repeated injection in the weight-bearing joints.
Most
individuals who require more than 3-4 intraarticular
injections
per year to control symptoms are probably candidates for
joint
lavage or surgical intervention.
The non-opioid, simple analgesic, acetaminophen, is the
initial
drug of choice for systemic treatment of symptomatic OA of
the
knee.
In individuals with OA of the knee who do not respond to
oral
analgesics or do not wish to take systemic therapy, the use
of
topical analgesics, is appropriate as either adjunctive or
monotherapy, respectively.
If the patient fails to respond to acetaminophen or other
oral or
topical analgesics, the use of a nonsteriodal
antiinflammatory
drug (NSAID) is indicated.
Closed tidal knee irrigation with saline, and arthroscopic
lavage, with or without debridement, are procedures which
can not
be routinely recommended at this time due to limited
evidence.
Patients with severe symptomatic OA of the knee who have
pain
that has failed to respond to medical therapy and
progressive
limitation in acitvities of daily living should be referred
to
orthopedic surgeons for evaluation.
CLINICAL ALGORITHM(S):
An algorithm is provided for the medical management of
patients
with symptomatic osteoarthritis of the knee.
DEVELOPER(S):
American College of Rheumatology (ACR) - Medical Specialty
Society
COMMITTEE:
Not applicable
GROUP COMPOSITION:
Authors: Marc C. Hochberg, MD, MPH; Roy D. Altman, MD;
Kennenth
D. Brandt, MD; Bruce M. Clark, CPT; Paul A. Dieppe, MD;
Marie R.
Griffin, MD, MPH; Roland W. Moskowitz, MD; Thomas J.
Schnitzer,
MD, PhD.
ENDORSER(S):
Arthritis Foundation - Disease Specific Society
GUIDELINE STATUS:
This is the current release of the guideline.
An update is in progress.
GUIDELINE AVAILABILITY:
Electronic copies: Available from the American College of
Rheumatology (ACR) Web site.
Print copies: Available from the American College of
Rheumatology, 1800 Century Place, Suite 250, Atlanta, GA
30345.
COMPANION DOCUMENTS:
The following is available:
Towheed TE and Hochberg MC. A systematic review of
randomized controlled trials of pharmacologic therapy in
osteoarthritis of the knee, with an emphasis on trial
methodology. Semin Arth Rheum 1997: 27:755-70.
PATIENT RESOURCES:
Not stated
NGC STATUS:
This summary was completed by ECRI on January 15, 1999. The
information was verified by the guideline developer as of
March
24, 1999.
COPYRIGHT STATEMENT:
This NGC summary is based on the original guideline, which
is
subject to the guideline developer's copyright
restrictions.
The guideline is copyrighted by the American College of
Rheumatology. Reproduction is prohibited. For multiple
copies,
contact the American College of Rheumatology at 404-633-377
or
acr@rheumatology.org
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{28} OSTEOPOROSIS - 22 Feb 2000
(PRIVATE) 246 Lines
----------------------------------------------------------------------------
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Organization
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------------------------------------------------------------------------
Brief Summary
TITLE:
Osteoporosis. Guide to prevention, diagnosis, and
treatment.
SOURCE(S):
Boston (MA): Brigham and Women's Hospital; 1999. 9 p. [6
references]
ADAPTATION:
Not applicable: Guideline was not adapted from another
source.
RELEASE DATE:
1999
MAJOR RECOMMENDATIONS:
Bone Health
Universal Recommendations for All Women
Calcium
Menarche to age 18 1,300 mg/day
Age 19 to menopause 1,000 mg/day
Postmenopause 1,200 mg/day
Dietary sources
Note: Most Americans get 400-800 mg calcium from diet,
primarily
from dairy sources.
Yogurt (8 oz) 300 mg (fruit)
400 mg (plain)
Milk (8 oz) 300 mg
Cheese slice (1 oz) 200 mg
Supplements
To maximize efficacy, split daily intake (e.g., <500 mg
twice per
day)
Calcium carbonate 500-600 mg
(e.g., Oscal/Oscal D. Caltrate/Caltrate D, generic; Tums =
200-500 mg)
Requires acid stomach for absorption; take meals to avoid
gastric distress.
Calcium citrate
(e.g., Citrical/Citrical 200-315 mg
D)
Better absorbed, fewer side effects, but more expensive.
Vitamin D
400-800 IU/day
400 IU is usual dose in multivitamins; for more, take
vitamin D
supplement or combined calcium-vitamin D supplement (e.g.,
Caltrate D, Citrical D, generic). Fortified milk (8 oz)
contains
100 IU. For patients with no vitamin D deficiency, upper
safely
limit is 2,000 IU/day; patients with vitamin D deficiency
require
higher doses
Exercise
Weight-bearing and strength-training (upper and lower body)
* Includes walking, jogging, stair climbing, dancing,
tennis,
and weight-lifting.
* Continuous activity <40 minutes (may substitute two
20-minute sessions) at least two times per week
Smoking
Avoid cigarette smoking
Alcohol
Avoid excessive alcohol
Low bone density in alcohol-dependent women has been
documented,
but the daily amount of alcohol intake that increases
osteoporosis risk is undetermined. Advice on alcohol should
be
balanced with research that suggests >1 drink/day increases
risk
of breast cancer; 2 drinks/day (upper limit) protects
against
cardiovascular disease.
Management Recommendations
Prevention of Osteoporosis
T-score between -1 and -2.5
* Review daily intake of calcium (1,200 mg) and vitamin D
(400-800 IUs)
* Review weight-bearing exercise, avoiding smoking and
excessive alcohol
* Consider preventive therapy with antiresorptive agent
(ie,
estrogen, alendronate, raloxifene; refer to Table 1 in the
original guideline for details); for patients already on
hormone replacement therapy, consider alternative therapy
or
possible combination
Treatment of Osteoporosis
T-score below 2.5
* Review daily intake of calcium (1,200 mg) and vitamin D
(400-800 IUs)
* Review weight-bearing exercise, avoiding smoking and
excessive alcohol
* Initiate osteoporosis therapy (ie, estrogen, alendronate,
calcitonin, raloxifene; refer to Table 2 in the original
guideline for details); for patients already on hormone
replacement therapy, consider alternative therapy or
possible combination
Follow-up for Osteopenia and Osteoporosis
* Annual visit; review nutritional and lifestyle guidelines
* Confirm compliance with therapy
(50% or more discontinue HRT within 1 yr)
* Repeat BMD in 12-24 months; subsequently at physician's
discretion
* If BMD is falling and antiresorptive therapy was not
initiated in osteopenia setting, reconsider antiresorptive
therapy
Indications for Referral to Specialist
* Secondary causes of osteoporosis
* Contraindications to standard osteoporosis therapy
* Bone loss on osteoporosis therapy
* Fracture on osteoporosis therapy
* Complex medical history
CLINICAL ALGORITHM(S):
An algorithm is provided for the evaluation and treatment
of
osteoporosis.
DEVELOPER(S):
Brigham and Women's Hospital (Boston) - Hospital/Medical
Center
COMMITTEE:
Not stated
GROUP COMPOSITION:
Osteoporosis Guideline Authors: Meryl S. LeBoff, MD; Bonnie
Bermas, MD; Andrea Dunaif, MD; Soheyla Gharib, MD; David G.
Fairchild, MD; Elizabeth Ginsburg, MD; Paula A. Johnson,
MD, MPH;
Caren G. Solomon, MD, MPH.
ENDORSER(S):
Not stated
GUIDELINE STATUS:
This is the current release of the guideline.
An update is not in progress at this time.
GUIDELINE AVAILABILITY:
Electronic copies: Not available at this time.
Print copies: Available from the Brigham and Women's
Hospital, 75
Francis Street, Boston, MA 02115; telephone: (800)
BWH-9999, Web
site, www.partners.org/bwh/home.html.
COMPANION DOCUMENTS:
None available
PATIENT RESOURCES:
The following is available:
* Health bones for life. Prevention, diagnosis and
treatment
for osteoporosis. Boston (MA): Brigham and Women's
Hospital;
1999. 10 p.
Electronic copies: Not available at this time.
Print copies: Available from the Brigham and Women's
Hospital, 75
Francis Street, Boston, MA 02115; telephone: (800)
BWH-9999, Web
site, www.partners.org/bwh/home.html.
Please note: This patient information is intended to
provide
health professionals with information to share with their
patients to help them better understand their health and
their
diagnosed disorders. By providing access to this patient
information, it is not the intention of NGC to provide
specific
medical advice for particular patients. Rather we urge
patients
and their representatives to review this material and then
to
consult with a licensed health professional for evaluation
of
treatment options suitable for them as well as for
diagnosis and
answers to their personal medical questions. This patient
information has been derived and prepared from a guideline
for
health care professionals included on NGC by the authors or
publishers of that original guideline. The patient
information is
not reviewed by NGC to establish whether or not it
accurately
reflects the original guideline's content.
NGC STATUS:
This summary was completed by ECRI on January 7, 2000.. The
information was verified by the guideline developer on
February
7, 2000.
COPYRIGHT STATEMENT:
This NGC summary is based on the original guideline, which
is
subject to the guideline developer's copyright
restrictions.
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{53} OSTEOPOROSIS (MAMC) - 22
Feb 2000 (PRIVATE) 84 Lines
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Department of Pharmacy
[Mamclogo.gif (11446 bytes)]
Guideline for Management of Post-Menopausal
Osteoporosis
Definition:
Osteoporosis is a metabolic bone disease
characterized by low bone mass, and
micro-architectural deterioration of bone tissue,
resulting in increased bone fragility and fracture
risk.
Who:
Criteria for the diagnosis: a Bone Mineral Density
more than 2.5 standard deviations below the young
adult mean. Established osteoporosis requires the
presence of at least one atraumatic fracture.
Practically, at Madigan Army Medical Center,
radiologic evidence of osteopenia and atraumatic
fractures in the absence of other bone disease =
symptomatic osteoporsis.
Morbidity & Mortality:
From osteoporosis is due solely to fractures.
Osteoporosis is an asymptomatic state. The goal of
therapy, therefore, is to reduce the fracture
rate.
There are currently three (3) agents on the MAMC formulary
that have FDA
approval for use in osteoporosis. They are: estrogen,
alendronate and
calcitonin. Of these only estrogen and alendronate are
approved for both
prevention and treatment of osteoporosis. Calcitonin is
approved only for
treatment of established osteoporosis as described above.
Both estrogen and
alendronate reduce fracture rates. Estrogen appears more
effective than
alendronate. Evidence that calcitonin reduces fractures is
scant. Based on
this data the following is a recommended approach to
osteoporosis
treatment.
1. General Measures: Adequate calcium and vitamin D intake
should be
assured for an individual's life time.
* Vitamin D: 400-800 units per day
* Calcium:
800mg/day to age 10
1200mg/day in adolescence
1000mg/day to age 65
1300-2000mg/day there after
Weight bearing exercise and avoidance of alcohol, tobacco
and extreme
thinness are also recommended.
2. Drug Therapy:
First Line: Estrogen @0.625mg of conjugated estrogens per
day.
Must use with progesterone in women who have not had
hysterectomies. Estrogen has been shown to prevent
fractures in
women regardless of years post menopause.
Second Line: If there is a contraindication to
estrogen,alendronate can be used. For established
osteoporosis
give alendronate 10mg per day. Must be given on an empty
stomach.
No food for 30 minutes. Patient must remain upright after
taking
the dose. For prevention in patients without Fx, but a Bone
Mineral Density more than 2.5 SD below the young adult mean
give
alendronate 5mg per day. Follow same precautions as for the
10mg
dose.
Option: If estrogen & alendronate cannot be used.
Calcitonin: 200
units/day be nasal spray or 100 units/day subcutaneous
injection.
(Exception: Alendronate and calcitonin may be considered at
anytime in
glucocorticoid induced osteoporosis.)
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{29} PEPTIC ULCER - 22 Feb 2000
(PRIVATE) 128 Lines
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------------------------------------------------------------------------
Brief Summary
TITLE:
Peptic ulcer disease.
SOURCE(S):
Ann Arbor (MI): University of Michigan Health System; 1997.
5 [4
references]
ADAPTATION:
Not applicable: Guideline was not adapted from another
source.
RELEASE DATE:
1996 Oct (revised 1997 Jan)
MAJOR RECOMMENDATIONS:
Note from NGC: The following key points summarize the
content of
the guideline. Refer to the full text for additional
information,
including detailed information on dosing and cost
considerations
for therapy for H. pylori associated peptic ulcer disease.
* Clinical approach. Eradication of HP infection alters the
natural history of peptic ulcer disease. Successful
eradication reduces PUD recurrence rate from 90% to <10%
per
year. PUD generally does not recur in the successfully
treated patient unless nonsteroidal anti-inflammatory drug
(NSAID) use is present.
* Diagnosis. A recent economic analysis demonstrated a cost
effectiveness advantage of initial serologic testing and
antibiotic therapy for HP in patients with symptoms
suggestive of PUD when compared to immediate endoscopy.
[evidence: C*]
* Treatment. H. pylori eradication therapy consists of
antibiotics and antisecretory drugs. [evidence: A*]
Long-term acid inhibition is inappropriate in the
management
of HP-related PUD in most instances.
* Follow-up. Referral to the gastroenterologist should
occur
for all patients with complicated ulcer disease and for
patients who fail initial serologic-guided therapy.
(Persistent symptoms after 2 weeks of therapy suggests an
alternative diagnosis.)
* Definitions
Levels of evidence for the most significant
recommendations:
A. Randomized controlled trials
B. Controlled trials, no randomization
C. Observational trials
D. Opinion of expert panel
CLINICAL ALGORITHM(S):
An algorithm is provided for the management of peptic ulcer
disease.
DEVELOPER(S):
University of Michigan Health Systems - Academic
Institution
COMMITTEE:
Peptic Ulcer Guideline Team
GROUP COMPOSITION:
Members: Catherine Adsit, RN; A. Mark Fendrick M.D.; Van
Harrison, PhD. Ray Rion, MD; James Scheiman, MD; Connie
Standiford, MD.
UMMC Guidelines Oversight Team: Connie Standiford, MD; Lee
Green,
MD, MPH; Van Harrison, PHD; Christopher Wise, PhD.
ENDORSER(S):
Not stated
GUIDELINE STATUS:
This is the current release of the guideline.
According to the guideline, an update is in progress at
this
time.
GUIDELINE AVAILABILITY:
Electronic copies: Available from the NGC Web site.
Print copies: Available from the University of Michigan
Health
System, Office of Clinical Affairs, The University of
Michigan
Hospitals, C-201 Med Inn, Box 0826, Ann Arbor, Michigan
49109-0826. Telephone: (734) 763-0555; Fax (734) 936-9406.
COMPANION DOCUMENTS:
None available
PATIENT RESOURCES:
Not stated
NGC STATUS:
This summary was completed by ECRI on May 20, 1999. The
information was verified by the guideline developer on June
17,
1999.
COPYRIGHT STATEMENT:
This NGC summary is based on the original guideline, which
is
copyrighted by the University of Michigan Health Systems
(UMHS).
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------------------------------------------------------------------------
Brief Summary
TITLE:
Pharyngitis.
SOURCE(S):
Ann Arbor (MI): University of Michigan Health System; 1996.
8 [8
references]
ADAPTATION:
Not applicable: Guideline was not adapted from another
source.
RELEASE DATE:
1996 Nov
MAJOR RECOMMENDATIONS:
General approach
* Viral agents cause most cases of pharyngitis: 90% in
adults,
60%-75% in children. [evidence: C*]
* The prime reason to identify and treat Group A
beta-hemolytic streptococcal (GABHS) pharyngitis is to
decrease the risk of acute rheumatic fever. [evidence: A*]
The endemic incidence of ARF is around 0.23-1.88 / 100,000.
* Early treatment of GABHS can decrease the time a patient
is
symptomatic by 1/2 - 2 days from a typical 3 - 7 days
[evidence: A*] and may decrease the period of
contagiousness
[evidence: C*].
Diagnosis
* Symptoms/signs can indicate the probability of GABHS,
with
the probability more accurate for adults than for children.
1. Adults: a limited set of symptoms and signs can
identify a low, intermediate, or high probability of
having GABHS pharyngitis. [evidence: C*]
2. Children: symptoms and signs can suggest a lower or
higher probability. [evidence: C*]
* Laboratory confirmation is most useful when GABHS is
suspected but not highly probable.
1. Adults: test those with intermediate probability.
[evidence: C*]
2. Children: test all cases where GABHS is suspected,
since the probability level is less certain. [evidence:
D*]
* Throat culture is the "gold standard" for diagnosis
[evidence: C*]. Strep screens identify GABHS more rapidly,
but are somewhat less sensitive [evidence: C*]. In patients
where GABHS is suspected and tested with a streptococcal
antigen screen, a negative result should be confirmed by
culture. If a rapid screen is done for a low probability
patient, a negative result need not be followed up by
culture. [evidence: C*]
Treatment
* Penicillin is the drug of choice (amoxicillin for
children);
erythromycin for patients allergic to penicillin.
[evidence:
C*]
* Antibiotic treatment must be carried out for an entire
10-day period. [evidence: D*]
Controversial areas:
* Based on a description over the phone, a clinician may
decide to treat for GABHS [evidence: C*]:
1. an adolescent or adult with symptoms suggesting a high
probability of GABHS pharyngitis.
2. a patient of any age with a family member with
documented GABHS pharyngitis.
* Definitions
Levels of evidence for the most significant
recommendations:
A. Randomized controlled trials
B. Controlled trials, no randomization
C. Observational trials
D. Opinion of expert panel
CLINICAL ALGORITHM(S):
Algorithms are provided for:
* Management of adult pharyngitis
* Management of pediatric pharyngitis
DEVELOPER(S):
University of Michigan Health Systems - Academic
Institution
COMMITTEE:
Pharyngitis Guideline Team
GROUP COMPOSITION:
Team Leader: John Crump, MD.
Team Members: Van Harrison, PhD; Michele Rea, RN; Barbara
Reed,
MD; Thomas Shope, MD; Connie Standiford, MD.
UMMC Guidelines Oversight Team: Connie Standiford, MD; lee
Green,
MD, MPH; Van Harrison, PhD; Christopher Wise, PhD.
ENDORSER(S):
Not stated
GUIDELINE STATUS:
This is the current release of the guideline.
An update is not in progress at this time.
GUIDELINE AVAILABILITY:
Print copies: Available from the University of Michigan
Health
System, Office of Clinical Affairs, The University of
Michigan
Hospitals, C-201 Med Inn, Box 0826, Ann Arbor, Michigan
49109-0826. Telephone: (734) 763-0555; Fax (734) 936-9406.
COMPANION DOCUMENTS:
None available
PATIENT RESOURCES:
Not stated
NGC STATUS:
This summary was completed by ECRI on May 20, 1999. The
information was verified by the guideline developer on June
17,
1999.
COPYRIGHT STATEMENT:
This NGC summary is based on the original guideline, which
is
copyrighted by the University of Michigan Health Systems
(UMHS).
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{54} PLANTAR FASCIITIS (MAMC)
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I. PLANTAR FASCIITIS CLINICAL MANAGEMENT STANDARD,MADIGAN
ARMY MEDICAL
CENTER
This standard is to complement the Plantar Fasciitis
referral guideline.
II. INDICATIONS FOR PLANTAR FASCIITIS CLINICAL
STANDARDS: Plantar Fasciitis ( "Arch Pain",
Symptomatic
"Flat Feet", Heel
Spur Syndrome) is a very common foot condition which is
easily the single
most common condition seen in the podiatry clinic. Because
of its
intractable nature it is frustrating to deal with both from
the patient and
provider point of view. The purpose of this standard is to
delineate a
treatment plan which can be used by primary care providers
and provide a
more consistent approach to the condition. With appropriate
treatment at
the primary care level this condition will have a greater
chance of
resolving early and not evolving into a long term chronic
problem. This
will also help to optimize the efficiency of the podiatry
clinic.
III. METRICS WHICH WILL BE USED TO MONITOR COMPLIANCE WITH
THE PRACTICE
RECOMMENDATIONS FOR PLANTAR FASCIITIS:
1. Documentation that patients have received written
information/education
(Patinet Information and Color Picture)* material regarding
plantar
fasciitis.
Documentation that patients have had at least a one month
trial
of non-steroidal
anti-inflammatory medication.
Documentation that patient is being referred to the
podiatry
clinic only after remaining symptomatic in spite of six
months of
treatment.
IV. DATE OF COMPLETION: 3 November 1998
V. AUTHORS: LTC Jeffrey Zimmerman, DPM; MAJ Michael
Johnson, MD;
LTC Fred Johnstone, MD
VI. AREAS OF DISAGREEMENT: No areas of significant
disagreement were noted
by the authors.
VII. PUBLISHED STANDARDS OF CARE/REFERENCES:
1) Comprehensive Textbook of Foot Surgery, E. Dalton
McGlamry, 1992
2) "Outcome of Nonsurgical Treatment for Plantar
Fasciitis", Lowell Gill
and Gary Kiebzak, Foot & Ankle International, Vol 17, No 9/
September 1996.
3) "Plantar Fasciitis in Runners", Barbara Warren,
Sports
Medicine, Vol 10,
No 5/ 1990.
4) "Use of Posterior Night Splints in the Treatment of
Plantar Fasciitis"
Jerry Ryan,
American Family Physician, Vol 53, No3/ September 1995
5) "Plantar Fasciitis, Orthopedic Sports Medicine
Kit".
Syntex 9005-17,
Syntex. Puerto Rico, Inc, 1989 Picture Handout
VIII. CLINICAL PRACTICE RECOMMENDATION: Refer to the
attached treatment
algorithm Treatment Infomation sheet and Picture.
Plantar Fasciitis usually presents in one of two forms: a
generalized type
which involves a diffuse area in the mid arch area of the
foot (commonly
associated with a flat foot) and a localized type which
usually involves
the plantar aspect of the heel (commonly associated with a
heel spur). The
treatment of these two types of fasciitis is essentially
the same.
Presenting Features:
Generalized type- The hallmark of this type of fasciitis is
increased pain
in the arch of the foot with any type of prolonged activity
(standing,
walking or running). The patient often complains of a sharp
"tearing" type
of pain in the arch of the foot which is relieved by rest.
Localized type- The hallmark of this type of fascitiis is
severe plantar
heel pain when rising out of bed in the morning. The
patient usually states
that they are forced to walk with a limp for several
minutes before the
pain subsides to a tolerable level. The pain in the heel
will then return
after any type of prolonged weightbearing activity. This
type of fasciitis
is more common in middle-aged people.
If the patient is experiencing excruciating heel or arch
pain which
prevents weightbearing on the foot, other etiologies should
be considered.
Patient should be referred to podiatry.
History:
Both types of fasciitis usually have an insidious onset
with no history of
trauma. Often times though the patient will give an
"overuse" type of
history and state that the pain started after spending an
excessive amount
of time on their feet ( "my foot hasn't felt the same since
the road march
I was on last month")
The patient should be queried about the amount of time they
spend walking
barefoot and the types of shoes that are worn. Active duty
patients should
be asked what type of shoe is worn off-duty. These
questions are very
important!- barefoot walking causes an excessive stretch on
the plantar
fascia and will aggravate both types of fasciitis. Many
times the sole
cause of plantar fasciitis (both types) is the shoe that
the patient is
wearing.
The following types of shoes can cause/exacerbate plantar
fasciitis:
Sandals
Loafers (moccasins, deck shoes)
Badly worn shoes
Shoes with no arch support
Shoes with a flexible shank (the shank is the middle part
of the sole,
immediately in
front of the heel)
Exam:
The exam is usually unremarkable except for tenderness
along the fascia as
it courses through the arch (generalized type) or point
tenderness at the
plantar/medial plantar area of the heel (localized type).
Rarely, diffuse
swelling may be seen over the involved area.
Ankle joint range of motion should be checked with the knee
fully extended:
10 degrees of ankle joint dorsiflexion is considered
adequate. Less than
this may tend to aggravate plantar fasciitis.
The overall position of the foot should be checked with the
patient
standing. Plantar fasciitis can be seen in any foot type
but is more in the
overpronated (flat) foot.
Radiograph evaluation:
Weightbearing radiograph of the foot is usually
unremarkable except for the
presence of a plantar heel spur. This is an incidental
finding. The
presence of a spur does not change the treatment plan and
symptoms are
identical whether a spur is present or not. Patients should
not be led to
believe that their spur needs to be removed surgically in
order to obtain
relief from their heel/arch pain. In spite of this a
weightbearing lateral
radiograph of the foot should be taken before referral to
podiatry.
Treatment for both types of fasciitis, both generalized and
local (also
described in Referral Guideline and Treatment Sheet and
Picture
Initial Visit- continue the following for one month
1. Limit Activity (profile for active duty). No high impact
type activity.
Amount of restrictions on walking, marching and running
contingent on
severity of symptoms.
2. Appropriate shoe (see shoes to avoid under
"history"). A
lace-up rigid
shanked shoe is recommended. The shank of the shoe is the
middle part of
the sole, immediately in front of the heel. No barefoot
walking allowed.
Patient should wear an over-the -counter type arch support
(e.g. Polysorb
insoles by Spenco, Dr, Scholls arch supports, Sorboair
insoles or similar
brand) in all shoes. These are available at the PX and at
sport shoe
stores.
4. Heel cord stretches- wall push up with knee bent. 30
second stretch,
three to five times daily. Place ice on symtomatic area for
twenty minutes
after aggravating activity.
5. Non steroidal anti-inflammatory medication
6. Dispense appropriate patient education/information*
regarding fasciitis.
It should be stressed to the patient that all of these
things should be
done every day, i.e. wearing an appropriate shoe during the
day and then
wearing loafers at night will only delay improvement of the
patient's
condition.
Second Month:If there has been at least a 50% improvement
in the patient's
condition, continue the above treatments. If less than 50%
improvement,
continue the above, plus:
1. Add "running shoes only" to profile.
2. Patient should wear a removable type of "L" splint
to
bed which will
force the foot to be kept at 90 degrees to the leg while
sleeping. It is
normally secured to the leg and foot with an Ace wrap. This
splint should
be requested from an orthopedic cast room. The request
should be worded:
"Posterior lower leg splint-removeable- for nighttime
use".
Indicate if
splint is for right side, left side or both. The request
should be taken by
the patient to the cast room and given to an orthopedic
technician .
3. Consider a change in NSAID used.
4. Assess ankle joint dorsiflexion /document compliance
with stretching.
Continue these treatments for another eight weeks.
Fourth Month:
If there has been at least a 50% improvement in the
patient's condition,
continue the above treatments. If less than 50%
improvement, continue the
above, plus:
1. Send patient to physical therapy for ultrasound or
iontophoresis
treatments to the affected area. Request a custom fit foot
orthoses (arch
support) from the orthotics lab. The most common type used
at Madigan is
the "Amfit" foot orthoses. Continue these treatments
for
another eight
weeks. If patient is still symptomatic after six months
they should be
referred to the podiatry clinic.
IX. IMPACT STATEMENT TO THE INSTITUTION: This standard of
care will impact
all providers who care for adult patients with foot pain:
All Primary Care
managers, Orthopedists, Physical Therapists and
Podiatrists. It will reduce
the current number of patients referred to the podiatry
clinic for
fasciitis and thereby increase the availability of
appointments to patients
with other foot pathology. This will reduce the number of
Prime patients
who are currently being disengaged due to nonavailability
of appointments.
X. PROPOSED ELECTRONIC LINKS:The Plantar Fasciitis clinical
standard will
be published on the MAMC Intranet within the Disease
Management
Recommendations, Clinical Pathways and Practice Guidelines.
It will be
hyperlinked to the related Referral Guidlines on the
Intranet and
referenced on the CHCS bulletin board within the
appropriate referral
guidelines (current related referral guidelines are: Arch
Pain, Flat Feet,
Heel Pain, Plantar Fasciitis) Electronic notice of the
approved Plantar
Fasciitis clinical standard will be sent to all providers
using current
electronic mail systems on CHCS and cc:Mail.
XI. METHODS OF PROVIDER EDUCATION:
1. Department Chiefs will notify their departments of the
standard and
emphasize the use of the guideline
2. The clinical standard and algorithm for the treatment of
plantar
fasciitis will be listed on the MAMC Intranet site.
3. Patient Information relative to Plantar Fasciitis will
be available at
patient care sites and will be hotlinked to the clinical
standard/practice
recommendations so that providers can assess it.
4. Publish the practice recommendation to providers at our
Regional care
facilities for reference.
XII. REVISION FREQUENCY: This standard of care for Plantar
Fasciitis will
be reviewed by the Clinical Standards Committee annually.
Revisions deemed
necessary by the authors, based on data such as updated
treatment
guidelines or outcomes of metric audits, will be
incorporated into the care
standard for plantar fasciits and will be forwarded to the
Clinical
Standards Committee for approval if these changes are
significant prior to
the annual review.
[PAGE]
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{31} PROSTATIC CANCER - 22 Feb
2000 (PRIVATE) 218 Lines
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MAP] [CONTACT NGC] [ABOUT NGC]
Search NGC: Search Help Detailed Search
Browse NGC: Disease/Condition Treatment/Intervention
Organization
Options: Brief Summary Complete Summary Full Text
Guideline Synthesis
Compare Guidelines: Add to Guideline Collection View
Guideline
Collection
------------------------------------------------------------------------
Brief Summary
TITLE:
Screening for prostate cancer.
SOURCE(S):
Ann Intern Med 1997 Mar 1;126(5):394-406 [181 references]
Ann Intern Med 1997 Mar 15;126(6):480-4 [52 references]
Ann Intern Med 1997 Mar 15;126(6):468-79
ADAPTATION:
Not applicable: Guideline was not adapted from another
source.
RELEASE DATE:
1996 Feb 10
MAJOR RECOMMENDATIONS:
Recommendation 1: Rather than screening all men for
prostate
cancer as a matter of routine, physicians should describe
the
potential benefits and known harms of screening, diagnosis,
and
treatment; listen to the patient's concerns; and then
individualize the decision to screen. Factors to consider
include
the following:
1. The principal reason for caution is that the balance of
benefit and harm from early treatment is unknown. The risks
of treatment are known, but the benefits are not known
because no controlled studies of the effect of early
treatment on death from prostate cancer have been done.
2. Indirect evidence based on decision models suggests that
if
screening and treatment prove beneficial, men who are 50 to
69 years of age will enjoy most of the benefit from
screening. Men older than 69 years of age will gain little
from screening.
3. It is important to note that because additional
information
is obtained from digital rectal examination (for example,
information on occult blood in the stool, masses, rectal
fissures, fistulas, and hemorrhoids), digital rectal
examination is valuable for evaluating conditions other
than
prostate cancer.
4. In issuing a general recommendation against the routine
use
of such tests, the College acknowledges that it may be
reasonable for a physician to recommend that an individual
patient be screened for prostate cancer. The area of
greatest controversy is screening for men who are between
50
and 69 years of age. For men in this age group, the
physician should be particularly guided by the patient's
preference and by the physician's and the patient's
interpretation of the risk-benefit equation. Clinicians
should be prepared to discuss this issue with their
patients, to provide counseling on an individual basis, and
to document these discussions. Potential benefits must be
balanced against the potential morbidity and mortality
related to treatment by radical prostatectomy or radiation
therapy.
5. Black men and men with a family history of prostate
cancer
should be made aware of their higher lifetime risk.
However,
available evidence does not suggest that they should be
cared for differently from men at average risk.
Recommendation 2: The College strongly recommends that
physicians
help enroll eligible men in ongoing clinical studies.
Counseling Patients
All men who are considering having digital rectal
examination and
PSA measurement should understand the potential risks and
benefits of screening and participate with their physicians
in
deciding whether to be tested. Before any testing occurs,
patients should be fully informed about the following:
1. Prostate cancer is an important health problem.
2. The benefits of one-time or repeated screening and
aggressive treatment of prostate cancer have not yet been
proven.
3. Digital rectal examination and PSA measurement can both
have
false-positive and false-negative results.
4. The probability that further invasive evaluation will be
required as a result of testing is relatively high.
5. Aggressive therapy is necessary to realize any benefit
from
the discovery of a tumor.
6. A small but finite risk for early death and a
significant
risk for chronic illness, particularly with regard to
sexual
and urinary function, are associated with these treatments.
7. Early detection may save lives.
8. Early detection and treatment may avert future
cancer-related illness.
Routine PSA measurement without a frank discussion of the
issues
involved is inappropriate. Patients who elect to be
screened,
either by digital rectal examination or PSA measurement,
should
provide verbal informed consent. In making this
recommendation,
the College acknowledges the logistical difficulties of
trying to
incorporate an informed decision-making approach to
screening for
prostate cancer into a busy practice. Various strategies,
ranging
from fact sheets to videotapes, have been devised to assist
clinicians in providing an unbiased summary of the
potential
benefits and harms that can result from screening. No
published
data have indicated the optimal way to facilitate such
physician-patient communication. As with much of clinical
medicine, the interpretation of the general information
that is
available in brochures or videotapes must be tailored to
the
individual patient. This interpretation is probably best
done in
the context of an ongoing relationship with a primary care
provider.
CLINICAL ALGORITHM(S):
None provided
DEVELOPER(S):
American College of Physicians (ACP) - Medical Specialty
Society
COMMITTEE:
Clinical Efficacy Assessment Subcommittee; Health and
Public
Policy Committee
GROUP COMPOSITION:
Authors: Christopher M. Coley, MD; Michael J. Barry, MD;
and
Albert G. Mulley, MD, MPP
Members of the Clinical Efficacy Assessment Subcommittee:
George
E. Thibault, MD, Chair; John R. Feussner, MD, Co-Chair;
Anne-Marie J. Audet, MD; Gottlieb C. Friesinger Jr., MD;
Daniel
L. Kent, MD; Keith I. Marton, MD; Valerie Anne Palda, MD;
John J.
Whyte, MD; and Preston L. Winters, MD.
ENDORSER(S):
American College of Physicians Board of Regents
GUIDELINE STATUS:
This is the current release of the guideline.
An update is not in progress at this time.
GUIDELINE AVAILABILITY:
Electronic copies: Available from the American College of
Physicians and American Society of Internal Medicine
(ACP-ASIM)
Web site at:
http://www.acponline.org/journals/annals/15mar97/ppscreen.htm
Print copies: Available from ACP-ASIM, 190 N. Independence
Mall
West, Philadelphia, PA 19106-1572.
COMPANION DOCUMENTS:
The following are available:
1. Coley CM, Barry MJ, Fleming C, Mulley AG. Early
detection of
prostate cancer. Part I: prior probability and
effectiveness
of tests. Ann Intern Med 1997 Mar 1;126(5):394-406.
Available from:
http://www.acponline.org/journals/annals/01mar97/ppcancer.htm
2. Coley CM, Barry MJ, Fleming C, Fahs MC, Mulley AG. Early
detection of prostate cancer. Part II: Estimating the
risks,
benefits, and costs. American College of Physicians. Ann
Intern Med 1997 Mar 15;126(6):468-479. Available from:
http://www.acponline.org/journals/annals/15mar97/pppros2.htm
3. Middleton RG. Prostate cancer: are we screening and
treating
too much? [editorial]. Ann Intern Med 1997 Mar
15;126(6):465-7
Print copies: Available from ACP-ASIM, 190 N. Independence
Mall
West, Philadelphia, PA 19106-1572.
The statements made by ACP in the guideline document are
developed using the information provided in the background
papers
(citations 1 and 2, above). Information contained in this
background paper is represented in the methodology fields
of the
NGC summary (i.e., Methods to Collect Evidence; Methods to
Analyze Evidence; Cost Analysis).
PATIENT RESOURCES:
Not stated
NGC STATUS:
This summary was completed by ECRI on August 15, 1998. The
information was verified by the guideline developer on
December
1, 1998.
COPYRIGHT STATEMENT:
This NGC summary is based on the original guideline, which
is
subject to the guideline developer's copyright
restrictions.
Summaries of ACP-ASIM guidelines may be downloaded from the
NGC
Web site and/or transferred to an electronic storage and
retrieval system solely for the personal use of the
individual
downloading and transferring the material. Permission for
all
other uses must be obtained from ACP-ASIM by contacting the
ACP-ASIM Permissions Coordinator, telephone: (800)
523-1546, ext.
2670.
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Date Modified: Monday, June 14, 1999
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{32} RHEUMATOID ARTHRITIS -
22 Feb 2000 (PRIVATE) 450 Lines
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Options: Brief Summary Complete Summary Full Text
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------------------------------------------------------------------------
Brief Summary
TITLE:
Guidelines for the management of rheumatoid arthritis.
SOURCE(S):
Arthritis Rheum 1996 May;39(5):713-22 [66 references]
ADAPTATION:
Not applicable: Guideline was not adapted from another
source.
RELEASE DATE:
1996 May
MAJOR RECOMMENDATIONS:
The seven essential components for the management of
rheumatoid
arthritis are summarized below.
1. Establishment of diagnosis of RA (versus other forms of
polyarthritis)
Baseline evaluation of patients with rheumatoid arthritis
should include the following:
Subjective
Degree of joint pain
Duration of AM stiffness
Presence or absence of fatigue
Limitation of function
Physical examination
Documentation of actively inflamed
joints
Documentation of mechanical joint
problems: loss of motion, crepitus,
instability, malalignment and/or
deformity
Documentation of extraarticular
manifestations
Laboratory
Erythrocyte sedimentation
rate/C-reactive protein
Rheumatoid factor*
Complete blood cell count†
Electrolytes†
Creatinine†
Hepatic panel†
Urinalysis†
Synovial fluid analysis‡
Stool guaiac†
Radiography
Radiography of selected involved joints§
Footnotes:
* Performed only at baseline to establish the
diagnosis; may be repeated 6-12 months after
disease onset if negative initially.
† Performed at baseline to assess organ
dysfunction due to comorbid diseases, before
starting medications.
‡ Performed at baseline if necessary, to
rule out other diseases; may be repeated during
disease flares to rule out septic arthritis.
§ May have limited diagnostic value early in the
disease, but helps to establish a baseline for
periodically monitoring disease progression and
response to treatment.
2. Systematic and regular evaluation of disease activity
Monitoring rheumatoid arthritis activity involves the
following:
Each visit: evaluation for subjective and
objective evidence of active disease
Degree of joint pain
Duration of AM stiffness
Severity of fatigue
Presence of actively inflamed joints on
examination
Limitation of function
Periodically: evaluation for disease activity or
progression
Evidence of disease progression on
physical examination (loss of motion,
instability, malalignment, and/or
deformity
Erythrocyte sedimentation rate or
C-reactive protein elevation
Progression of radiographic damage of
involved joints
Other parameters for assessing response
to treatment (outcomes)
Physician global assessment of
disease activity
Patient global assessment of
disease activity
Tender and swollen joint count
Pain assessment
Functional status assessment
3. Patient education/rehabilitation interventions
Managed or coordinated multidisciplinary care is
efficacious
in maintaining the function and productivity of patients
with RA. Depending on the patient's problems, expertise
from
nursing, physical and occupational therapy, social work,
health education, clinical psychology, vocational
rehabilitation, podiatry, and/or orthopedic surgery
perspectives may be needed.
A longitudinal treatment plan needs to be developed with
the
patient. The discussion should address disease prognosis
and
treatment options, taking into account the costs, adverse
effects, expected time for response, and monitoring
requirements of pharmacologic agents, in addition to the
patient's preferences. Expectations for treatment and
potential barriers to carrying out the recommendations
should be discussed. Patient education is critical to
engaging the patient in an effective partnership for
managing the disease. Useful patient education materials
are
available from the Arthritis Foundation.
4. Treatments with NSAIDS (nonsteroidal antiinflammatory
drugs)
Use of nonsteroidal antiinflammatory drugs for rheumatoid
arthritis involves the following considerations:
Goal
Symptomatic relief of pain and swelling
Limitation
Unlikely to prevent damage
Factors for selecting drugs
Dosing regimen
Efficacy
Tolerance
Costs
Patient's age
Presence of comorbid disease(s)
Concurrent drugs
Patient preferences
Monitoring efficacy
Symptoms and signs of active synovitis
Monitoring toxicity
5. Treatment with DMARDs (disease-modifying antirheumatic
drugs)
Use of disease-modifying antirheumatic drugs for rheumatoid
arthritis involves the following considerations:
Goal
Remission or optimal control
inflammatory joint disease
Limitations
May not prevent damage in spite of
apparent clinical control
May not have lasting efficacy
May not be tolerated due to toxicity
Factors for selecting drugs
Convenience and cost of
medication and monitoring for
toxicity
Risk of adverse reactions,
including frequency and
seriousness
Physician estimate of efficacy
and disease prognosis
Monitoring efficacy
Is disease in remission or
optimally controlled?
Monitoring toxicity
6. Use of local or low-dose oral gluticocorticoids
Use of glucocorticoid therapy for rheumatoid arthritis
involves the following considerations:
Local injection
Goals
Treatment of the most
symptomatic joints early in
the disease course
Treatment of flares in 1 or a
few joints
Recovery of lost joint motion
Limitations
Local therapy, but disease is
a systemic process
Only temporary benefit if
disease is not controlled
systemically
Factors for selecting drugs
Need for long-acting
preparation
Concentration varies with size
of joint being injected
Monitoring efficacy
Improvement in synovitis,
restoration of range of motion
Monitoring toxicity*
Avoid repetitive injections
into same joint more than once
every 3 months
Low-dose oral (<10 mg prednisone daily)
Goals†
Minimizing disease
activity while
awaiting DMARD
response
Decreasing disease
activity for a
limited time period
(i.e., a short
course for flares or
special life events)
Control of active
disease in spite of
optimal NSAID
treatment and trials
of DMARDS (i.e.,
unacceptable
discomfort of
limitations of
function)
Limitation
Damage may progress
despite symptomatic
control
Factors for selecting drugs
Initial and
maintenance dose
selection critical
Monitoring efficacy
Symptoms and signs
of active synovitis
Improvement in
function
Monitoring toxicity
7. Minimization of the impact on the individual's function
8. Assessment of the adequacy of the treatment program
If the patient's disease is active or progressing, other
options, including consultation with a rheumatologist,
should be considered. If disease activity is confined to 1
or a few joints, local glucocorticoid injection may help.
Change in the drug regimen may be considered, especially
increasing DMARD dosage, changing the DMARD, or adding a
DMARD. Patients with severe symptoms may need to start
taking or to increase the dosage of systemic
glucocorticoids. Active joint disease may be aggravated by
physical activity; consultation with a physical therapist,
occupational therapist, and/or vocational counselor should
be considered. Periods of rest, time off from work, changes
in occupation, or stopping work may be necessary. For
symptoms that are mechanical, surgical options need to be
explored.
9. General health maintenance
A general health maintenance strategy should be developed
and responsibility coordinated among the patient's health
care providers. Routine prevention measures should be
recommended and risk factors modified. The lifespan of a
patient with RA may be shortened by infection, pulmonary
disease, renal disease, or GI bleeding. Patients at risk
for
GI bleeding may benefit from avoidance of gastric irritants
and the use of gastroprotective drug therapy. For patients
at risk for osteoporosis (by history, inactivity, and/or
glucocorticoid treatment), evaluation with bone
densitometry
at baseline and treatment with calcium supplementation,
vitamin D (400 units daily), bisphosphonates, or calcitonin
should be considered. Estrogen replacement therapy should
be
discussed with postmenopausal women.
CLINICAL ALGORITHM(S):
A clinical algorithm is provided for the management of
rheumatoid
arthritis.
DEVELOPER(S):
American College of Rheumatology (ACR) - Medical Specialty
Society
COMMITTEE:
Ad Hoc Committee on Clinical Guidelines
GROUP COMPOSITION:
Names of Committee Members: C. Kent Kwoh, MD (co-chair);
Robert
W. Simms, MD (co-chair); Larry G. Anderson, MD; Diane M.
Erlandson, RN, MS, MPH; Jerry M. Greene, MD; Carolee
Moncur, PhD;
James R. O'Dell, MD; Alison J. Partridge, LICSW; Robert B.
Brigham; W. Neal Roberts, MD; Mark L. Robbins, MD, MPH;
Robert A.
Yood, MD; Matthew H. Liang, MD, MPH.
ENDORSER(S):
Not stated
GUIDELINE STATUS:
This is the current release of the guideline.
According to the guideline developer, an update is in
progress.
GUIDELINE AVAILABILITY:
Electronic copies: Available from the American College of
Rheumatology (ACR) Web site.
Print copies: Available from the American College of
Rheumatology, 1800 Century Place, Suite 250, Atlanta, GA
30345.
COMPANION DOCUMENTS:
None available
PATIENT RESOURCES:
Not stated
NGC STATUS:
This summary was completed by ECRI on January 15, 1999. The
information was verified by the guideline developer as of
March
5, 1999.
COPYRIGHT STATEMENT:
This NGC summary is based on the original guideline, which
is
subject to the guideline developer's copyright
restrictions.
The guideline is copyrighted by the American College of
Rheumatology. Reproduction is prohibited. For multiple
copies,
contact the American College of Rheumatology at 404-633-377
or
acr@rheumatology.org
Return to top
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National
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MAP] [CONTACT NGC] [ABOUT NGC]
Search NGC: Search Help Detailed Search
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Organization
Options: Brief Summary Complete Summary Full Text
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------------------------------------------------------------------------
Brief Summary
TITLE:
Diagnosis and management of rhinitis.
SOURCE(S):
Ann Allergy Asthma Immunol 1998 Nov;81(5 Pt 2):478-518 [297
references]
ADAPTATION:
Not applicable: Guideline was not adapted from another
source.
RELEASE DATE:
1998 Nov
MAJOR RECOMMENDATIONS:
This listing of summary statements is intended to assist
the
clinician in rapidly reviewing and identifying key points
of
evaluation and treatment of rhinitis that are
comprehensively
discussed in the guideline document.
EVALUATION OF RHINITIS
History
Full evaluation of the patient with rhinitis should include
a
determination of the pattern, chronicity, and seasonality
of
symptoms (or lack thereof), response to medications,
presence of
coexisting conditions, occupational exposure, a detailed
environmental history and identification of precipitating
factors.
History of Impact on Quality of Life
Symptoms of rhinitis may significantly impact the patient's
quality of life, by causing fatigue, headache, cognitive
impairment and other systemic symptoms. An assessment of
the
degree to which these symptoms interfere with the patient's
ability to function should be made.
Physical Examination
An examination of the nose should be performed in patients
with a
history of rhinitis. This should include examination of the
nasal
passageways, secretions, turbinates, septum, and
determination of
whether nasal polyps are present.
Testing for Specific IgE
The demonstration of specific IgE antibodies to known
allergens
by skin testing or in vitro tests (as delineated in the
"Parameters for Diagnostic Testing") is of particular
importance
in determining whether the patient has allergic rhinitis
and for
identifying specific allergens for which avoidance measures
and/or allergen immunotherapy are warranted.
Special Diagnostic Techniques
In selected cases, special techniques such as fiberoptic
nasal
endoscopy and/or rhinomanometry may be useful in evaluation
patients presenting with rhinitis symptoms. These tests may
require special expertise for appropriate administration
and
interpretation. Patients with nasal disease require
appropriate
examination for associated diseases, such as sinusitis and
otitis
media.
Nasal Cytology
Nasal cytology may aid in differentiating allergic rhinitis
and
NARES from other forms of rhinitis, eg, vasomotor,
infectious
rhinitis, if the correct procedure is followed and the
appropriate stain are utilized.
Unproven or Inappropriate Testing
Neither "total serum IgE" nor total circulation
eosinophil
counts
are routinely indicated in the diagnosis of rhinitis.
Cytotoxicity testing, provocative and neutralization
testing
carried out by either intracutaneous or subcutaneous
injection or
sublingual administration, and measurement of specific and
non-specific IgG4 are controversial, unproven and/or not
appropriate for diagnostic use in evaluation of rhinitis.
MANAGEMENT OF RHINITIS
Environmental Control Measures
Avoidance of inciting factors, eg, allergens, irritants,
medications, is fundamental to the management of rhinitis.
Triggers should be identified and avoidance measures
instituted.
Pharmacologic Therapy
Pharmacologic management should be considered in relation
to the
etiology and pathophysiology of the condition. If it is
possible
to anticipate the onset of symptoms, eg, seasonal rhinitis
or
rhinitis triggered by sporadic exposure, initiating
prophylactic
use of mediations may lessen the impact of such exposure in
the
patient.
Antihistamines
Oral antihistamines are effective in reducing symptoms of
itching, sneezing, and rhinorrhea, and are first line
therapy for
treatment of allergic rhinitis. However, oral
antihistamines have
little objective effect on nasal congestion. Antihistamines
reduce symptoms of allergic conjunctivitis, which are often
associated with allergic rhinitis.
Issues with Sedation and Performance Impairment from
Antihistamines
Sedation and performance impairment are undesirable and
potentially dangerous side effects of first generation
antihistamines. Consequently, second generation
antihistamines
that are associated with less risk or no risk for these
side
effects should usually be considered before first
generation
antihistamines for treatment of allergic rhinitis, and are
even
mandated in some segments of the transportation industry.
Studies
have demonstrated that many patients may not perceive
performance
impairment that is associated with first generation
(classical)
antihistamines. In the majority of states, patients taking
sedating antihistamines are legally considered "under the
influence of drugs."
Adverse Cardiac Effects of Some Second Generation
Antihistamines
Some older non-sedating antihistamines such as astemizole
and
terfenadine (the latter withdrawn from US market in 1998)
may
cause prolongation of the QTc interval that may lead to the
ventricular arrhythmia torsade de pointes especially with
overdose, administration with certain concomitant
medications
(eg, some macrolide antibiotics, azole anti-fungal agents),
and
in the presence of severe liver disease.
Intranasal Antihistamines
Intranasal antihistamines are effective for treatment of
allergic
rhinitis. These agents are appropriate for use as
first-line
treatment for allergic rhinitis, and in contrast to most
oral
antihistamines, may help reduce nasal congestion. However,
patients may perceive them as having a bitter taste and
because
significant systematic absorption may occur, they may be
associated with resultant sedation in some patients.
Oral and Nasal Decongestants
Oral decongestants, such as pseudoephedrine or
phenylpropanolamine, can effectively reduce nasal
congestion
produced by rhinitis, but can cause insomnia, loss of
appetite or
excessive nervousness. In addition, these agents should be
used
with caution in patients with certain conditions, eg,
arrhythmias, angina pectoris, some patients with
hypertension and
hyperthyroidism. Topical sympathomimetics can be useful for
short-term (eg, 2 to 3 days) therapy for nasal congestion
associated with rhinitis.
Nasal Corticosteroids
Nasally inhaled corticosteroids are the most effective
medication
class in controlling symptoms of allergic rhinitis. They
are
particularly useful for treatment of more severe allergic
rhinitis and may be useful for treatment of more severe
allergic
rhinitis and may be useful in some other forms of rhinitis.
Except for intranasal dexamethasone, these agents are
generally
not associated with significant systemic side effects in
adults.
Although local side effects are minimal if the patient is
carefully instructed in the use of this class of drugs,
nasal
irritation and bleeding may occur, and nasal septal
perforations
are rarely reported. Intranasal corticosteroids should be
considered before initiating treatment with systemic
corticosteroids for the treatment of severe rhinitis.
Oral and Parenteral Corticosteroids
A short (3 to 7 day) course or oral corticosteroids may be
appropriate for the treatment of very severe or intractable
nasal
symptoms or to treat significant nasal polyposis. However,
the
use of parenteral corticosteroids, particularly if
administered
recurrently, is discouraged because of greater potential
for HPA
axis suppression and long-term corticosteroid side effects.
Intranasal Cromolyn
Intranasal cromolyn sodium is effective in some patients in
controlling symptoms of allergic rhinitis and is associated
with
minimal side effects.
Intranasal Anti-cholingerics
Intranasal Anti-cholingerics may effectively reduce
rhinorrhea
but have no effect on other nasal symptoms. Although side
effects
are minimal, dryness of the nasal membranes may occur.
Oral Anti-leukotriene Agents
Although there is evidence that oral anti-leukotriene
agents may
be of value in treatment of allergic rhinitis, their role
in
therapy needs to be defined by further study.
Allergen Immunotherapy
Allergen immunotherapy may be highly effective in
controlling
symptoms of allergic rhinitis. Patients with allergic
rhinitis
should be considered candidates for immunotherapy based on
the
severity of their symptoms, failure of other treatment
modalities, presence of comorbid conditions, and of
preventing
worsening or possibly the development of comorbid
conditions.
Selection of the patient's immunotherapy extract should be
based
on a correlation between the presence of specific IgE
antibodies
(demonstrated by allergy skin testing or in vitro testing)
and
the patient's history (see parameters on immunotherapy and
on
diagnostic testing).
Surgical Approaches for Co-morbid Conditions
Although there is no surgical treatment for allergic
rhinitis per
se, surgery may be indicated in the management of co-morbid
conditions, e.g. nasal obstruction from severe nasal septal
deviation or recurrent refractory sinusitis.
Important Considerations in Management
Management of rhinitis should be individualized, based on
the
spectrum and severity of symptoms, with consideration of
cost
effectiveness and utilization of both step-up and step-down
approaches. More severe rhinitis may require multiple
therapeutic
interventions, including: 1) use of multiple medications,
2)
evaluation for possible complications, and 3) instruction
in
and/or modifications of the medication or immunotherapy
program.
Similar to other chronic diseases, appropriate follow-up of
patients with allergic rhinitis on a periodic basis is
recommended.
Education of Patient and Caregivers
Education of the patient and/or the patient's caregiver in
the
regard to the management of rhinitis is essential. Such
education
maximized compliance and the possibility of optimizing
treatment
outcomes.
Importance of Rhinitis Management for Concomitant Asthma,
Sinusitis, Otitis Media
Appropriate management of rhinitis may be an important
component
in effective management of co-existing or complicating
respiratory conditions, such as asthma, sinusitis, or
chronic
otitis media. Data suggest that failure to reduce
inflammation in
the upper airway may lead to suboptimal results in asthma
treatment.
Special Considerations in Children, the Elderly, Pregnancy,
Athletes and Rhinitis Medicamentosa
Special diagnostic and therapeutic considerations are
warranted
in selected patient subsets, including in children, the
elderly,
pregnant women, athletes, and in those with rhinitis
medicamentosa.
Consultation with an Allergist-Immunologist
There are a variety of circumstances in which the special
expertise and training of an allergist-immunologist may
offer
benefits to a patient with rhinitis. Reasons for
consultation
include, but are not limited to:
1. Clarification and identification of allergic or other
triggers for the patient's rhinitis condition.
2. When management of rhinitis is unsatisfactory due to
inadequate efficacy or adverse reactions from treatment.
3. When education in allergen avoidance techniques is
needed.
4. When allergy immunotherapy may be a consideration
5. When there is impairment of patient's performance
because of
rhinitis symptom manifestations or medication side effects,
e.g. patient involved in the transportation industry,
athletes, students, etc.
6. When the patient's quality of life is significantly
affected
(eg, patient comfort and well-being, sleep disturbance,
smell, taste).
7. When complications of rhinitis develop, eg, sinusitis,
otitis media, nasal polyps.
8. In the presence of comorbid conditions such as recurrent
or
chronic sinusitis, asthma or lower airway disease, otitis
media, nasal polyps.
9. When patients require systemic corticosteroids to
control
their symptoms.
10. When the duration of rhinitis symptoms is greater than
three
months.
11. When there is a significant cost from use of multiple
medications.
CLINICAL ALGORITHM(S):
Algorithms are provided for the diagnosis and management of
rhinitis.
DEVELOPER(S):
American Academy of Allergy, Asthma and Immunology (AAAAI)
-
Medical Specialty Society
American College of Allergy, Asthma and Immunology (ACAAI)
-
Medical Specialty Society
Joint Council of Allergy, Asthma and Immunology (JCAAI) -
Medical
Specialty Society
COMMITTEE:
Workgroup on Rhinitis
GROUP COMPOSITION:
Editors: Mark S. Dykewicz, MD; Stanley Fineman, MD, MBA.
Workgroup Chair: David P. Skoner, MD.
Associate Editors: Richard Nicklas, MD; Rufus Lee, MD;
Joann
Blessing-Moore, MD; James T. Li, MD, PhD; I. Leonard
Berstein,
MD; William Berger, MD, MBA; Sheldon Spector, MD; Diane
Schuller,
MD.
ENDORSER(S):
Not stated
GUIDELINE STATUS:
This is the current release of the guideline.
An update is not in progress at this time.
GUIDELINE AVAILABILITY:
Electronic copies: Available from the Joint Council of
Allergy,
Asthma, and Immunology (JCAAI) Web site.
Print copies: Available from JCAAI, 50 N. Brockway, Ste 3-3
Palatine, IL 60067.
COMPANION DOCUMENTS:
The following are available:
1. Joint Task Force summary statements on diagnosis and
management of rhinitis. Ann Allergy Asthma Immunol 1998
Nov;81(5 Pt 2):474-7. Available electronically from the
JCAAI Web site.
2. Joint Task Force algorithm and annotations for diagnosis
and
management of rhinitis. Ann Allergy Asthma Immunol 1998
Nov;81(5 Pt 2):469-73. Available electronically from the
JCAAI Web site.
3. Executive Summary of Joint Task Force Practice
Parameters on
diagnosis and management of rhinitis. Ann Allergy Asthma
Immunol 1998 Nov;81(5 Pt 2):463-8. Available electronically
from the JCAAI Web site.
PATIENT RESOURCES:
Not stated
NGC STATUS:
This summary was completed by ECRI on June 29, 1999. The
information was verified by the guideline developer on
August 10,
1999.
COPYRIGHT STATEMENT:
This NGC summary is based on the original guideline, which
is
subject to the guideline developer's copyright
restrictions. This
copyrighted material may only be used personally and may
not be
distributed further. All rights reserved. Mosby-Year Book,
Inc.
[Diagnosis and management of rhinitis. Ann Allergy Asthma
Immunol
1998 Nov;81(5 Pt 2):478-518.]
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{55} RHINITIS (MAMC) - 22 Feb 2000
(PRIVATE) 71 Lines
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Antihistamines Department of Pharmacy
[Mamclogo.gif (11446 bytes)]
Guideline for use of Nonsedating Antihistamines
in Allergic
Rhinitis (and Urticaria)
1. Initial treatment is PRN use of short acting
antihistamines, with (x:
chlorpheniramine and pseudoephedrine (Deconamine SR)) or
without
decongestant (x: diphenhydramine(Benadryl) or
chlorpheniramine(CTM)). If
required several times a week, it is best taken routinely
at bedtime to
provide antihistamine prophylaxis while minimizing sedative
side effects.
Tolerance to the sedative side effect usually develops with
continued use.
2. Patients who are intolerant of antihistamines therapy as
described
above, or can not be adequately controlled on them should
start a nasal
corticosteroid spray if they regularly require medications.
The usual
starting dose for nasal beclomethasone (Vancenase) is 2
puffs in each
nostril BID. Advise the patient that this takes days to
work and should be
continued for at least two to four weeks before the dose
may be tapered to
a level adequate to maintain symptom control. Patients not
tolerating the
regular Vancenase aerosol due to (nosebleed, irritation,
etc.) should be
tried on nasal triamcinolone (Nasacort AQ), 2 sprays each
nostril QD
initially. Again, taper to minimal dose required for
control.
3. Patients intolerant of antihistamines not requiring
frequent
medications, or those who fail to improve on nasal steroids
and are
intolerant to standard antihistamines, should be given a
trial of a
nonsedating antihistamine. Fexofenadine (Allegra) should be
started as a
single AM dose of 60 mg supplemented, by a standard
antihistamine at
bedtime. The reason that Allegra is being given should be
noted on the
prescription or in the comment field for CHCS users.
4. If the patient is still sedated the following day from
taking the qhs
dose of standard antihistamines, or who by their
occupations or medical
conditions require that they use nonsedating
antihistamines, either Allegra
bid (fully nonsedating) or Cetirizine (Zyrtec- relatively
nonsedating) ½
tablet qd should be tried. Though marketed as a relatively
nonsedating
antihistamine, cetirizine may cause sedation and carries
the warning about
operating machinery or driving. If ½ tablet of Zyrtec is
ineffective the
whole dose can be tried. Again it should be noted on the
prescription or in
the comment field for CHCS users.
5. If all of the above fail, or the occupation requires a
fully
nonsedating antihistamine and the patient does not respond
to Allegra, the
physician may then prescribe Loratadine (Claritin) after
submitting a New
Drug Request. This drug is administered as a single daily
10 mg dose.
Again it should be noted on the prescription or in the
comment field for
CHCS users.
6. Any patient who fails to be controlled with a good
therapeutic trial of
the above drugs or is intolerant of them should be offered
referral for
Allergy evaluation. Skin testing can facilitate avoidance
of allergens.
Immunotherapy may offer more long-term improvement while
lessening or even
eliminating the need for medications.
7. These guidelines apply to allergic rhinitis and not to
chronic
urticaria. If the patient with chronic urticaria is
unresponsive to full
doses of hydoxyzine (Atarax) and diphenhydramine (Benadryl)
or is
intolerant of them, then Ceterizine (Zyrtec) 10mg, and if
this is
ineffective Loratadine (Claritin) 10mg should be used.
Again, this should
be noted in the comment field.
Pharmacy Home Page MAMC Home Page
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{34} SINUSITIS - 22 Feb 2000 (PRIVATE) 120
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National
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Organization
Options: Brief Summary Complete Summary
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------------------------------------------------------------------------
Brief Summary
TITLE:
Acute sinusitis in adults.
SOURCE(S):
Ann Arbor (MI): University of Michigan Health System; 1996.
6 [10
references]
ADAPTATION:
Not applicable: Guideline was not adapted from another
source.
RELEASE DATE:
1996 May
MAJOR RECOMMENDATIONS:
Note from NGC: The following key points summarize the
content of
the guideline. Refer to the full text for additional
information,
including detailed information on best predictors of
sinusitis,
preferred treatment regimens, and dosing and cost
considerations
for first and second trial antibiotic treatments.
* Treatment. An adequate trial of medical therapy will
result
in relief of symptoms in nearly 85% of cases [evidence:
A*].
Adequate therapy is up to two courses of antibiotics
[evidence: D*]. First trial for 10 - 14 days with
decongestants (topical up to 3 days or oral until symptoms
improve); second trial of antibiotics for minimum of 7 days
after the resolution of symptoms with a maximum of 21 total
days.
* Follow-up. If symptoms persist after two adequate courses
of
antibiotics, a screening sinus CT scan (coronal plane)
should be ordered to reassess diagnosis and determine need
for referral [evidence: C, D*]. A screening sinus CT ($308)
provides adequate information compared to a full sinus CT
scan/maxillofacial CT ($801) and provides much better
definition than a plain sinus x-ray series ($204).
* Definitions
Levels of evidence for the most significant
recommendations:
A. Randomized controlled trials
B. Controlled trials, no randomization
C. Observational trials
D. Opinion of expert panel
CLINICAL ALGORITHM(S):
An algorithm is provided for the management of acute
sinusitis in
adults.
DEVELOPER(S):
University of Michigan Health Systems - Academic
Institution
COMMITTEE:
Sinusitis Guideline Team
GROUP COMPOSITION:
Members: James Brunberg, MD; Daniel Dubay, MD; Charles
Koopman,
MD; Katherine Maddox, N.P.; Jane McCort, MD; James Peggs,
MD;
Connie Standiford, MD; Jeffrey Terrell, MD; Christopher
Wise,
PhD; Jim Woolliscroft, MD.
ENDORSER(S):
Not stated
GUIDELINE STATUS:
This is the current release of the guideline.
According to the guideline, an update is in progress at
this
time.
GUIDELINE AVAILABILITY:
Print copies: Available from the University of Michigan
Health
System, Office of Clinical Affairs, The University of
Michigan
Hospitals, C-201 Med Inn, Box 0826, Ann Arbor, Michigan
49109-0826. Telephone: (734) 763-0555; Fax (734) 936-9406.
COMPANION DOCUMENTS:
None available
PATIENT RESOURCES:
Not stated
NGC STATUS:
This summary was completed by ECRI on May 20, 1999. The
information was verified by the guideline developer on June
17,
1999.
COPYRIGHT STATEMENT:
This NGC summary is based on the original guideline, which
is
copyrighted by the University of Michigan Health Systems
(UMHS).
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{56} SINUSITIS (MAMC) - 22 Feb 2000 (PRIVATE) 334 Lines
----------------------------------------------------------------------------
I.. TITLE: MADIGAN ARMY MEDICAL CENTER CLINICAL STANDARD
FOR SINUSITIS
MANAGEMENT (updated 10/30/98)
II. INDICATIONS FOR THE CLINICAL STANDARD FOR DIAGNOSIS AND
MANAGEMENT OF
SINUSITIS: Sinusitis affects an estimated 35 million
Americans each year.
Its prevalence is estimated to be 5-15% in adults and up to
5% in children.
It is increasing in prevalence in all age groups and
accounted for nearly
25 million office visits in the United States in 1993 and
1994. It was the
fifth most common diagnosis for which an antibiotic was
prescribed.
Antibiotic prescriptions for sinusitis rose from 5.8
million in 1985 to 13
million in 1992. The direct medical cost of sinusitis in
1992 was $2.4
billion. Ideal management includes administration of
preventive measures as
well as the application of proper baseline medical therapy
in adequate
dosages and duration. It is important for the primary care
physician to
know the factors associated with the diagnosis of chronic
rhinosinusitis
and properly diagnose acute, chronic, recurrent sinusitis.
III. METRICS WHICH WILL BE USED TO MONITOR ADHERANCE TO THE
SINUSITIS
CLINICAL STANDARD:
1. Documented history of 2 major symptoms (face
pain-pressure,
facial congestion-fullness, nasal obstruction-blockage,
nasal
discharge-purulence-discolored postnasal drip,
hyposmia-anosia)
or 1 major symptom and 2 minor symptoms (fever-chronic,
halitosis, fatigue, dental pain, cough, and ear
pain-pressure-fullness), or nasal purulence on examination.
2. Documented first line antibiotic therapy (Pharmacy
Antibiogram, Sinusitis Practice Recommendation in Section
VIII
below) with appropriate decongestant therapy for a minimum
of 7
days beyond the last symptom of facial pain or purulent
rhinorrhea. Include antihistamines and nasal steroids if a
history of allergy is present.
3. Documented repeat first line therapy or second line
antibiotic
(refer to Pharmacy Antibiogram, Section VII of this
document,
(Pathway)and with appropriate decongestant therapy for a
minimum
of 7 days beyond the last symptom of facial pain or
purulent
rhinorrhea. Again include antihistamines and nasal steroids
if a
history of allergy is present.
4. Documentation that all cases, which fail antibiotic
therapy,
requiring referral (Referral Guidelines)(Pathway) to ENT or
Allergy must have an abnormal sinus CT scan. Abnormal
paranasal
sinus Coronal CT scan without contrast is defined as having
air-fluid levels, or mucosal thickening > 2mm, or sinus
opacification or obstructive or neoplastic pathology or
complicated sinusitis extention of disease beyond the
sinuses
(i.e., meningitis, CNS empyema, brain abscess, cavernous
sinus
thrombosis, osteomyelitis, and periorbital infections).
IV. DATE: 4 May 98
V. AUTHORS: LTC Vincent D. Eusterman, C,
Otolaryngology-Head & Neck
Surgery, LTC Marcia Muggelberg, C, Allergy & Immunology,
COL Tom Michels,
C, Dept of Family Practice, MAJ Mary Fairchok, Dept of
Pediatrics
Point of Contact: LTC Eusterman, 968-1430, FAX 968-3154
VI. AREAS OF DISAGREEMENT:There are no major areas of
disagreement,
however antibiotic resistance is a growing concern. The
medical
practitioner should first, prescribe and teach prevention
considering
decongestants (topical and systemic) and/or antihistamines
as the first
line of therapy, and second understand the sign and
symptoms of sinusitis
before prescribing antibiotics.[1] The length of antibiotic
therapy is also
controversial, we feel that because infected sinus fluids
are extracellular
they require a minimum of ten days of therapy or at least 3
days beyond the
last symptoms.[2] Choice of antibiotics should be selected
from
culture-proven bacterial sinusitis, however in most cases
cultures are
difficult to obtain and hospital antibiograms (Pharmancy
Antibiogram)are
often used successfully in their place. Costs of antibiotic
therapy is a
major consideration however, second line therapy is
becoming more
reasonable, and may be better value in light of antibiotic
resistance in
first line therapy, these medications will become important
for refractory
and atypical cases [3]. Signs and symptoms of acute and
chronic sinusitis
have not been standardized and have been an area of
disagreement. A sinus
taskforce recently outlined the factors associated with
sinusitis to
establish "standard" definitions and guidelines to
help
guide the
practitioner to improve the treatment of sinusitis.[4]
VII. PUBLISHED STANDARDS OF CARE RELATING TO PROPOSAL:
1. Gross CW, Becker DG, et al: Advances in sinus and Nasal
Surgery, The Otolaryngology Clinics of North America, June
1997.
2. Williams: Randomized Controlled Trial of 3 vs. 10 Days
of
Trimethoprim-
Sulfamethoxazole for Acute Maxillary sinusitis, JAMA, April
5,
1995-vol 273, No.13
3. MAMC Pharmacy Guidelines: Oral antibiotic Guidelines:
Sinusitis (Adults), 1998.
4. Lanza DC, Kennedy DW, et al. Adult Rhinosinusitis
Defined.
Report of the
Rhinosinusitis Task Force Committee Meeting.
Otolaryngology-Head
and Neck
Surgery 1997; 117; S4-S5.
5. Senior BA, Kennedy DW: Long-term Results of Functional
Endoscopic Sinus
Surgery. Laryngoscope 1998 Feb:108(2):151-7.
6. OTG-D7 sinusitis ICD-9: 461.X, 473.X. Ear Nose and
Throat
Conditions, Chapter II
7. OTGs for Common Conditions Usually Treated in an
Ambulatory
Setting, Healthcare Management Guidelines, Milliman &
Robertson,
Inc., November 1997.
8. ISP: Otolaryngology, Dental & Oro-Maxillo-Facial Surgery
(OS
64-69), Inter Qual, Inc. 1995.
VIII. CLINICAL PRACTICE RECOMMENDATIONS:
1. Diagnosis of Sinusitis = 2+ Major // 1 Major + 2 Minor
or
Nasal Purulence
Major Factors: Minor Factors:
Face pain-pressure Headache
Facial congestion-fullness Fever (non-acute)
Nasal obstruction-blockage Halitosis
Nasal discharge-purulence-discolored postnasal drip Fatigue
Hyposmia-anosmia, Dental Pain
Purulence in nasal cavity on examination. Cough
Ear pain-pressure
2. Acute Sinusitis (Adult) (Pathway) - Diagnosis: Acute
sinusitis
must be differentiated from viral URI that improves in 5-10
days;
bacterial sinusitis worsens and has a duration of < 4 weeks
to be
considered acute. To diagnose and treat with antibiotics a
strong
history of 2 or more major factors, or 1 major factor and 2
minor
factors or nasal purulence on examination. Medical therapy
includes antibiotics, decongestants, mucolytics, steroids
and
analgesics discussed below.
Acute Sinusitis - Common Pathogens (Pathway): Streptococcus
pneumonia, Haemophilus influenza, and Moraxella
catarrhalis.
Occasionally Group A Streptococci are isolated from
children, as
is Staphylococcus aureus from adults. There is no evidence
that
atypical pathogens (e.g., Mycoplasma, Chlamydia) have any
significant role in sinusitis.
Acute Sinusitis - Medical Treatment (Pathway): Nasal saline
rinses (1 pint water + 1/2 tsp. Salt and 1/4 tsp. baking
soda)
several times a day reduces mucosal swelling and clears
secretions. Topical decongestants, phenylephrine nose drops
for
children or oxymetazoline HCL (Afrin) nose spray for adults
bid
for 3-4 days only to promote drainage. Supplement with
systemic
decongestants if not hypertensive, pseudoephedrine 30-60mg
po
bid. Consider mucolytics like guiafenesin (Humabid)
600-1200mg po
bid to thin secretions and reduce coughing. Analgesics are
added
for pain, and steroids are indicated for nasal polyposis
that is
complicating the disease process. Use antihistamines only
if
underlying allergic disease is present.
Acute Sinusitis: Antibiotic Therapy (use after viral URI is
ruled
out) (Pharmancy Antibiogram)
First Line: (for the common organisms treat for 2-3 weeks)
1. amoxicillin trihydrate (generic) 500mg q 8 hours for
14 days
2. trimethoprim/sulfamethoxazole DS (generic) bid for
14 days for patients allergic to penicillin (avoid in
pregnancy).
Second Line: (for initial treatment failure, consider
Streptococcus pneumonia resistance or a B-lactamase
resistance).
See current guidelines(Pharmancy Antibiogram) for
availability.
Culture directed antibiotics are the procedure of choice
but they
are often difficult to do in clinical settings, antibiogram
(Pharmancy Antibiogram) for local hospital resistance is
second
choice.
Second Line:
a. azithromycin (Zithromax) 500mg, then 25mg
x 4 days, repeat in 10 days. (used but not
approved for sinusitis)
b. amoxicillin-clavulanate (Augmentin) 875mg
bid 10-14+ days
c. cefuroxime axetil (Ceftin) 250mg po bid
for 10-12+ days
d. clarithromycin (Biaxin) 500mg po bid for
14+ days (taste)
e. trovafloxacin mesylate (Trovan) 200mg qd
10+ days (photosens, adults)
f. ciprofloxacin HCL (Cipro) 500mg bid
10+days (adults)
Third Line: (persistent-unresponsive to the above, consider
anaerobic org.)
a. clindamycin HCL (Cleocin) 150mg qid for
14-21 days
3. Chronic Sinusitis (Adult): By definition this condition
is >12
weeks with the same factors as above, usually bacteria role
is
minimal, opportunistic anaerobic organisms colonize,
etiology is
chronic obstruction from allergies, chronic mucosal
disease,
polyposis, cystic fibrosis, neutropenia or immunological
compromise (pseudomonas aeruginosa, mycobacteria,
aspergillosis,
cytomegalovirus). Often anatomic abnormalities exist,
septal
obstruction, osteomeatal scarring, contact point pain,
odontogenic (dental) infections, or mucociliary
dysfunction.
Surgery improves these symptoms in 98% of the cases over
the long
term.[5]
4. Recurrent Sinusitis (Adult): > 4 episodes per year with
each
lasting 7-10 days and absence of chronic rhinosinusitis.
5. Acute Sinusitis (Pediatric): Starts as a complication to
viral
URI, obstructive, purulent rhinorrhea with fever, lasting
longer
than 10 days. Same acute organisms as adult. Treat if
symptoms
persist after 14 days, use nasal saline irrigation and
decongestant with 2 weeks of antibiotics. For second line
consider Amoxicillin-Augmentin combination to achieve 80
mg/kg/day total of the Amoxicillin with ½ being Augmentin
to
cover beta lactamase producers and resistant Streptococcus
pneumonia. Refer to pediatric dosages; flouroquinolones are
not
appropriate for pediatric use.
6. Chronic Sinusitis (Pediatric): purulent rhinorrhea,
daytime
cough, worse at night emesis from coughing fits, nasal
obstruction, headaches, rare fever. Organisms are also
alpha-hemolytic strep and staphylococcus and can contain
anaerobes. Chronic sinusitis work up includes an
allergy-immunology work up, sweat testing for cystic
fibrosis,
tobacco exposure history, and esophageal reflux evaluation.
Radiology is not necessary unless failed maximal medical
therapy
or has a complication of sinusitis. Antibiotic treatment is
second line for 6 weeks), to include nasal steroids and
saline
irrigation, and should be offered a yearly influenza
vaccine.
Disease is generally self-limiting, and rarely is surgery
required. CT scan is required for persistent disease after
prolonged maximal therapy. ENT referral is considered for
evaluation for intense medical management, adenoidectomy
and/or
limited functional endoscopic sinus surgery.
7. Clinical Indications for Imaging
Acute Sinusitis: None required unless primary therapy
fails.
Chronic Sinusitis: Coronal CT Sinuses without contrast
for medically refractory symptoms (unsuccessful 12-week
course of antibiotics), recurrent sinusitis (>4 per
year). For complicated sinusitis (i.e., meningitis, CNS
empyema, brain abscess, cavernous sinus thrombosis,
osteomyelitis, and periorbital infections). For cases
requiring ENT referral.
8. Surgical referral (ENT Guidelines) : For (1) chronic
sinusitis
(after aggressive medical therapy-decongestant spray,
systemic
decongestants, 12 weeks of antibiotics, include
antihistamines
and nasal steroids if a history of allergy is present) or
recurrent sinusitis (>4 per year with appropriate therapy
as
above) or paranasal sinus (2)Coronal CT scan without
contrast
demonstrating air-fluid levels, or mucosal thickening >
2mm, or
sinus opacification or obstructive or neoplastic pathology
or
complicated sinusitis (i.e., meningitis, CNS empyema, brain
abscess, cavernous sinus thrombosis, osteomyelitis, and
periorbital infections. 3) Immune defects (IG2 and IgA) not
responsive to medical therapy, 4) refractory sinusitis
complicating chronic pulmonary disease (asthma, cystic
fibrosis,
triad asthma, etc.) and 5) persistent headache, nasal
polyposis,
or anosmia. All cases requiring ENT referral or other
subspecialty referral should have a CT scan first.
9. Allergy referral: Prior to referral to allergy clinic,
patients with chronic or frequent recurrent sinusitis
should be
evaluated with CT scan of the sinuses to rule out a
structural
problem. They should also be treated with a 4-week course
of
nasal steroids in conjunction with the other medical
therapy as
noted above. If that is ineffective, sinusitis secondary to
allergic rhinitis can often be improved by immunotherapy
(allergy
shots) and/or changes in the patient's environment once
allergic
triggers are known. They should be considered for RAST or
referral to allergy clinic. If the patient has been found
to be
nonallergic, they do not need to be referred to the allergy
clinic again unless a new problem has developed.
IX. IMPACT STATEMENT TO INSTITUTION: The treatment of
sinusitis occurs
through Madigan Army Medical Center the surrounding
military medical
centers in all the primary care portals, troop medical
clinics, pediatric
clinics, allergy-immunology services and otolaryngology
services.
X. PROPOSED LINKS WITHIN MAMC INTRANET: Hot link in the
MAMC Intranet -
Other links within the topic are the pharmacy guidelines,
referral
guidelines and the hospital antibiogram, enabling
clinicians to review the
antimicrobial resistance for our community and adjust
second line
antibiotic therapy without requiring cultures.
XI. METHODS OF PROVIDER EDUCATION: Provider education by
CME classes,
Intranet accesses, referral guideline menus, pocket guides,
clinic copies
of clinical standards with hospital briefings.
XII. REVISION FREQUENCY: This pathway will be reviewed by
the POC and
presented to the Clinical Standards Committee annually or
sooner if needed.
Hotlinks to data sites like the pharmacy guidelines,
referral guidelines,
and the antibiogram would refresh and give up-to-date data
on a regular
basis. Additions from the portal and specialty areas can be
added as
needed.
[PAGE]
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Department of Pharmacy
[Mamclogo.gif (11446 bytes)]
SSRI Treatment Guidelines
PLEASE NOTE: This table may not include all reported
drug-drug
interactions. Please consult the current prescribing
literature as new
drug-drug interactions continue to be identified.
1. General: SSRI's are generally considered first
line treatment for major depression and other
depressive disorders, panic disorder, and
obsessive-compulsive disorder. All have
approximately equal efficacy, although not all
have FDA approval for all of the above conditions.
All SSRIs are metabolized by, and have an
inhibiting effect on the cytochrome P-450
metabolizing system (CYP). The subsystems of most
clinical relevance include 2D6 and 3A4. 2D6 is
responsible for metabolizing certain
antiarrhythmics, beta blockers, antipsychotics,
opiates, and antidepressants. 3A4 is responsible
for other antiarrhythmics, benzodiazaphines,
calcium channel blockers, non-sedating
antihistamines, antidepressants, some steroids,
carbamazepine, and a variety of miscellaneous
medications. The following guidelines are
submitted for assistance in selecting and
administering SSRI's.
2. Celexa: A recent addition to the formulary, Celexa
is this facility's preferred agent for the
treatment of depression. It is less expensive
when used according to guidelines. It has a
slightly more rapid onset. It may have fewer side
effects. It inhibits CYP isoenzymes, particularly
2D6, less potently than other SRIs do, therefore
causing fewer drug interactions. Standard dosage
is 20 mg po qd, prescribed as 40 mg, 1/2 tab qd.
The 20 mg tab should only be used if titration or
treatment with lower doses (1/2 or 20 mg tab) is
required.
3. Prozac: All things being equal, if a patient has
no issues regarding age, metabolism, concurrent
drug therapy, or other issues to consider, Prozac
is the simplest and least expensive SSRI to use.
Due to its greater potential to activate patient,
it may be the drug of choice for the lethargic
patient. Dosage should start at 20mg po qd and
usually does not have to change. Prozac has FDA
approval for OCD and bulimia. Prozac strongly
inhibits both CYP 2D6 and 3A4.
4. Zoloft: If a patient has an increased potential
for mania or hypomania, or any other potential
need to clear the medication rapidly for the
patient's system, Zoloft has the shortest
half-half (although it has a longer acting active
metabolite) and may be considered a first choice
in these individuals. The usual starting dosage is
50mg po qd (½ of a 100mg tab for economic
reasons). Anticipate the likelihood of needing to
increase to 100mg qd but refrain from doing so
prior to a four week trial at 50mg qd. Zoloft has
FDA approval for OCD. Zoloft has less effect on
both the CYP 2D6 and 3A4.
5. Paxil: In older individuals or patients who are
being treated with calcium channel blockers or
non-sedating antihistamines such as his Hismanol
or Seldane, Paxil is a good choice of SSRI's.
Paxil's half life is almost as short as Zoloft's
and it has no active metabolites. Paxil strongly
inhibits CYP 2D6, but has little, if any effect n
3A4. A starting dose of 20mg po qd is usually
sufficient. Paxil is also FDA approved for the
treatment of panic disorder and OCD.
6. Other Considerations: Previous successful
treatment with a particular medication is the best
predictor of future response. If a patient has
responded well to any of these medications in the
past, that medication should be the first choice
for retreatment. Additionally, if a family member
has responded well to a particular medication,
there is evidence that the patient has an
increased chance of responding well to that
medication.
Dosages given above are rough guidelines and should be
adjusted as needed.
Treatment of OCD, panic disorder, and bulimia usually
require higher doses.
Pharmacy Home Page MAMC Home Page
------------------------------------------------------------------------
Send mail to Pharmacy Pagemaster with questions or comments
about this web
site.
Copyright © 1999
Last modified: January 04, 2000
[PAGE]
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{35} STREPTOCOCCAL
PHARYNGITIS - 22 Feb 2000 (PRIVATE) 350
Lines
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National
Guideline
Clearinghouse
[HOME] [NGC RESOURCES] [HELP] [WHAT'S NEW] [SITE
MAP] [CONTACT NGC] [ABOUT NGC]
Search NGC: Search Help Detailed Search
Browse NGC: Disease/Condition Treatment/Intervention
Organization
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Guideline
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------------------------------------------------------------------------
Brief Summary
TITLE:
Diagnosis and management of group A streptococcal
pharyngitis: a
practice guideline.
SOURCE(S):
Clin Infect Dis 1997 Sep;27(3):574-83 [58 references]
ADAPTATION:
Not applicable: Guideline is an original and was not
adapted from
another source.
RELEASE DATE:
1997 (reviewed 1999)
MAJOR RECOMMENDATIONS:
Excerpted by NGC:
Diagnosis
The diagnosis of acute group A streptococcal pharyngitis
should
be suspected on clinical and epidemiological grounds and
then
supported by the results of a laboratory test. Either a
positive
throat culture or rapid antigen detection test (RADT)
provides
adequate confirmation of the presence of group A
beta-hemolytic
streptococci in the pharynx, but a negative RADT result
should be
confirmed with a throat culture (category A, grade II).
Repeated Diagnostic Testing
With rare exceptions, follow-up throat cultures are not
indicated
for asymptomatic patients who have received a complete
course of
therapy for group A streptococcal pharyngitis (category A,
grade
II).
Throat cultures should be performed routinely for patients
with
histories of rheumatic fever. Such cultures should also be
considered for patients who develop acute pharyngitis
during
outbreaks of either acute rheumatic fever or
post-streptococcal
acute glomerulonephritis as well as during outbreaks of
group A
streptococcal pharyngitis in closed or semi-closed
communities.
Follow-up throat cultures may also be indicated when
"Ping-Pong"
spread of group A streptococci has been occurring within a
family
(category B, grade III).
B. Management
Antimicrobial therapy is indicated for individuals with
symptomatic pharyngitis after the organism's presence in
the
throat is confirmed by microbiological or immunologic
means. When
there is clinical or epidemiological evidence that results
in a
high index of suspicion, antimicrobial therapy can be
initiated
while laboratory confirmation is pending provided such
therapy is
discontinued if the diagnosis of streptococcal pharyngitis
is not
confirmed.
Patients with acute streptococcal pharyngitis should
receive
therapy with an antimicrobial agent in a dosage and for a
duration that is likely to eradicate the infecting organism
from
the pharynx. On the basis of penicillin's narrow spectrum
of
antimicrobial activity, the infrequency with which it
produces
adverse reactions, and its modest cost, it is the drug of
choice
for non-allergic patients. Intramuscular benzathine
penicillin G
is preferred for patients who are unlikely to complete a
full
10-day course of oral therapy. Erythromycin is a suitable
alternative for patients who are allergic to penicillin.
First-
or second-generation cephalosporins are also acceptable for
treating patients who do not exhibit immediate
hypersensitivity
to beta-lactam antibiotics.
Table. Antimicrobial therapy for group A streptococcal
pharyngitis.
Antimicrobial Agent Dose Duration Category Grade
Oral
Penicillin V* Children 250 b.i.d. or A II
mg t.i.d. x 10 d
Adolescents
and adults: A II
t.i.d. or
250 mg q.i.d. C III
or 500 mg b.i.d. x 10 d
Parenteral
Benzathine 1.2 x 106 1 dose A II†
penicillin G units
1 A II
6.0 x 105 dose‡
B II
C-R bicillin units 1 dose
(900/300)§
1.2 x 106
units
For
penicillin-allergic
patients| | 20-40
mg/kg/d#
Erythromycin b.i.d. or A II
estolate 40 mg/kg/d# t.i.d. x 10 d
A II
Erthromycin ethyl b.i.d. or
succinate t.i.d. x 10 d
* Amoxicillin is often used in place of oral penicillin V
in
young children; the efficacy of amoxicillin appears to be
equal to that of penicillin V, and this choice is primarily
related to acceptance of the taste of the suspension.
† See text of guideline document.
‡ For patients weighing less than 60 lbs (27 kg).
§ Two milliliters of C-R bicillin (900/300) contains
900,000
units of benzathine penicillin G and 300,000 units of
procaine penicillin G; this preparation thus contains less
benzathine penicillin G than is conventionally used in the
treatment of adolescents or adults.
| | Available data indicate that orally administered first-
and second-generation cephalosporins also are effective in
eradicating group A streptococci from the upper respiratory
tract; these agents should not be used in patients with
immediate hypersensitivity to b -lactam antibiotics.
First-generation cephalosporin A II Second-generation
cephalosporin A II.
# These are total daily doses (maximum daily dose, 1 g per
day).
Management of close contacts and pharyngeal carriers
It is not necessary to perform throat cultures or provide
treatment for household contacts of patients with group A
streptococcal pharyngitis, except in specific situations in
which
there is increased risk of frequent infections or of
nonsuppurative sequelae (category B, grade III).
Management of Patients with Repeated Episodes of Acute
Pharyngitis and Cultures or RADTs Positive for Group A
Beta-Hemolytic Streptococci
When physicians suspect Ping-Pong spread to be associated
with
multiple repeated episodes of group A streptococcal
infections in
one family, performing simultaneous cultures for all family
contacts and treating those whose cultures are positive may
be
helpful (category B, grade III). There is no credible
evidence
that family pets are reservoirs for group A streptococci or
that
they contribute to familial spread.
Continuous antimicrobial prophylaxis for group A
streptococcal
infection is not recommended because there is insufficient
evidence to show that it is effective, except for
preventing
recurrences of acute rheumatic fever. Surgical removal of
the
tonsils may be considered for the rare patient whose
symptomatic
episodes do not diminish in frequency over time and for
whom no
alternative explanation for the recurrent pharyngitis is
evident.
Tonsillectomy may decrease recurrences of symptomatic
pharyngitis
in selected patients, but only for a limited period of time
(category A, grade I).
A small percentage of patients will have recurrences of
acute
pharyngitis and throat cultures (or RADTs) positive for
group A
streptococci within a short period of time following
completion
of a course of antimicrobial therapy. A single such episode
may
be retreated with the regimens recommended (e.g. oral
penicillin
V, intramuscular Benzathine penicillin G or C-R bicillin
(900/300), or for penicillin-allergic patients,
erythromycin).
When multiple episodes occur over the course of months or
years,
it may be difficult to differentiate viral infections from
true
group A streptococcal infections in a streptococcal
carrier. Use
of certain antimicrobial agents has been shown to yield
high
rates of streptococcal eradication in the pharynx under
these
particular circumstances (category A, grade II).
Table. Retreatment of symptomatic aptients with multiple
repeated
culture-positive episodes of pharyngitis.
Antimicrobial agent Dose Category Grade
Oral*†
Clindamycin Children: 20-30 mg/(kg * d) B II
for 10 d
Adults: 600 mg/d in 2-4
equally divided doses for
10 d
Amoxicillin/clavulanate 40 mg/(kg • d) in 3 B II
equally divided doses for
10 d‡
Parenteral agents
Benzathine penicillin G (for dose, see table 2)§ B II
* Macrolides (e.g., erythromycin) and cephalosprins are not
included in this table, as there are insufficient data to
support their efficacy in this specific circumstance.
† Although shorter courses of some new macrolides
and
cephalosporins have been reported to be effective for
treating group A streptococcal upper respiratory tract
infections, the evidence is not yet sufficient to recommend
these agents for therapy at this time (this is also true
for
patients with repeated infections or for those in whom the
organism is difficult to eradicate).
‡ Maximum dose, 750 mg of amoxicillin per day.
§ Benzathine penicillin G is useful for patients whose
compliance with previous courses of oral antimicrobials is
questionable. Limited data suggest that the addition of
rifampin (10 mg/kg b.i.d. x 4 days; maximum dose, 300 mg
b.i.d.) to a benzathine penicillin G regimen may be
beneficial for eradicating streptococci from the pharynx.
Definitions
Categories reflecting the strength of each recommendation
for or
against its use:
A Good evidence to support a recommendation for use
B Moderate evidence to support a recommendation for use
C Poor evidence to support a recommendation for or against
use
D Moderate evidence to support a recommendation against use
E Good evidence to support a recommendation against use
Categories reflecting the quality of evidence for each
recommendation:
I Evidence from at least one properly randomized,
controlled trial
II Evidence from at least one well-designed clinical
trial without randomization, from cohort or
case-controlled analytic studies (preferably from more
than one center), or from multiple time-series studies
or dramatic results from uncontrolled experiments
III Evidence from opinions of respected authorities
based on clinical experience, descriptive studies, or
reports of expert committees
CLINICAL ALGORITHM(S):
An algorithm which can be applied to uncomplicated cases of
acute
pharyngitis is provided.
DEVELOPER(S):
Infectious Diseases Society of America (IDSA) - Medical
Specialty
Society
COMMITTEE:
The Acute Pharyngitis Guideline Panel
GROUP COMPOSITION:
Names of Panel Members: Alan L. Bisno, MD, Chairman,
Michael A.
Gerber, MD, Jack M. Gwaltney, Jr., MD, Edward L. Kaplan,
MD, and
Richard H. Schwartz, MD
ENDORSER(S):
Not stated
GUIDELINE STATUS:
This is the current release of the guideline.
According to the guideline developer, this guideline was
reviewed
in 1999. No changes.
GUIDELINE AVAILABILITY:
Electronic copies: Available from the Infectious Diseases
Society
of America (IDSA) Web site.
Print copies: Available from IDSA, 99 Canal Center Plaza,
Suite
210, Alexandria, VA 22314.
COMPANION DOCUMENTS:
The following is available:
Gross PA, Barrett TL, Dellinger EP, Krause PJ, Martone WJ,
McGowan JE Jr, Sweet RL, Wenzel RP. Purpose of quality
standards
for infectious diseases. Infectious Diseases Society of
America.
Clin Infect Dis 1994 Mar;18(3):421.
Electronic copies: Available from the IDSA Web site.
Print copies: Available from IDSA, 99 Canal Center Plaza,
Suite
210, Alexandria, VA 22314.
PATIENT RESOURCES:
Not stated
NGC STATUS:
This summary was completed by ECRI on January 15, 1999. The
information was verified by the guideline developer as of
March
22, 1999.
COPYRIGHT STATEMENT:
This NGC summary is based on the original guideline, which
is
subject to the guideline developer's copyright
restrictions.
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© 2000 National Guideline Clearinghouse
Date Modified: Monday, June 14, 1999
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{36} SUBSTANCE ABUSE - 22 Feb 2000
(PRIVATE) 191 Lines
----------------------------------------------------------------------------
National
Guideline
Clearinghouse
[HOME] [NGC RESOURCES] [HELP] [WHAT'S NEW] [SITE
MAP] [CONTACT NGC] [ABOUT NGC]
Search NGC: Search Help Detailed Search
Browse NGC: Disease/Condition Treatment/Intervention
Organization
Options: Brief Summary Complete Summary Full Text
Compare Guidelines: Add to Guideline Collection View
Guideline
Collection
------------------------------------------------------------------------
Brief Summary
TITLE:
A guide to substance abuse services for primary care
clinicians.
SOURCE(S):
Rockville (MD): U.S. Department of Health and Human
Services,
Public Health Service, Substance Abuse and Mental Health
Services
Administration, Center for Substance Abuse Treatment; 1997.
187
p. (Treatment improvement protocol (TIP) series; no.
24).[210
references]
ADAPTATION:
Not applicable: Guideline was not adapted from another
source.
RELEASE DATE:
1997
MAJOR RECOMMENDATIONS:
Excerpted by NGC
The Consensus Panel that developed this Treatment
Improvement
Protocol (TIP) recommends that primary care clinicians -- a
term
that includes physicians, physician assistants, and
advanced
practice nurses -- follow the guidelines below. The
guidelines
supported by the research literature are followed by (1);
clinically based recommendations are marked (2).
Screening
* Periodically and routinely screen all patients for
substance
use disorders. (2)
* Ask questions about substance abuse in the context of
other
lifestyle questions. (2)
* Use the Alcohol Use Disorders Identification Test (AUDIT)
to
screen for alcohol problems among English-speaking,
literate
patients, or use the first three quantity/frequency
questions from the AUDIT, supplemented by the (CAGE)
questionnaire. (1)
* Use the CAGE-AID (Cage Adapted to Include Drugs) to
screen
for drug use among patients. (1)
* Ask "Have you used street drugs more than five times in
your
life?" A positive answer suggests further screening and
possibly assessment. (2)
* Ask high-risk patients about alcohol and other drug use
in
combination. (2)
* Use the TWEAK to screen pregnant women for alcohol use.
(1)
* Ask pregnant women "Do you use street drugs?" If the
answer
is yes, advise abstinence. (2)
* Use the CAGE, the AUDIT, or the Michigan Alcoholism
Screening Test -- Geriatric Version (MAST-G) to screen
patients over 60. (1)
* Screen adolescents for substance abuse every time they
seek
medical services. (2)
* When recording screening results, indicate that a
positive
screen is not a diagnosis. (2)
* Present results of a positive screen (and conduct all
discussions about substance use) in a nonjudgmental manner.
(1)
Brief Intervention
* Perform a brief intervention with patients whose
substance
abuse problems are less severe. (1)
* Include in the brief intervention feedback about
screening
results and risks of use, information about safe
consumption
limits and advice about change, assessment of patient's
readiness to change, negotiated goals and strategies for
change, and arrangements for follow-up visits. (1)
Assessment and Treatment
* Refer high-risk patients to a specialist, if possible,
for
in-depth assessment. (2)
* Ensure that a specialized assessor has familiarity with
psychiatric disorders. (2)
* Ascertain that assessment is sequential and
multidimensional. (1)
* Check the gamma-glutamyl transferase (GGT) as part of the
assessment process. (2)
* Use the criteria in the American Psychiatric
Association's
Diagnostic and Statistical Manual of Mental Disorders,
Fourth Edition, in combination with the American Society of
Addiction Medicine's Patient Placement Criteria, Second
Edition, to make a diagnosis and devise an assessment-based
treatment plan. (1)
* Become familiar with available assessment and treatment
resources. (2)
* Keep encouraging reluctant patients with substance use
disorders to accept treatment of some kind. (2)
Confidentiality
* Establish recordkeeping systems and reminder programs to
provide cues about the need to screen and reassess patients
for alcohol and drug abuse. (2)
* Do not perform screening or laboratory tests (such as
blood
or urine tests) without the patient's consent. (2)
* Consult the patient before discussing his or her
substance
use with anyone else -- family, employers, treatment
programs, or the legal system. (2)
The Primary Care Clinician's Opportunity
Visits to primary care clinicians provide unparalleled
opportunities to intervene with substance abuse problems at
a
relatively early stage in disease progression. Office or
clinic
visits also give clinicians an opening to discuss substance
abuse
prevention with patients and in many cases, forestall
problems
from ever developing.
CLINICAL ALGORITHM(S):
An algorithm is provided for following a patient with
substance
use problems who presents in a primary care setting.
DEVELOPER(S):
Substance Abuse and Mental Health Services Administration
(U.S.)
(SAMHSA) - Federal Government Agency [U.S.]
COMMITTEE:
Treatment Improvement Protocol (TIP) Series 24 Consensus
Panel
GROUP COMPOSITION:
Names of Panel Members: Eleanor Sullivan, Ph.D., R.N.,
F.A.A.N,
Co-Chair , Michael Fleming, M.D., M.P.H. Co-Chair; Michael
J.
Bohn, M.D., Myra Muramoto, M.D., Madeline A. Naegle, R.N.,
Ph.D.,
F.A.A.N., Daniel Vinson, M.D., M.S.P.H., Allen Zweben,
D.S.W.,
Steven Adelman, M.D., Michelle H. Allen, M.D., Kathleen
Austin,
C.D.C. III, N.C.A.C. II, Mark L. Carlson, M.D., Theodore M.
Godlaski, M.Div., I.C.D.C., Derrick Harris, L.C.S.W.,
C.A.C. II,
Susan Hernandez, Mark L. Kraus, M.D., E. Joyce Roland,
Ph.D.,
Marilyn Sawyer Sommers, Ph.D., R.N., Robert Taylor, M.D.,
Ph.D.
ENDORSER(S):
Not stated
GUIDELINE STATUS:
This is the current release of the guideline.
An update is not in progress at this time.
GUIDELINE AVAILABILITY:
Electronic copies: Available from the National Library of
Medicine (NLM) Health Services Technology Assessment Text
(HSTAT)
database.
Print copies: Available from the National Clearinghouse for
Alcohol and Drug Information (NCADI), P.O. Box 2345,
Rockville,
MD 20852. Publications may be ordered from NCADI's Web site
or by
calling (800) 729-6686 (United States only).
COMPANION DOCUMENTS:
None available
PATIENT RESOURCES:
Not stated
NGC STATUS:
This summary was completed by ECRI on April 25, 1999. It
was
verified by the guideline developer on July 26, 1999.
COPYRIGHT STATEMENT:
No copyright restrictions apply.
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------------------------------------------------------------------------
Brief Summary
TITLE:
Diagnosing syncope.
SOURCE(S):
Ann Intern Med 1997 Jun 15;126(12):989-96 [34 references]
Ann Intern Med 1997 Jul 1;127(1):76-86 [110 references]
ADAPTATION:
Not applicable: Guideline was not adapted from another
source.
RELEASE DATE:
1997 Jun 15
MAJOR RECOMMENDATIONS:
Approach to Syncope
The algorithm depicted in the guideline provides a
diagnostic
approach to syncope. It is intended to provide a framework
for
clinical judgment, not to replace it. Key points in the
algorithm
that are discussed in the text include the following.
1. History, physical examination, and electrocardiography
are
the core of the workup for patients with syncope.
2. Carotid sinus massage may be useful in elderly patients
but
should not be done by the generalist if bruits are present,
if the patient has a history of ventricular tachycardia, or
in the setting of a recent stroke or myocardial infarction.
A false-positive test result should be suspected if carotid
massage is positive but the history does not suggest
carotid
hypersensitivity.
3. Special issues for elderly patients include the
multifactorial nature of syncope, polypharmacy, use of
carotid sinus massage, and cardiac testing (exercise stress
test and echocardiography) to exclude cardiac disease.
4. Nondiagnostic arrhythmias found on Holter monitor
readings
should not usually be treated.
5. Intracardiac electrophysiologic studies are most useful
in
patients who have organic heart disease and otherwise
unexplained syncope.
6. In a patient with exertional syncope, echocardiography
should precede exercise stress testing.
7. The assessment of patients with a normal heart who have
frequent episodes of syncope should include a loop recorder
and psychiatric evaluation.
8. The workup of patients with a normal heart who have
infrequent episodes of syncope should include a tilt test
and psychiatric evaluation.
9. Neurologic testing, including electroencephalography,
computed tomography, and carotid and transcranial Doppler
ultrasonography, should be reserved for patients who have
neurologic signs or symptoms or carotid bruits.
CLINICAL ALGORITHM(S):
An algorithm for diagnosing syncope is provided in the
guideline.
DEVELOPER(S):
American College of Physicians (ACP) - Medical Specialty
Society
COMMITTEE:
Clinical Efficacy Assessment Subcommittee, Health and
Public
Policy Committee
GROUP COMPOSITION:
Authors: Mark Linzer, MD; Eric H. Yang, BS; N.A. Mark Estes
III,
MD; Paul Wang, MD; Vicken R. Vorperian, MD; and Wishwa N.
Kapoor,
MD, MPH.
Members of the Clinical Efficacy Assessment Subcommittee:
George
E. Thibault, MD, Chair; John R. Feussner, MD, Co-Chair;
Anne-Marie J. Audet MD; Gottlieb C. Friesinger Jr., MD;
Daniel L.
Kent, MD; Keith I. Marton, MD; Valerie Anne Palda, MD; John
J.
Whyte, MD; and Preston L. Winters, MD.
ENDORSER(S):
American College of Physicians Board of Regents
GUIDELINE STATUS:
This is the current release of the guideline.
An update is not in progress at this time.
GUIDELINE AVAILABILITY:
Electronic copies: Available from the American College of
Physicians and American Society of Internal Medicine
(ACP-ASIM)
at
http://www.acponline.org/journals/annals/15jun97/ppsyncop.htm
Print copies: Available from ACP-ASIM, 190 N. Independence
Mall
West, Philadelphia, PA 19106-1572
COMPANION DOCUMENTS:
The statements made by ACP in the guideline document are
developed using the information provided in the following
background paper:
Linzer M, Yang EH, Estes M 3rd, Wang P, Vorperian VR,
Kapoor WN.
Diagnosing syncope. Part 2: Unexplained syncope. Clinical
Efficacy Assessment Project of the American College of
Physicians. Ann Intern Med 1997 Jul 1;127(1):76-86.
Information contained in this background paper is
representd in
the methodology fields of the NGC summary (i.e., Methods to
Collect Evidence; Methods to Analyze the Evidence; Cost
Analysis).
Electronic copies: Available from the American College of
Physicians and American Society of Internal Medicine
(ACP-ASIM)
at
http://www.acponline.org/journals/annals/01jul97/ppsync2.htm
Print copies: Available from ACP-ASIM, 190 N. Independence
Mall
West, Philadelphia, PA 19106-1572
PATIENT RESOURCES:
Not stated
NGC STATUS:
This summary was completed by ECRI on September 1, 1998.
The
information was verified by the guideline developer on
December
1, 1998.
COPYRIGHT STATEMENT:
This NGC summary is based on the original guideline, which
is
subject to the guideline developer's copyright
restrictions.
Summaries of ACP-ASIM guidelines may be downloaded from the
NGC
Web site and/or transferred to an electronic storage and
retrieval system solely for the personal use of the
individual
downloading and transferring the material. Permission for
all
other uses must be obtained from ACP-ASIM by contacting the
ACP-ASIM Permissions Coordinator, telephone: (800)
523-1546, ext.
2670.
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{22} THYROID DISEASE
(HYPER/HYPO) - 22 Feb 2000 (PRIVATE)
420 Lines
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------------------------------------------------------------------------
Brief Summary
TITLE:
Treatment guidelines for patients with hyperthyroidism and
hypothyroidism.
SOURCE(S):
JAMA 1995 Mar 8;273(10):808-12 [13 references]
ADAPTATION:
Not applicable: Guideline was not adapted from another
source.
RELEASE DATE:
1995 Mar 8 (reviewed 1999)
MAJOR RECOMMENDATIONS:
TREATMENT GUIDELINES FOR PATIENTS WITH HYPERTHYROIDISM
Initial Visit
Medical History. A detailed medical history will
usually provide the clinician with sufficient clues to
suggest the diagnosis of hyperthyroidism. Patients
should be asked about nervousness, fatigue,
palpitations, exertional dyspnea, weight loss, heat
intolerance, irritability, tremor, muscle weakness,
decreased menstrual flow in women, sleep disturbance,
increased perspiration, increased frequency of bowel
movements, change in appetite, and thyroid enlargement.
Patients should also be asked about photophobia, eye
irritation, diplopia, or a change in visual acuity.
In individuals in whom Graves' disease is not obvious,
questions regarding recent iodine exposure, prior or
current thyroid hormone use, anterior neck pain,
pregnancy, or history of goiter should be included. A
family history of thyroid disease should be sought.
Physical Examination. An appropriately thorough
physical examination should be performed during the
initial evaluation including weight and height, pulse
rate and regularity, blood pressure, cardiac
examination, thyroid enlargement (diffuse or nodular),
proximal muscle weakness, tremor, an eye examination
(for evidence of ophthalmopathy), and a skin
examination (for pretibial myxedema).
Older individuals may have few if any symptoms and
signs of hyperthyroidism except for weight loss and
cardiac abnormalities, in particular atrial
fibrillation and/or congestive heart failure.
Laboratory Evaluation. Specific tests to establish the
diagnosis of hyperthyroidism include an estimate or
direct measurement of free thyroxine (T4; which is
elevated in hyperthyroidism), as well as and a serum
thyroid-stimulating hormone (TSH) measurement (which is
suppressed in hyperthyroidism) . If hyperthyroidism is
confirmed, other tests may be performed according to
the clinical situation. These may include total
triiodothyronine (T3), thyroid autoantibodies, and a
radioactive iodine uptake test. The latter test should
be obtained if the diagnosis of Graves' disease is not
secure. Specific treatment should generally be withheld
until the biochemical diagnosis and cause of
hyperthyroidism are confirmed. In most instances,
symptomatic relief can be obtained with
beta-adrenergic-blocking drugs while the patient is
undergoing additional diagnostic testing.
Treatment Plan
The treatment of Graves' hyperthyroidism is directed
toward lowering the serum concentrations of thyroid
hormones to reestablish a eumetabolic state. There are
currently three available modalities of treatment, all
of which are effective. These include antithyroid drugs
(ATDs), radioactive iodine (131I), and thyroid surgery.
The patient should have a clear understanding of the
indications and implications of all forms of therapy,
including risks, benefits, and side effects, and should
be an active participant in the decision-making process
regarding type of therapy. Because therapy is
frequently ablative, the participation of an
endocrinologist in the patient's treatment may be
beneficial in those cases in which the primary care
physician does not have experience with the disorder.
Antithyroid Drugs.--The ATDs, methimazole and
propylthiouracil, are useful either as a primary form
of therapy or to lower thyroid hormone levels before
(and in some cases after) radioactive iodine therapy or
surgery. Long-term ATD therapy may lead to remission in
some patients with Graves' disease. Initial daily doses
of methimazole generally range from 10 to 40 mg, and
for propylthiouracil, 100 to 600 mg. There is no
clear-cut standard for duration of therapy with ATDs,
but when used as primary therapy, they are usually
given for 6 months to 2 years, although a longer period
of administration is acceptable. Some physicians prefer
a regimen of combined ATD and thyroid hormone to avoid
frequent adjustments of ATD doses.
Adverse reactions to both methimazole and
propylthiouracil occur, including rash, itching, and
less commonly, arthralgias or hepatic abnormalities.
Hepatic necrosis caused by propylthiouracil and
cholestatic jaundice caused by methimazole are
sufficiently rare enough that routine monitoring of
liver function tests is unnecessary. The most serious
reaction to either drug is agranulocytosis, which
occurs in about 0.3% of patients. Patients should be
cautioned about the side effects of ATD prior to the
initiation of therapy. Some clinicians obtain white
blood cell (WBC) counts prior to initiating ATD, since
mild leukopenia is common in Graves' disease. A
baseline WBC may therefore be useful for comparison if
subsequent WBC counts are obtained.
Patients developing fever, rash, jaundice, arthralgia,
or oropharyngitis should promptly discontinue their
medication, contact their physician, and have
appropriate laboratory studies including a complete
blood cell count with WBC differential.
Lithium carbonate or stable iodine has been used to
block release of thyroid hormone from the thyroid gland
in patients who are intolerant to ATDs, although their
use is infrequent.
Radioactive Iodine Therapy.--Radioactive iodine (131I)
is the most commonly used form of treatment in the
United States. It is safe, the principal side effect
being the early or late development of hypothyroidism,
necessitating life-long thyroid hormone replacement
following 131I treatment. Treatment with 131I does not
cause a reduction in fertility and does not cause
cancer, nor has it been shown to produce ill effects in
offspring of those so treated prior to pregnancy. It is
contraindicated during pregnancy. Its use in
individuals under the age 20 years, while
controversial, is common. Pregnancy needs to be
excluded before 131I is administered to young women and
should be deferred for a few months following therapy.
Therapy with 131I is also contraindicated in women who
are breast-feeding. Elderly patients or individuals at
risk for developing cardiac complications may be
pretreated with ATDs prior to 131I therapy, especially
if hyperthyroidism is severe, to deplete the gland of
stored hormone, thereby minimizing the risk of
exacerbation of hyperthyroidism due to 131I-induced
thyroiditis. In some patients, ATDs may be required for
control for several months following radioiodine
therapy. A radioactive iodine uptake test is usually
performed just prior to the administration of 131I to
determine the appropriate dose.
Surgery. Thyroidectomy is infrequently recommended for
patients with Graves' disease. Specific indications
include patients with very large goiters who may be
relatively resistant to 131I, those who have
coincidental thyroid nodules, pregnant patients
allergic to ATDs, and patients who are allergic to ATDs
and/or do not wish 131I therapy. The procedure should
be performed only by an experienced surgeon and only
after careful medical preparation. Patients must be
cautioned about potential complications of surgery,
including hypoparathyroidism and injury to the
recurrent laryngeal nerve. Hyperthyroidism may persist
or recur if insufficient thyroid tissue is removed,
whereas hypothyroidism usually develops after
near-total thyroidectomy.
Adjunctive Therapy. The most useful adjuncts are
beta-adrenergic blockers such as propranolol or
nadolol, which can provide symptomatic improvement
until the euthyroid state has been achieved. Patients
who cannot tolerate beta-blockers may be treated with
calcium channel blockers such as diltiazem.
Continuing Care
Since the treatment of hyperthyroidism may last for a
few years, a follow-up plan must be established.
Antithyroid Drugs. Patients treated with ATDs should
generally be seen initially at 4- to 12-week intervals,
depending on the severity of the illness, until
euthyroidism is achieved. At this time, the ATD dose
can often be reduced. Patients are then monitored every
3 to 4 months thereafter while continuing to take ATDs.
An interval examination should include weight, pulse,
blood pressure, thyroid, and an eye examination. Once
ATDs are discontinued, patients should be seen at 4- to
6-week intervals for the first 3 to 4 months after the
medication is stopped, and then at increasing intervals
for the duration of the first year. If clinical and
biochemical euthyroid status persists, patients should
be evaluated yearly for the next 2 to 3 years and at
increasing intervals thereafter.
Radioactive Iodine. Patients should be seen at 4- to
6-week intervals for the first 3 months following
radioactive iodine therapy, and then at intervals as
the clinical situation dictates.
Surgery. After thyroidectomy, the patient should be
followed as warranted for postoperative care, and at
approximately 2 months after surgery, to assess thyroid
status. Patients can be followed at yearly intervals
after establishing clinical and biochemical
euthyroidism.
Special Problems
Refer to the original and complete guideline document
for discussion of the following special problems:
* Hyperthyroidism and pregnancy
* Graves' ophthalmopathy
* Toxic nodular goiter
* Thyroid storm
TREATMENT GUIDELINES FOR PATIENTS WITH HYPOTHYROIDISM
Initial Visit
Medical History. A comprehensive medical history is
recommended. Patients should be asked about symptoms of
tiredness, weakness, fatigue, sleepiness, cold
intolerance, dry skin, hoarseness, constipation, joint
pains, muscle cramps, mental impairment, depression,
menstrual disturbances in women and especially
menorrhagia, infertility, and weight gain.
Physical Examination. A comprehensive physical
examination should be performed during the initial
evaluation. Findings from the physical examination that
may indicate hypothyroidism include goiter or a
nonpalpable thyroid gland, bradycardia, edema,
hoarseness, delayed relaxation of deep tendon reflexes,
slow speech, and cool, dry skin.
Laboratory Evaluation. A serum TSH measurement and a
free T4 estimate (or direct measurement) should be
performed. When autoimmune thyroiditis is the suspected
underlying cause, it is helpful to confirm antithyroid
antibody titers, either antimicrosomal antibody
(anti-TPO antibody) or antithyroglobulin antibody.
Treatment Plan. Levothyroxine sodium is the treatment
of choice for the routine management of hypothyroidism.
Levothyroxine preparations are manufactured in many
different dosages and allow precise titration of an
individual patient's requirements. Adults with
hypothyroidism require approximately 1.7 microg/kg of
body weight per day for full replacement. Children may
require higher doses (up to 4 microg/kg of body weight
per day). Older patients may need less than 1 microg/kg
per day. Therapy is usually initiated in patients under
the age of 50 years with full replacement. For those
patients who are older than 50 years, or in younger
patients with a history of cardiac disease, a lower
initial dosage is indicated, starting with 0.025 to
0.05 mg of levothyroxine daily, with clinical and
biochemical reevaluations at 6- to 8-week intervals
until the serum TSH concentration is normalized. Some
individuals older than 50 years, such as those recently
treated for hyperthyroidism or those known to have had
hypothyroidism for only a short time, such as a few
months, may be treated with full replacement doses of
levothyroxine. Certain drugs, eg, cholestyramine,
ferrous sulfate, sucralfate, and aluminum hydroxide
antacids, may interfere with levothyroxine absorption
from the gut. Levothyroxine administration should be
spaced at least 4 hours apart from these medications.
Other drugs, especially the anticonvulsants phenytoin
and carbamazepine and the antituberculous agent
rifampin, may accelerate levothyroxine metabolism,
necessitating higher levothyroxine doses.
Continuing Care
Patients should be evaluated initially about every 6 to
8 weeks to monitor the response to the dose of
levothyroxine. Once the TSH concentration has been
normalized, the need for frequent visits is reduced.
Visit frequency of every 6 to 12 months is then
sufficient, depending on the clinical situation. Should
it be necessary to adjust a patient's dosage, he or she
should return in 2 to 3 months to assess the
therapeutic response and to remeasure the TSH
concentration.
An interim history should assess response to therapy
with thyroid hormone, evaluating clinical improvement
in symptoms, as well as possible side effects of the
medication. A physical examination relevant to the
thyroid status should be performed annually. A TSH
concentration should be measured at least annually. For
patients who have recently started receiving
levothyroxine or who have had their dosage, type, or
brand of thyroid preparation changed, the TSH
concentration should be measured after 8 to 12 weeks.
Special Considerations
Refer to the guideline document for special
considerations in the following patient populations and
clinical scenarios:
* Elderly persons
* Pregnancy
* Iatrogenic hyperthyroidism
* Subclinical hypothyroidism
Use of Other Thyroid Hormone Preparations
There are few indications for thyroid hormone
preparations other than levothyroxine. Liothyronine may
be useful prior to treatment of thyroid cancer with
radioactive iodine. Chronic liothyronine therapy for
hypothyroidism is not recommended. Biological and
synthetic thyroid hormone preparations containing both
T4 and T3 are also not currently recommended for
therapy, although their use is not necessarily
contraindicated.
Use of Thyroid Hormone for Other Situations
Thyroid hormone therapy has been used for nonthyroidal
problems, including obesity, infertility, menstrual
irregularity, short stature, and chronic fatigue. There
is no scientific proof that such conditions respond to
thyroid hormone therapy and its use is not felt to be
appropriate. Some psychiatrists, however, report the
benefit of adding thyroid hormone medication to
tricyclic antidepressants in selected patients with
depression, and clinical improvements have been noted.
CLINICAL ALGORITHM(S):
None provided
DEVELOPER(S):
American Thyroid Association
COMMITTEE:
Standard of Care Committee of the American Thyroid
Association
GROUP COMPOSITION:
Members: Peter A. Singer, MD; David S. Cooper, MD; Elliot
G.
Levy, MD; Paul W. Ladenson, MD; Lewis E. Braverman, MD;
Gilbert
Daniels, MD; Francis S. Greenspan, MD; I. Ross McDougall,
MB,
ChB, PhD; Thomas F. Nikolai, MD.
ENDORSER(S):
American Thyroid Association Executive Council
GUIDELINE STATUS:
This is the current release of the guideline.
An update is not in progress at this time. According to the
guideline developer, the guideline is reviewed annually for
current applicability.
GUIDELINE AVAILABILITY:
Electronic copies: Available from the online Archives of
Internal
Medicine at the American Medical Association (AMA) Web
site. A
link is also provided at the American Thyroid Association
Web
site.
Print copies: Available from the American Thyroid
Association,
Montefiore Medical Center, 111 East 210th St, Bronx, NY
10467;
telephone: (718) 882-6047; fax: (718) 882-6085; e-mail:
admin@thyroid.org.
COMPANION DOCUMENTS:
None available
PATIENT RESOURCES:
Not stated
NGC STATUS:
This summary was completed by ECRI on May 31, 1999. The
information was verified by the guideline developer as of
July
20, 1999.
COPYRIGHT STATEMENT:
This summary is based on the original guideline, which is
copyrighted by the American Thyroid Association.
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{38} URINARY INCONTINENCE - 22 Feb 2000 (PRIVATE) 621 Lines
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------------------------------------------------------------------------
Brief Summary
TITLE:
Urinary incontinence in adults: acute and chronic
management.
SOURCE(S):
Rockville (MD): U.S. Department of Health and Human
Services,
Public Health Service, AHCPR; 1996 Mar. 125 p. (Clinical
practice
guideline; no. 2 [update]).
ADAPTATION:
Not applicable: Guideline was not adapted from another
source.
RELEASE DATE:
1996 Mar
MAJOR RECOMMENDATIONS:
Strength of Evidence
The panel rated the strength of evidence supporting each
recommendation, based on the following criteria:
A. The recommendation is supported by scientific evidence
from
properly designed and implemented controlled trials
providing statistical results that consistently support the
guideline statement.
B. The recommendation is supported by scientific evidence
from
properly designed and implemented clinical series that
support the guideline statement.
C. The recommendation is supported by expert opinion.
Please note that these rating represent the strength of the
supporting research evidence, not the strength of the
recommendation itself. The strength of each recommendation
is
conveyed in the language describing it.
Identifying and Evaluating Urinary Incontinence
General Principles of Diagnostic Evaluation:
Health care providers are encouraged to be knowledgeable
about
and initiate the basic evaluation of patients with UI.
(Strength
of Evidence = C.)
Basic Evaluation:
All patients with UI should undergo a basic evaluation that
includes a history, physical examination, measurement of
postvoid
residual volume, and urinalysis. (Strength of Evidence =
B.)
Risk factors that are associated with UI should be
identified and
attempts made to modify them. (Strength of Evidence = B.)
Supplementary Assessments
Blood testing (BUN, creatinine, glucose, and calcium) is
recommended if compromised renal function is suspected or
if
polyuria (in the absence of diuretics) is present.
(Strength of
Evidence = C.)
Urine cytology is not recommended in the routine evaluation
of
the incontinent patient. (Strength of Evidence = B.)
Further Evaluation
After the basic evaluation, treatment for the presumed type
of
urinary incontinence should be initiated unless there is an
indication for further evaluation. (Strength of Evidence =
B.)
After the basic evaluation and initial treatment, patients
who
fail or those who are not appropriate for treatment based
on
presumptive diagnosis should undergo further evaluation.
(Strength of Evidence = C.)
Specialized Tests
Specialized tests are not intended to be part of the basic
evaluation of UI. (Strength of Evidence = B.)
Urodynamic Tests
In the further evaluation of UI, simple cystometry is
appropriate
for detecting abnormalities of detrusor compliance and
contractability, measuring PVR, and determining capacity.
(Strength of Evidence = A.)
In some instances of complicated diagnostic situations or
involved therapeutic plans, multichannel cystometric tests
are
appropriate. (Strength of Evidence = B.)
When performing urodynamic studies, the health care
provider
should attempt to reproduce the patient's symptoms.
(Strength of
Evidence = C.)
Endoscopic Tests
Cystoscopy is not recommended in the basic evaluation of
UI.
(Strength of Evidence = B.) However, cystoscopy may be
indicated
in the further evaluation when the following situations are
present: (a) sterile hematuria or pyuria (Strength of
Evidence =
B); (b) when urodynamics fail to duplicate symptoms
(Strength of
Evidence = C); (c) new onset of irritative voiding
symptoms,
bladder pain, recurrent cystitis, or suspected foreign
body.
(Strength of Evidence = B.)
Imaging Tests
Radiographic, ultrasonographic, and other imaging tests
should be
used for the evaluation of anatomic conditions associated
with UI
when clinically needed. (Strength of Evidence = C.)
Treatment of Urinary Incontinence
Behavioral Techniques:
Toileting Assistance
Routine or scheduled toileting should be offered to
incontinent
patients on a consistent schedule. This technique is
recommended
for patients who cannot participate in independent
toileting.
(Strength of Evidence = C.)
Habit training is recommended for patients for whom a
natural
voiding pattern can be determined. (Strength of Evidence =
B.)
Prompted voiding is recommended in patients who can learn
to
recognize some degree of bladder fullness or the need to
void, or
who can ask for assistance or respond when prompted to
toilet.
Patients who are appropriate for prompted voiding may not
have
sufficient cognitive ability to participate in other, more
complex behavioral therapies. (Strength of Evidence = A.)
Bladder training
Bladder training is strongly recommended for management of
urge
and mixed incontinence. Bladder training is also
recommended for
management of SUI. (Strength of Evidence = A.)
Pelvic Muscle Exercise
Teaching women pelvic muscle exercises (PMEs) may prevent
UI.
(Strength of Evidence = C.)
Teaching exercises to strengthen pelvic muscles may
decrease the
incidence of UI. (Strength of Evidence = C).
PMEs are strongly recommended for women with SUI (Strength
of
Evidence = A.)
PMEs are also recommended in men and women in conjunction
with
bladder training for urge incontinence. (Strength of
Evidence =
B.)
PMEs may also benefit men who develop urinary incontinence
following prostatectomy (Strength of Evidence = C.)
PME and Bladder Inhibition Augmented by Biofeedback Therapy
Pelvic muscle rehabilitation and bladder inhibition using
biofeedback therapy are recommended for patients with
stress UI,
urge UI, and mixed UI. (Strength of Evidence = A.)
Pelvic Muscle Exercises Augmented with Vaginal Weight
Training
Vaginal weight training is recommended for SUI in
premenopausal
women. (Strength of Evidence = B.)
Pelvic Floor Electrical Stimulation
Pelvic floor electrical stimulation has been shown to
decrease
incontinence in women with SUI. (Strength of Evidence = B.)
Pelvic floor electrical stimulation may be useful for urge
and
mixed incontinence. (Strength of Evidence = B.)
Pharmacologic Treatment:
Urge Incontinence: Detrusor Instability
The following pharmacologic agents are reported to be
useful in
Detrusor Instability (DI) as observed in clinical practice.
(Strength of Evidence = B.)
* Anticholinergic agents: oxybutynin, dicyclomine
hydrochloride, and propantheline.
* Tricyclic antidepressants: imipramine, doxepin,
desipramine,
and nortriptyline.
Anticholinergic agents are the first-line pharmacologic
therapy
for patients with DI. (Strength of Evidence = A.)
When pharmacologic therapy is to be used for patients with
DI,
oxybutynin is the anticholinergic agent of choice. The
recommended dosage is 2.5-5 mg taken orally three or four
times
per day. (Strength of Evidence = A.)
Propantheline is the second-line anticholinergic agent in
the
treatment of patients with DI who can tolerate the full
dosage.
The recommended dosages are 7.5-30 mg administered three to
five
times per day; higher dosages (15-60 mg qid) may be
required.
(Strength of Evidence = B.)
Flavoxate is not recommended for the treatment of patients
with
DI. (Strength of Evidence = A.)
Tricyclic Agents
The use of tricyclic agents (TCAs) should be reserved for
carefully evaluated patients. The usual oral dosages are
10-25 mg
initially administered one to three times per day, but less
frequent administration is usually possible because of the
long
half-life of these drugs. The daily total dosage is usually
25-100 mg. (Strength of Evidence = B.)
Nonsteroidal Anti-Inflammatory Drugs
Nonsteroidal anti-inflammatory drugs (NSAIDs) are not
recommended
for the primary treatment of DI. (Strength of Evidence =
C.)
Stress Incontinence: Urethral Spincter Insufficiency
Alpha-Adrenergic Agonist Drugs
Phenylpropanolamine (PPA) or pseudoephedrine is the
first-line
pharmacologic therapy for women with SUI have no
contraindications for its use, particularly hypertension.
The
recommended dosage for PPA is 25-100 mg in
sustained-release
form, administered orally, twice daily. The usual dosage of
pseudoephedrine is 15-30 mg, orally, three times daily.
(Strength
of Evidence = A.)
Estrogen Therapy
Estrogen (oral or vaginal) may be considered as an
adjunctive
pharmacologic agent for postmenopausal women with SUI or
mixed
incontinence. Conjugated estrogen is usually administered
either
orally (0.3-1.25 mg/day) or vaginally (2 g or
fraction/day).
Progestin (e.g., medroxyprogesterone 2.5-10 mg/day) may be
given
continuously or intermittently. (Strength of Evidence = B.)
Alpha-Adrenergic Agonist and Estrogen Supplementation
Combination therapy of oral or vaginal estrogens and PPA is
recommended in the treatment of SUI in postmenopausal women
when
initial single-drug therapy has proven inadequate.
(Strength of
Evidence = A.)
Other Drugs of Possible Benefit
Imipramine is recommended as an alternative pharmacologic
therapy
for SUI when first-line agents have proven unsatisfactory.
(Strength of Evidence = C.)
The use of propranolol or other beta-blockers cannot be
recommended for treatment of SUI because of lack of
clinical
experience and clinical studies. (Strength of Evidence =
C.)
Surgical Treatment:
Surgery is recommended for treatment of stress incontinence
in
men and women and may be recommended as first-line
treatment for
appropriately selected patients who are unable to comply
with
other nonsurgical therapies. (Strength of Evidence = B.)
Stress Incontinence in Women: Hypermobility or Intrinsic
Sphincter Deficiency:
Retropubic or needle suspension is recommended for women
with
hypermobility when SUI is the primary indication for
surgery. On
the basis of greater efficacy, these procedures are
recommended
over anterior vaginal repair for hypermobility. (Strength
of
Evidence = B.)
Sling procedures are recommended for women who have
intrinsic
sphincter deficiency (ISD) with coexisting hypermobility or
as
first-line treatment for ISD. (Strength of Evidence = B.)
Periurethral bulking injections are recommended as
first-line
treatment for women with ISD who do not have coexisting
hypermobility. (Strength of Evidence = B.)
Artificial sphincter is recommended for ISD patients who
are
unable to perform intermittent catheterization and have
severe
SUI that is unresponsive to other surgical treatments.
Because of
the high complication rate, this treatment is rarely used
as
primary therapy. (Strength of Evidence = B.)
Stress Incontinence in Men: Intrinsic Sphincter Deficiency
Periurethral bulking injections are recommended as a
first-line
surgical treatment for men with ISD. (Strength of Evidence
= B.)
Artificial sphincter may be elected for ISD during the 6
months
after prostatectomy. Behavioral intervention should also be
tried
during this period. (Strength of Evidence = B.)
Urge Incontinence: Detrusor Instability
Augmentation intestinocystoplasty is recommended for those
patients with intractable, severe bladder instability or
poor
bladder compliance that is unresponsive to nonsurgical
therapies.
(Strength of Evidence = B.)
Urinary diversion is recommended in severe intractable
cases of
detrusor instability or poor bladder compliance that is
unresponsive to other therapies. (Strength of Evidence =
C.)
Overflow Incontinence: Bladder Neck or Urethral Obstruction
Symptoms of overflow or incontinence secondary to urethral
obstruction can be addressed with a surgical procedure to
relieve
the obstruction. (Strength of Evidence = B.)
Intermittent catheterization (IC) or an indwelling catheter
may
be considered in patients who are not candidates for
surgery and
suffer overflow incontinence due to urethral obstruction.
(Strength of Evidence= C.)
There is no evidence to support the use of urethral
dilation for
the treatment of incontinence in women, although it may be
useful
in the extremely rare cases of primary obstruction.
(Strength of
Evidence = C.)
Internal urethrotomy is not recommended for treating
urethral
obstruction in women. (Strength of Evidence = C.)
Other Measures and Supportive Devices
Intermittent Catheterization
IC is recommended as a supportive measure for patients with
spinal cord injury, persistent UI, or chronic urinary
retention
secondary to underactive or partially obstructed bladder.
(Strength of Evidence = B.)
Clean technique for IC is recommended for young, male,
neurologically impaired individuals. (Strength of Evidence
= B.)
Sterile technique for IC is recommended for elderly
patients and
patients with compromised immune system. (Strength of
Evidence =
C.)
Routine use of long-term suppressive therapy with
antibiotics in
patients with chronic, clean IC is not recommended.
(Strength of
Evidence = B.)
In high-risk populations, for example, those with an
internal
prosthesis or those who are immunosuppressed because of age
or
disease, the use of antibiotic therapy for asymptomatic
bacteriuria must be individually reviewed. (Strength of
Evidence
= C.)
Indwelling Urethral Catheters:
Indwelling catheters may be recommended as a supportive
measure
for patients whose incontinence is caused by obstruction
and for
whom other interventions are not feasible. Indwelling
catheters
are recommended for selected incontinent patients who are
terminally ill or for patients with pressure ulcers as
short-term
treatment. (Strength of Evidence = B.)
Indwelling catheters are recommended in severely impaired
individuals in whom alternative interventions are not an
option
and when a patient lives alone and a caregiver is
unavailable to
provide other supportive measures. (Strength of Evidence =
C.)
Suprapubic Catheters:
Suprapubic catheters are for short-term use following
gynecologic, urologic, and other surgery, or as an
alternative to
long-term catheter use. Suprapubic catheterization is
contraindicated as a long-term management option in persons
with
chronic unstable bladder (DI, DH) and ISD. (Strength of
Evidence
= B.)
External Collection Systems:
External collection systems are recommended for incontinent
men
and women who have adequate bladder emptying, who have
intact
genital skin, and in whom other therapies have failed or
are not
appropriate. (Strength of Evidence = C.)
Penile Compression Devices:
Penile compression devices are known to be used in clinical
practice in the treatment of UI. No scientific literature
was
found to support the use of these devices. The panel
recognizes
the temporary use of penile compression devices in males in
selected circumstances under the supervision of a health
care
provider. (Strength of Evidence = C.)
Pelvic Organ Support Devices
Pessaries are recommended for women who have symptomatic
pelvic
organ prolapse. (Strength of Evidence = C.)
Data are not available to recommend or discourage the use
of
pessaries for the treatment of UI in women. (Strength of
Evidence
= C.)
Absorbent Products
Absorbent products are recommended during evaluation, as an
adjunct to other therapy, and for long-term care of
patients with
chronic, intractable urinary incontinence. (Strength of
Evidence
= C.)
Chronic Intractable Urinary Incontinence
Interventions for Chronic UI:
Care of persons with chronic UI should include attention to
toileting schedules, fluid and dietary intake, strategies
to
decrease urine loss at night, use of the most absorbent and
skin-friendly protective garments possible, and prevention
and
early treatment of skin breakdown. (Strength of Evidence =
B.)
Physical and Environmental Alterations:
All caregivers for elderly or disabled individuals must
assess
the environment in which the patient resides. Simple
alterations,
or the addition of toileting or ambulation devices, can
often
eliminate or reduce episodes of involuntary urine loss.
(Strength
of Evidence = C.)
Strategies that maintain or improve mobility are likely to
prevent or reduce incontinent episodes in the frail
elderly.
(Strength of Evidence = B.)
Fluid and Dietary Management:
Constipation is a common problem for patients with chronic
UI.
Establishing a bowel regimen based on adequate fiber and
fluid
intake is often helpful. Elimination of bowel impaction and
consequent pressure on the bladder and urethra are often
necessary first steps in the treatment of chronic UI.
(Strength
of Evidence = C.)
Management of Nocturia:
Night-time voiding and incontinence are major problems for
adults
of all ages. Preventive measures to decrease night-time
voids are
recommended. The use of simple electronic urine detection
devices
should be encouraged for more efficient and effective
patient
monitoring of night-time urine loss. (Strength of Evidence
= B.)
Other Measures and Supportive Care
Protective garments and external collecting devices have a
major
part in the management of chronic incontinence. The most
absorbent and skin-friendly products should always be
utilized.
However, no scientific literature is available to guide
selection
of the most effective product. (Strength of Evidence = C.)
Intermittent Catheterization:
Intermittent catheterization appears to be preferable to
the use
of indwelling catheters for the management of urinary
retention
and overflow incontinence. (Strength of Evidence = B.)
Suprapubic Catheters:
Suprapubic catheters may be an acceptable alternative for
indwelling urethral catheters when patient choice or
circumstances require the use of a bladder drainage device.
(Strength of Evidence = B.)
Skin Care:
Recommended measures of cleansing the skin immediately
before and
after urine loss are helpful in preserving skin integrity.
(Strength of Evidence = B.)
Some pads and garments may provide some protection from
skin
damage. (Strength of Evidence = C.)
Education
Public Education:
Increased efforts to inform and educate the public about
incontinence are essential. (Strength of Evidence = C.)
The public should be aware that incontinence is not
inevitable or
shameful but is treatable or at least manageable. (Strength
of
Evidence = C.)
Patient education needs to be comprehensive and
multidisciplinary
so as to explain all management alternatives. (Strength of
Evidence = C.)
More research is needed to test the effectiveness of
patient
education activities. (Strength of Evidence = C.)
Professional Education:
Education about UI evaluation and treatment should be
included in
the basic curricula of undergraduate and graduate training
programs of all health care providers. Continuing education
programs on UI should be offered to all health care
providers.
(Strength of Evidence = C.)
CLINICAL ALGORITHM(S):
The overview algorithm provides the health care provider
with a
visual display of the organization, procedural flow,
decision
points, and preferred management pathways discussed in the
guideline.
DEVELOPER(S):
Agency for Healthcare Research and Quality (AHRQ) - Federal
Government Agency [U.S.]
COMMITTEE:
Urinary Incontinence in Adults Guideline Update Panel
GROUP COMPOSITION:
Names of Committee Members: J. Andrew Fantl, MD (Co-Chair);
Diane
Kaschak Newman, RNC, MSN, FAAN (Co-Chair); Joyce Colling,
PhD,
RN, FAAN; John O.L. DeLancey, MD; Christopher Keeys,
PharmD;
Richard Loughery, FACHA; B. Joan McDowell, PhD, RN, FAAN;
Peggy
Norton, MD; Joseph Ouslander, MD; Jack Schnelle, PhD; David
Staskin, MD; Jeannette Tries, MS, OTR; Vernon Urich, MD;
Sharon
H. Vitousek, MD; Barry D. Weiss, MD; Kristene Whitmore, MD
ENDORSER(S):
Not stated
GUIDELINE STATUS:
This is the current release of the guideline.
This guideline is an update of the Clinical Practice
Guideline on
Urinary Incontinence in Adults, first published in March
1992.
This update reflects new research findings and experience
with
emerging technologies for urinary incontinence (UI)
diagnosis and
treatment, and provides specific recommendations for
diagnosing
and managing adults with UI.
An update for the current guideline is not in progress at
this
time.
GUIDELINE AVAILABILITY:
Electronic copies: Available from the National Library of
Medicine's HSTAT database.
Print copies: Information regarding the availability of
these
publications can be found in the Agency for Healthcare
Research
and Quality (AHRQ) (formerly the Agency for Health Care
Policy
and Research [AHCPR]) Publications Catalog, which is
available at
the AHRQ Web site.
COMPANION DOCUMENTS:
The following documents are available:
1. Managing acute and chronic urinary incontinence.
Rockville,
MD: AHCPR, 1996 Mar. (Quick reference guide for clinicians;
no. 2 [1996 Update]). AHCPR Publication No. 96-0686.
Available from the National Library of Medicine's HSTAT
database.
2. Helping people with incontinence. Rockville, MD: AHCPR,
1996
Aug. (Caregiver guide: clinical practice guideline; no. 2
[1996 Update]). AHCPR Publication No. 96-0683. Available
from the National Library of Medicine's HSTAT database.
3. Fantl JA, Newman, DK, Colling J, et al. Management of
acute
and chronic urinary incontinence in adults. Rockville, MD:
AHCPR, 1996 Mar. 274 p. (Guideline technical report; no. 2
[1996 Update]). AHCPR Publication No. 96-0691.
Print copies: Information regarding the availability of
these
publications can be found in the Agency for Healthcare
Research
and Quality (AHRQ) (formerly the Agency for Health Care
Policy
and Research [AHCPR]) Publications Catalog, which is
available at
the AHRQ Web site.
PATIENT RESOURCES:
The following are available:
1. Understanding incontinence. Rockville, MD: AHPCR, 1996
Mar.
(Consumer guide; no. 2 [1996 Update]). AHCPR Publication
No.
96-0684. Available from the National Library of Medicine's
HSTAT database.
2. La incontinencia urinaria en los adultos (falta de
control
de orina). Rockville, MD: AHCPR, 1996 Apr. (Consumer guide,
Spanish; no. 2 [1996 Update]). AHCPR Publication No.
96-0685. Available from the National Library of Medicine's
HSTAT database.
Print copies: Information regarding the availability of
these
publications can be found in the Agency for Healthcare
Research
and Quality (AHRQ) (formerly the Agency for Health Care
Policy
and Research [AHCPR]) Publications Catalog, which is
available at
the AHRQ Web site.
Please note: This patient information is intended to
provide
health professionals with information to share with their
patients to help them better understand their health and
their
diagnosed disorders. By providing access to this patient
information, it is not the intention of NGC to provide
specific
medical advice for particular patients. Rather we urge
patients
and their representatives to review this material and then
to
consult with a licensed health professional for evaluation
of
treatment options suitable for them as well as for
diagnosis and
answers to their personal medical questions. This patient
information has been derived and prepared from a guideline
for
health care professionals included on NGC by the authors or
publishers of that original guideline. The patient
information is
not reviewed by NGC to establish whether or not it
accurately
reflects the original guideline's content.
NGC STATUS:
This summary was completed by ECRI on November 1, 1998. It
was
verified by the guideline developer on December 1, 1998.
COPYRIGHT STATEMENT:
The contents of these Clinical Practice Guidelines are in
the
public domain within the United States only and may be used
and
reproduced without special permission in America, except
for
those copyrighted materials noted for which further
reproduction,
in any form, is prohibited without the specific permission
of
copyright holders. Citation as to source is requested.
Permission to reproduce copyrighted materials must be
obtained
directly from copyright holders and they may charge fees
for the
use of copyrighted materials. It is the responsibility of
the
user to contact and obtain the needed copyright permissions
prior
to reproducing materials in any form.
Foreign countries must additionally request specific
permission
to reproduce any part or whole of any guideline product
because
the public domain does not extend outside of the United
States.
Requests should be sent to: Gerri M. Dyer, Electronic
Dissemination Advisor, Agency for Healthcare Research and
Quality
(formerly the Agency for Health Care Policy and Research),
Center
for Health Information Dissemination, Suite 501, Executive
Office
Center, 2101 East Jefferson Street, Rockville, MD 20852;
Facsimile: 301-594-2286; E-mail: gdyer@ahrq.gov.
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Date Modified: Friday, May 28, 1999
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================================================================================
{39} VENOUS THROMBOEMBOLISM - 22 Feb 2000 (PRIVATE) 172
Lines
----------------------------------------------------------------------------
National
Guideline
Clearinghouse
[HOME] [NGC RESOURCES] [HELP] [WHAT'S NEW] [SITE
MAP] [CONTACT NGC] [ABOUT NGC]
Search NGC: Search Help Detailed Search
Browse NGC: Disease/Condition Treatment/Intervention
Organization
Options: Brief Summary Complete Summary
Compare Guidelines: Add to Guideline Collection View
Guideline
Collection
------------------------------------------------------------------------
Brief Summary
TITLE:
Venous thromboembolism (VTE).
SOURCE(S):
Ann Arbor (MI): University of Michigan Health System; 1998.
10 [6
references]
ADAPTATION:
Not applicable: Guideline was not adapted from another
source.
RELEASE DATE:
1998 Jun
MAJOR RECOMMENDATIONS:
Note from NGC: The following key points summarize the
content of
the guideline. Refer to the full text for additional
information,
including detailed information on dosing recommendations
(i.e., a
body weight-based intravenous heparin dosing nomogram) and
test
performance characteristics of V/Q scanning.
* Initiate treatment immediately. Patients without
contraindications to heparin should begin full-dose
heparinization at once [evidence: A*]. If PE is clinically
likely, initiation should not await testing; if only DVT is
suspected and testing will be prompt, initiation may await
testing. Therapeutic levels should be achieved as quickly
as
possible. Warfarin should be initiated on day 1 of
treatment, after heparin loading is complete.
* Diagnosis
o Clinical findings uncertain. Symptoms and signs are not
adequately sensitive or specific for diagnosis or
exclusion of DVT.
o Lower extremity DVT: Venous duplex imaging is the
standard for diagnosis.
o Pulmonary embolism
+ Lab tests inadequate. ECG and laboratory
(including blood gas determination) are not
adequately sensitive or specific to diagnose or
exclude PE.
+ Clinical findings + V/Q scan. Diagnosis requires a
combination of clinical likelihood estimation plus
ventilation-perfusion (V/Q) scanning.
+ Pulmonary angiography is indicated: When the
clinical likelihood estimate yields a reasonable
likelihood of PE but V/Q results are neither high
probability nor normal and lower extremity Doppler
studies are negative, and when the risk of
complications of treatment is high.
* Treatment
o Heparin
+ Low molecular weight heparin (LMWH) preferred for
DVT. LMWH is preferred over unfractionated heparin
(UFH) for treatment of DVT for both safety and
cost reasons [evidence: A*]. PE should be treated
with full-dose IV UFH at this time.
+ Outpatient use of LMWH. LMWH is appropriate for
selected patients to use at home after initial
brief hospital admission and stabilization. It may
be appropriate for use without admission, but
patient selection criteria for such use are not
yet defined.
+ Unfractionated heparin. If UFH is used, it should
be initiated and dosed in a structured manner, in
order to achieve therapeutic levels quickly and
without excessive adjustment of dosing [evidence:
A*].
+ Minimum time period. Heparin must be continued for
at least five days in order to minimize the risk
of extension of thrombosis or occurrence or
recurrence of embolism [evidence: B*].
o Warfarin. Patients should begin warfarin on day one of
heparin therapy after heparin loading is complete, and
INRs must be in the 2-3 range before discontinuation of
heparin [evidence: A, B*].
o If heparin contraindicated. Patients who are not
candidates for heparin anticoagulation due to risk of
major bleeding or to drug sensitivity should have an
inferior vena cava filter placed to prevent pulmonary
embolization [evidence: B*].
o If warfarin contraindicated. Patients who can receive
heparin but cannot take warfarin (e.g., during
pregnancy) may be anticoagulated for several months
with full-dose subcutaneous heparin [evidence: A*],
preferably LMWH.
* Definitions
Levels of evidence for the most significant
recommendations:
A. Randomized controlled trials
B. Controlled trials, no randomization
C. Observational trials
D. Opinion of expert panel
CLINICAL ALGORITHM(S):
An algorithm is provided for the diagnosis of pulmonary
embolism.
DEVELOPER(S):
University of Michigan Health Systems - Academic
Institution
COMMITTEE:
Venous Thromboembolism Guideline Team
GROUP COMPOSITION:
Team Leader: Lee Green, MD, MPH.
Team Members: William Fay, MD; Van Harrison, PhD; Mary
Kleaveland, MD; Richard Wahl, MD; Thomas Wakefield, MD;
John Weg,
MD; David Williams, MD.
UMHS Guidelines Oversight Team: Connie Standiford, MD; Lee
Green,
MD, MPH; Van Harrison, PhD; Christopher Wise, PhD.
ENDORSER(S):
Not stated
GUIDELINE STATUS:
This is the current release of the guideline.
An update is not in progress at this time.
GUIDELINE AVAILABILITY:
Print copies: Available from the University of Michigan
Health
System, Office of Clinical Affairs, The University of
Michigan
Hospitals, C-201 Med Inn, Box 0826, Ann Arbor, Michigan
49109-0826. Telephone: (734) 763-0555; Fax (734) 936-9406.
COMPANION DOCUMENTS:
None available
PATIENT RESOURCES:
Not stated
NGC STATUS:
This summary was completed by ECRI on May 20, 1999. The
information was verified by the guideline developer on June
17,
1999.
COPYRIGHT STATEMENT:
This NGC summary is based on the original guideline, which
is
copyrighted by the University of Michigan Health Systems
(UMHS).
Return to top
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© 2000 National Guideline Clearinghouse
Date Modified: Friday, September 03, 1999
[PAGE]
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================================================================================
{58} VIAGRA (MAMC) - 22 Feb 2000 (PRIVATE) 76 Lines
----------------------------------------------------------------------------
Department of Pharmacy
[Mamclogo.gif (11446 bytes)]
Sildenafil Prescribing Guidelines
* Indications:
Erectile dysfunction (ED)
Efficacy response decreases for more severe degrees or
longer duration of
dysfunction.
*Dosage: 25 mg, 50 mg, 100 mg PO
- effective from 30 mins to 4 hrs after ingestion with peak
serum
level at 1 hr
- nonfasting state delays absorption and action > 1 hr
- most men with substantial ED will require 50 to 100 mg
- reserve 25 mg dose for younger patients with minimal ED
------------------------------------------------------------------------
* Action:
Sildenafil is a type-5 phosphodiesterase inhibitor
-does not produce erection without sexual stimulation
------------------------------------------------------------------------
*Adverse Effects:
Only 2.3% drop out rate over long term related to side
effects
- higher dose produces higher incidence of side effects
- 15% headache
- 10% flushing (face and upper torso)
- 6% dyspepsia
- 4% nasal congestion
- 3% mild, transient blue/green color discrimination
- no reported occurrence of priapism
* Contraindications:
Any known allergies to a type-5 phosphodiesterase inhibitor
- ABSOLUTE concomitant use of nitrates (e.g., Isordil ®,
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* Combination of Sildenafil with other treatments for ED
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studied. Therefore, the use of such
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Brief Summary
TITLE:
Comprehensive adult eye and vision examination.
SOURCE(S):
St. Louis (MO): American Optometric Association (AOA);
1994. 16
p. (Optometric clinical practice guideline; no. 1).[69
references]
ADAPTATION:
Not applicable: Guideline was not adapted from another
source.
RELEASE DATE:
1994 (reviewed 1998)
MAJOR RECOMMENDATIONS:
Potential components of the comprehensive adult eye and
vision
examination:
A. Patient History
1. Nature of presenting problem, including chief complaint
2. Visual and ocular history
3. General health history, which may include social
history and review of systems
4. Medication usage and medication allergies
5. Family eye and medical histories
6. Vocational and avocational visual requirements
7. Identity of patient's other health care providers
B. Visual Acuity
1. Distance visual acuity testing
2. Near visual acuity testing
C. Preliminary Testing
1. General observation of patient
2. Observation of external ocular and facial areas
3. Pupillary responses
4. Versions and ductions
5. Near point of convergence
6. Cover test
7. Stereopsis
8. Color vision
D. Refraction
1. Measurement of patient's most recent optical correction
2. Measurement of anterior corneal curvature
3. Objective measurement of refractive status
4. Subjective measurement of monocular and binocular
refractive status at distance and near
E. Ocular Motility, Binocular Vision, and Accommodation
1. Evaluation of ocular motility and alignment
2. Evaluation of vergence amplitude and facility
3. Assessment of accommodative amplitude and facility
4. Assessment of suppression
5. Measurement of fixation disparity and associated phoria
F. Ocular Health Assessment and Systemic Health Screening
1. Evaluation of the ocular anterior segment and adnexa
2. Measurement of intraocular pressure
3. Evaluation of the ocular media
4. Evaluation of the ocular posterior segment
5. Visual field screening (confrontation)
6. Systemic health screening tests
Recommended Eye Examinations Frequency for Adult Patients:
Patient Age Examination Interval
(Years)
Asymptomatic/ At Risk
Risk Free
18 to 40 Every two to three Every one to two
years years or as
recommended
41 to 60 Every two years Every one to two
years or as
recommended
61 and Annually Annually or as
older recommended
Patients at risk include those with diabetes, hypertension,
or a
family history of ocular disease (e.g., glaucoma, macular
degeneration); those working in occupations that are highly
demanding visually or eye hazardous; those taking
prescription or
nonprescription drugs with ocular side effects; those
wearing
contact lenses; and those with other health concerns or
conditions.
CLINICAL ALGORITHM(S):
An algorithm is provided for comprehensive adult eye and
vision
examination.
DEVELOPER(S):
American Optometric Association (AOA) - Professional
Association
COMMITTEE:
American Optometric Association Consensus Panel on
Comprehensive
Adult Eye and Vision Examination
GROUP COMPOSITION:
Members: Linda Casser, OD (Principal Author); David A.
Goss, OD.,
PhD; Jeffrey T. Keller, OD; Beth A. Kneib, OD; Kenneth N.
Moats,
OD; John E. Musick, OD.
ENDORSER(S):
Not stated
GUIDELINE STATUS:
This is the current release of the guideline. According to
the
guideline developer, this guideline has been reviewed on a
biannual basis and is considered to be current.
An update is not in progress at this time.
GUIDELINE AVAILABILITY:
Electronic copies: Available from the American Optometric
Association Web site
Print copies: Available from the American Optometric
Association,
243 N. Lindbergh Blvd, St. Louis, MO 63141-7881.
COMPANION DOCUMENTS:
The following is available:
* Quick reference guide. Comprehensive adult eye and vision
examination. St. Louis, MO: AOA, 1994.
Print copies: Available from the American Optometric
Association
(AOA), 243 N. Lindbergh Blvd, St. Louis, MO 63141-7881.
PATIENT RESOURCES:
The following are available:
* Family guide to vision care. St. Louis, MO: American
Optometric Association. (Patient information pamphet).
* Your vision: the second 50 years. St. Louis, MO: American
Optometric Association. (Patient information pamphet).
* Answers to your questions about common vision conditions.
St. Louis, MO: American Optometric Association. (Patient
information pamphet).
* Answers to your questions about 20/20 vision. St. Louis,
MO:
American Optometric Association. (Patient information
pamphet).
Print copies: Available from the American Optometric
Association,
243 N. Lindbergh Blvd., St. Louis, MO 63141-7881; Web site,
www.aoa.net.org.
Please note: This patient information is intended to
provide
health professionals with information to share with their
patients to help them better understand their health and
their
diagnosed disorders. By providing access to this patient
information, it is not the intention of NGC to provide
specific
medical advice for particular patients. Rather we urge
patients
and their representatives to review this material and then
to
consult with a licensed health professional for evaluation
of
treatment options suitable for them as well as for
diagnosis and
answers to their personal medical questions. This patient
information has been derived and prepared from a guideline
for
health care professionals included on NGC by the authors or
publishers of that original guideline. The patient
information is
not reviewed by NGC to establish whether or not it
accurately
reflects the original guideline's content.
NGC STATUS:
This summary was completed by ECRI on October 15, 1999. The
information was verified by the guideline developer as of
November 15, 1999.
COPYRIGHT STATEMENT:
This NGC summary is based on the original guideline, which
is
subject to the guideline developer's copyright restrictions
as
follows:
Copyright to the original guideline is owned by the
American
Optometric Association (AOA). NGC users are free to
download a
single copy for personal use. Reproduction without
permission of
the AOA is prohibited. Permissions requests should be
directed to
Jeffrey L. Weaver, O.D., Director, Clinical Care Group,
American
Optometric Association, 243 N. Lindbergh Blvd., St. Louis,
MO
63141; (314) 991-4100, ext. 244; fax (314) 991-4101;
e-mail,
ClinicalGuidelines@theAOA.org.
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