Initiate therapy with SSRI - ! fluoxetine 20 mg ( mg) or citalopram 20 mg ( mg) Exercise, Pt education: response expectations, followup ~ 1 week, at least 4 total contacts/12 weeks, referral options PHQ9 Assess (including suicide risk & bipolar MDQ ref), select and initiate therapy A. Mild / Moderate - Pharmacotherapy or psychotherapy (PHQ ) B.Major - Pharmacotherapy with psychotherapy (PHQ9 > 20) ! Reassess suicide risk, Not for Bipolar patients, Consider lower dosages for elderly Adult (>18) Depression 4-6 weeks followup Clearly better: PHQ decrease > 5 or more Somewhat better: PHQ decrease 2-4 Not better: PHQ decrease < 1 Continue Therapy, reassess ~ 4-12 weeks Full Symptom Remission? (PHQ < 10) Continue Treatment Total ~ 6-9 months Full Symptom Remission? (PHQ < 10) Discontinue Treatment, Educate re: relapse, or maintenance if > 3 total depressive episodes B Adjust therapy Increase dose and/or psychotherapy change Reassess 1-6 weeks Adjust therapy, assess adherence Maximize dose, consider psychotherapy change, reassess 1-6 weeks Add medication bupropion mg/day or change to venlafaxine mg/day ?? Consider referral Better Not Better Not Better Not Better MU FCM 8/17/07 Version 1 A

Osteoarthritis ! – Caution with long term use/liver ds Knee – consider intra-articular Synvisc 2 ml weekly X 3 weeks Specialist referral Non- Pharmacologic methods: Self management, Exercise or Physical therapy, Weight loss Pain & functional assessment each visit Acetaminophen up to 1 gm po QID ! Knee - Consider Orthotics (lateral wedge [podiatry], taping [PT]), consider trial of glucosamine 1500 mg/d Hands – splint for thumbs Consider topical Capsaicin – % cream to skin TID/QID Knee - If knee joint effusion present, consider aspiration and intra-articular corticosteroids 40 mg Triamcinolone NSAID: Naproxen mg po BID or Naproxen Sodium mg po BID or Salsalate 1500 mg po BID If GI risk factors (Age > 65, Hx PUD/GI Bleed, Steroid, ASA, or warfarin use, smoker, EtOH use) may add omeprazole 20 mg po daily If renal ds, no response, or age > 65, consider Tramadol 50 mg daily to QID, or Opiates: Acetaminophen/codeine 30 mg QID or Acetaminophen/hydrocodone 5 mg 1-2 tabs QID MU FCM 8/17/07 Version 1 A If no response, consider change of NSAID (Diclofenac 50 mg BID) or EC Aspirin 650 mg TID or COX 2 inhibitor (Celecoxib 200 mg daily)

Still in draft, obviously....

COPD (FEV1/FVC < 70%) Smoking Cessation, Education (activities, MDI, SX, breathing), Immunizations MildFEV1 pred >80 % If dyspnea: Albuterol 2-4 puffs q 4 hrs or Atrovent 2-3 puffs q 4 hrs or Combivent 1-2 puffs q 4 hrs Moderate60-80% If Sx uncontrolled, add Spiriva 1 cap q day or Serevent 1 q 12 hrs Consider pulm rehab referral Severe30-60% Add: Flovent HFA puffs BID or Advair 250/50 or 500/50 1 cap BID (stop serevent) Very Severe <30 or < 60 if resp failure Oxygen if resting PO2 < 88, titrate to > 90 continuous Consider pulmonary referral Ref: ACP and Gold