1. MU Family Medicine Algorithms Algorithms/Pathways are based on national guidelines with modification for local practice. They do not replace clinical judgment, and should be modified as needed for best individual patient care. The goal is to improve care, not mandate treatment. Feedback is welcome, please email comments to hoganmt@missouri.edu hoganmt@missouri.edu Algorithms: –Glycemic control/DiabetesGlycemic control/Diabetes –Coronary Artery Disease (CAD)Coronary Artery Disease (CAD) –HypertensionHypertension –HyperlipidemiaHyperlipidemia –Heart FailureHeart Failure MU FCM 7/2/07 Version 1

2. Glycemic Control Adult DM type 2 Diet and exercise, Metformin 500 mg - 2000 mg/d (!!- renal ds, Check Creat q 12 mos) / Sulfonylurea - Glipizide 2.5 mg/d, max 20 mg/d, $ OR Add Glitazone -Actos 15mg/d, max 45mg/d (no hypoglycemia) !! – HF or heart disease, Check hepatic fx 3- 6 mos OR (esp if A1C> 9) Basal Insulin 10-20 u /day (Lantus pm or NPH ($) BID), titrate per fasting glucose (most effective) Maximize combination Rx, And/or intensify insulin 2-3 mos A1c > 7?. A Yes No !! = Caution $ = cost preferred Monitor q 6 mos B 2-3 mos A1c > 7?. No Monitor q 6 mos Yes Pathway does not replace clinical judgment and should be modified as needed for individual patients. MU FCM 7/2/07 Version 1

3. Stable CAD Treatment Stable CAD Non Vasospastic, no secondary causes (thyroid, O2, Anemia, etc) A Lifestyle Modification: Stop Smoking; Diet (w/ omega-3 fatty acids), Exercise, Wt maint/reduction, NTG 0.4 mg SL prn and: Aspirin 81 mg po qd !! – bleeding or, if stent: Plavix 75 mg po qd !! Bleeding, $$ 1. B Blockers - Metoprolol 50-400 mg/d (post MI) 2. ACE inhibitors/ARB - Lisinopril 10-80 mg/d (LVEF < 40, post MI, DM) Revascularization? If L main, 3 vessel ds, > sx or other reason Risk factor control: BP, Lipids, DM D Pathway does not replace clinical judgment and should be modified as needed for individual patients. !! = Caution $$= cost issue C MU FCM 7/2/07 Version 1 B

4. Hypertension 1. Diuretics: HCTZ 12.5-25 mg/d, then 2. B Blockers: Metoprolol 25-400 mg/d or ACE-I :Enalapril 5 -40 mg/d or lisinopril 10-80 mg/d 3. Long Acting Ca Channel Blocker: Felodipine 5-10 mg/d 4. ARB: Losartan 25 – 100 mg/d, $$ Adjust therapy every 2-8 weeks as needed BP >140/90 (130/80 if DM or renal dx), no secondary cause A DM: ACE-I Renal insufficiency- ACE-I CAD: ACE-I, B Blocker post MI Heart Failure – ACE-I or ARB, + diuretic Elderly Systolic HTN – diuretic Post MI, Angina, atrial tachycardia/fib, tremor, hyperthyroid, migraine, preop – B Blocker Adjust therapy every 2-8 weeks as needed MU FCM 7/2/07 Version 1 Other disease/indication No other disease !! = Caution $$= cost issue If not meeting targets, consider adherence, referral, or further evaluation. Lifestyle modifications – wt loss, DASH diet, activity, NaCl, Alcohol B Pathway does not replace clinical judgment and should be modified as needed for individual patients.

5. HTN & Other disease issues A B Back to HTN guideline Pathway does not replace clinical judgment and should be modified as needed for individual patients. MU FCM 7/2/07 Version 1

6. Hyperlipidemia Treatment LDL > 130 Or Chol/HDL > 5 Lifestyle Mods: Diet, Exercise, Wt, Smoking, BP, mod Etoh, fish oil, Benecol B Re-evaluate q 2 months, if no response: Statins: Atorvastatin 10-80 mg/d or Simvastatin 10-80mg/d to target LDL by Framingham risk group: < 5 % : 190 Add ASA 81 mg/d if male & > 5% 5-10% : 160 10-20% : 130 > 20% : 100 !! * Watch for myopathy, check FLP & liver enzymes at 6-12 weeks C Pathway does not replace clinical judgment and should be modified as needed for individual patients. A !! = Caution * = check X, baseline and freq shown Males > Age 40, Females > 45 MU FCM 7/2/07 Version 1

7. Heart Failure LV Systolic Dysfunction !! = Caution * = check X, baseline and freq shown @ = Push to Max Dose as tolerated Ejection Fraction < 50% Or prior exacerbation of Systolic HF Class 1 = no Sx Class 2 = Mild Sx Class 3 = Moderate w/ Exercise limits Class 4 = Severe, unable to do physical activities Pathway does not replace clinical judgment and should be modified as needed for individual patients. A Control DM, HTN, Lipids, Daily weight, Weight loss, Home BP, Low Na Diet, Exercise as tolerated, Smoking Cessation, Etoh/drug cessation, Stop contraindicated meds (TZD, NSAIDs, CCB, Antiarrhythmics), Flu/pneumovax prn Symptomatic? Edema/dyspnea No Yes ACE-I :Enalapril 2.5 -20 BID or lisinopril 2.5-40 mg QD @ !! = renovascular ds, Cr > 3, K+, pregnant Mild Sx with HTN & CrCl > 40 : HCTZ 12.5-25 mg/d OR Moderate Sx or CrCl <40, Furosemide 20-40 mg/d, max 80 mg BID * lytes, BP, Creat in 1 week and with any change If no volume overload > 1 mon and no contraindications: B Blockers: Toprol XL 12.5-200 mg/d or Bisoprolol 1.25-10 mg/d @ Class 3 hospitalized or Class 4: Creat < 2.5 male, < 2.0 female, And K+ < 5.0 : Start Spironolactone 12.5 -25mg/d or QOD * K+ weekly, stop oral K+ prn If continued symptoms, no contraindications: Digoxin 0.125 (age > 70, renal ds, low BMI) to 0.25 mg/d Target dig level 0.5 – 1 ng/ml Refer to cardiology if symptoms persist or EF < 30-35% or Class 4 MU FCM 7/2/07 Version 1

8. Initiate therapy with SSRI - ! fluoxetine 20 mg (10 -80 mg) or citalopram 20 mg (10 -60 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 (PHQ9 10-19) 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 200-450 mg/day or change to venlafaxine 150-375 mg/day ?? Consider referral Better Not Better Not Better Not Better MU FCM 8/17/07 Version 1 A

9. 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 – 0.025 % cream to skin TID/QID Knee - If knee joint effusion present, consider aspiration and intra-articular corticosteroids 40 mg Triamcinolone NSAID: Naproxen 250 - 500 mg po BID or Naproxen Sodium 220-550 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)