Download Scott & White Health Plan Provider Manual Section 3: Clinical Practice and

Scott & White Health Plan
Provider Manual
Section 3: Clinical Practice and
Preventive Health Guidelines
All Scott & White Health Plan guidelines are available at the following:
1. Internet:OnlineProviderManual–www.swhp.org.Clickon“Providers”greentab.
Clickon“QualityImprovement”.Clickon“ClinicalGuidelines”.
.
ApapercopyisavailableuponrequestfromtheScott&WhiteProviderRelations
Department.Calltollfree18003217947ext.3064or2542983064.
Tier #2 Address the management of a disease process managed by multiple
organizational units or departments.
OSTEOPOROSIS GUIDELINE
Purpose: To recommend management of osteoporosis
Patient Population: Women age 50 and over and men age 70 and
over.
Developed by: Veronica Piziak, MD PhD Endocrinology
Endorsed by: Scott and White Health Plan Quality Improvement
Subcommittee
Adopted: 1998. Revised: 10/2000, 8/2002, 9/2003, 11/2007,
01/2008, 04/2010, 04/2012
Reviewed: 04/2012, Reviewed 05/2014 Next Scheduled Review
Date: 05/2016
Recommend to patient:
Calcium 1,200mg (may need supplement.)
1
Vitamin2 D3 800 to 1,000 IU per day (may need supplement
Encourage weight-bearing and muscle-strengthening
exercises.
Discontinue tobacco use, excess alcohol (if applicable).
Patient has had a vertebral, hip, or fragility fracture and is not currently on prescription treatment.
Yes
3
No
Get baseline measurement of
B for monitoring purposes.
Yearly perform one of the following:
 In post-menopausal women
 Fracture Risk Assessment (FRAX)
4
or
5
 Osteoporosis Risk Assessment (ORAI) with assessment for
secondary causes for osteoporosis.
Screen for secondary causes
7
- Woman 65 years or older.
- Man 70 or older.
- Alendronate 70mg per
wk. - Risedronate 35mg wk.
No
Yes
If intolerant, consider:
- Denosumab 60 mg sub q every 6
months
- Zoledronate 5 mg yearly.
7, 8
-
.
Get baseline BMD measure
PTH (1-34)
Normal
Intolerant
Osteoporosis
Osteopenia
One of the following:
Screen for secondary causes
- Raloxifene 60mg
- Calcitonin (nasal
spray or injectable).
Continue yearly assessments
9
Continue yearly assessments
and recommendations
Yes
6
Is patient?
One of the following is indicated:
No
Continue present
therapy.
7
Frax calculation = 20% risk of
osteoporotic fracture or hip
fracture risk 3%.
One of the following:
- Alendronate 35mg per wk
- Risedronate 35mg wk
If intolerant, consider
7, 8, 9
- Zoledronic acid 5 mg IV
yearly
- Raloxifene 60mg per day
7
-Alendronate 70mg per wk
-Ibandronate 150 mg a month
-Risedronate 35 mg wk
If intolerant,consider
- Zoledronic acid 5 mg IV yearly.
7, 8, 9
- Denosumab 60 mg sub q every 6 months, then
- PTH (1-34)
- Raloxifene 60mg per day
- Calcitonin (nasal spray or injectable)
Follow-up recommendations:
- Yearly assessment of patient's persistence of therapies (i.e. continued use
of medications, supplements and life-style modifications). Encourage compliance
- Consider follow-up BMD in 1 to 5 years as guided by medical necessity, expected
response.
- If hip fracture occurs on bisphosphonates OR > 3-5 years use consider medication
change to PTH 1-34 or drug holiday.
7
Follow-up recommendations:
- Yearly assessment of patient's persistence of therapies (i.e. continued use
of medications, supplements and life-style modifications). Encourage compliance.
-Consider follow-up BMD in 1 to 5 years as guided by medical necessity, expected
response.
- If hip fracture occurs on bisphosphonates OR > 5 years use consider medication
change to PTH 1-34.
4, 7
1. Patients with normal renal function.
2. Vitamin D3 = cholecalciferol.
3. NCQA/HEDIS measure women 67 or older who have had a fracture (and no BMD or treatment for osteoporosis) will have BMD or prescription treatment within
6 months of fracture.
4.The Osteoporosis Risk Assessment instrument (ORAI) is a 3 item tool that uses age, body weight, and current use of estrogen therapy to assess individual risk. It should be combined with a review
for secondary causes. This tool is suggested by U.S. Preventive Service Task Force (USPSTF) ((http://www.ahrq.gov/clinic/3rduspstf/osteoporosis/osteorr.htm).
5.Tool developed by World Health Organization (WHO) and recommended by the National Osteoporosis Foundation (NOF) for risk assessment. Online calculator or paper version can be
found at http://www.shef.ac.uk/FRAX/
6. NOF, in agreement with USPSTF recommendations for postmenopausal women, recommends testing of all women age 65 and older and men age 70 and older
7. After 3 years of bisphosphonate treatment, patients should be encouraged to discuss the risks and benefits of further treatment with their personal physician.
8. IV bisphosphonates are only funded by Medicare if patient is intolerant of oral bisphosphonates. Denosumab is funded by Medicare for postmenopausal patients with osteoporosis at high
risk for fracture and in males with osteopenia or osteoporosis using androgen deprivation therapy.
9. Consider Endocrinology Consult
For health plan formulary questions: Phone (800) 344-2301. E-mail [email protected]
Sources: National Osteoporosis Foundation, World Health Organization, U.S. Preventive Service Task Force (USPSTF), Division of Endocrinology.
Scott and White Health Plan Treatment Guideline for Hypertension
Developed by: Scott and White Physicians Approved: 10/14/2003 Reviewed: 10/2005; Revised 12/2007, 11/2009, 9/2011, 5/2012, 5/2014
Baseline workup (ECG & Lab: BMP, Lipid Panel, UA)
Assess for Major CVD risk factors- See Figure 1
Adult aged ≥18 years with hypertension
Implement lifestyle interventions (Continue throughout management)
See Figure 2
Set blood pressure goal and initiate blood pressure loweringmedication based on age, diabetes, and chronic kidney disease (CKD)
General Population - (no diabetes or CKD)
Diabetes or CKD present
Age <60 years
Age ≥60 years
All ages Diabetes present No
CKD
Blood pressure goal
Blood pressure goal
SBP<150 mm Hg
SBP <140 mm Hg
DBP <90 mm Hg
DBP<90 mm Hg
Non-black
Blood pressure goal
Blood pressure goal
SBP <140 mm Hg
SBP <140 mm Hg
DBP <90 mmHg
DBP <90 mm Hg
Black
Initiate thiazide-type
diuretic or ACE1 or ARB or
CCB, alone or in
All ages CKD present with or
without diabetes
All races
Initiate thiazide-type diuretic
or CCB, alone or in
combination
Initiate ACE1 or ARB, alone or
in combination with other drug
class
Select a drug treatment monthly and titration strategy until BP goal achieved
A.
B.
C.
D.
Maximize first medication before adding second or
Add second medication before reaching maximum does of first medication or
Start with 2 medication classes separately or as fixed-dose combination if BP ≥160 SBP and/or ≥100 DBP
Compelling indications for individual drug classes-See Figure 3
At one month; At goal blood pressure?
YES
NO
Consider causes of Resistant Hypertension- See Figure 4
Reinforce medication and lifestyle adherence
For strategies A and B, add and titrate thiazide-type diuretic or ACE1 or ARB or CCB (use medication
class not previously selected and avoid combined use of ACE1 and ARB).
At two months; At goal blood pressure?
YES
NO
Consider causes of Resistant Hypertension- See Figure 4
Reinforce medication and lifestyle adherence
Add additional medication class (eg, β-blocker, aldosterone antagonist, or others)
and/or refer to physician with expertise in hypertension management.
At three months; At goal blood pressure?
YES
NO
Consider causes of Resistant Hypertension- See Figure 4
Check for Identifiable causes of Hypertension- See Figure 5
Reinforce medication and lifestyle adherence.
Add additional medication class (eg, β-blocker, aldosterone antagonist, or others) and/or refer to
physician with expertise in hypertension management.
At four months; At goal blood pressure?
NO
Consider referral or consultation with HTN specialist
YES
Continue current treatment
and monitoring. Follow up @
3, 6, 12 months at providers
discretion
*This guideline is not meant to substitute for the provider’s clinical judgment
*If BP is <140/90 orthostatic without symptoms, then no need to adjust medications downward
Copyright 2013 American Medical Association. All right reserved.
Figure 1
Major CVD Risk Factors

Hypertension
2
Obesity (BMI ≥30 kg/m
Dyslipidemia
Diabetes mellitus
Cigarette smoking
Physical inactivity
Microalbuminuria, estimated GFR
60mL/min
Age (>55 for men,>65 for
women)
Family history of premature CVD
(men age<55, women age <65)








Figure 2
MODIFICATION
Weight reduction
DASH eating plan
Dietary sodium reduction
Aerobic physical activity
Moderation of alcohol
consumption
RECOMMENDATION
2
Maintain normal body weight (BMI 18.5-24.9 kg/m )
Adopt a diet rich in fruits, vegetables, and lowfat dairy
products with reduced content of saturated and total fat.
Reduce dietary sodium intake to ≤100 mmol per day (2.4 g
sodium or 6 g sodium chloride).
Regular aerobic physical activity (e.g., brisk walking) at
least 30 minutes per day, most days of the week
Men: limit to ≤2 drinks* per day. Women and lighter
weight persons: limit to ≤1 drink* per day. (*1 drink= ½ oz
or 15 ml ethanol (e.g., 12 oz beer, 5 oz wine, 1.5 oz 80
proof whiskey).
Figure 3
COMPELLING INDICATION
INITIAL THERAPY OPTIONS
Heart failure
Post myocardial infarction
High CVD risk
Diabetes
Chronic kidney disease
Recurrent stroke prevention
THIAZ, BB, ACEI, ARB, ALDO ANT
BB, ACEI, ALDO ANT
THIAZ, BB, ACEI, CCB
THAIZ, BB, ACEI, ARB, CCB
ACEI, ARB,
THIAZ, ACEI
Figure 4
CAUSES OF RESISTANT HYPERTENSION






Improper BP measurement
Excess sodium intake
Inadequate diuretic therapy
Medication
o Inadequate doses
o Drug actions and interactions (e.g., NSAIDS, illicit
drugs, sympathomimetics, oral contraceptives)
o OTC drugs and herbal supplements
Excess alcohol intake
Identifiable causes of hypertension (See Figure 5)
Figure 5
Identifiable Causes of HTN









Sleep Apnea
Drug induced/related
Chronic Kidney Disease
Primary Aldosteronism
Renovascular Disease
Cushing’s Syndrome or Steroid Therapy
Pheochromocytoma
Coarctation of Aorta
Thyroid/Parathyroid Disease
AVG. SBP REDUCTION
RANGE (Effects are dose
and time dependent)
5-20 mmHg/10kg
8-14 mmHg
2-8 mmHg
4-9 mmHg
2-4 mmHg
Chronic Obstructive Pulmonary Disease (COPD) Guideline
Tier 2 Guideline
Developed by: The Scott & White COPD CHASM Working group
Contact physician: Dr. Jim Barker, MD
Date of adoption: November 2009 Revision date: January 2014
SWHP COPD GUIDELINE, 2014.
This is an evidence based guideline built by the CHASM COPD working group and based on
multiple published guidelines. Please see references at end.
COPD (Chronic Obstructive Pulmonary Disease) is, in general, a combination of Chronic
Bronchitis and Pulmonary Emphysema. It may also be seen in patients with other obstructive
lung diseases such as asthma, bronchiectasis, and bronchopulmonary dysplasia when those
individuals have smoked. The pathogenesis is by far tobacco smoking related. The 10 to 15% of
individuals with COPD (at least in the United States) who are never smokers have had second
hand smoke exposure, occupational exposure, or a genetic proclivity. Patients who grew up in
third world countries could also develop fixed obstructive lung disease (COPD) from inhaling
burning biomass under poor ventilation.
COPD is the third leading cause of death in the United States and is very expensive in loss of
health care dollars. See Figure 1.
Specific recommendations are the following:
1. Prevention:
a. Teens and pre-teens are high risk for smoking onset if their peers or parents
smoke. SWHP should partner with community agencies to actively deter onset
of smoking in these high risk individuals.
2. Screening:
a. Smokers or former smokers age 40 or older should be screened with a simple
five question questionnaire. See Figure 2. A score of 5 or higher (out of a
possible 10) should trigger a diagnostic spirometry test.
b. Others should be screened if there is a high index of suspicion such as positive
family history, daily productive cough two years in a row, or significant
occupational exposure.
c. Alpha 1 antitrypsin testing should be done on those with COPD onset at age less
than 45, familial COPD, or low alpha 1 serum levels.
3. Diagnosis:
a. Spirometry is the gold standard. Spirometry should be done in any individual
suspected of having COPD. Spirometry can be office based or Pulmonary
Function hospital laboratory based. A high quality test is present when values
are reproducible on at least three attempts +/- 3%. An FEV1 less than 80% and
FEV1/FVC ratio below 70% is considered abnormal and proof of disease, in
appropriate settings. Post bronchodilator results are the preferred ones
(according to GOLD criteria).
b. Suggestive symptoms are shortness of breath with minor exertion, daily
productive cough, and wheezing. However, these are non-specific.
c. All patients who have a positive population health screener or who are
suspected of having COPD should have spirometry. Other lung diseases or even
anemia can induce shortness of breath. An accurate diagnosis is always
desirable!
4. Emergency Department and Inpatient Diagnosis and Treatment:
a. The recommended corticosteroid dose is 40 mg/day of oral prednisone (or
equivalent intravenously) for 10 days or less.
b. Frequent albuterol inhalations via MDI or nebulizer are recommended.
c. Antibiotics are useful in an exacerbation especially if increased sputum and fever
are present.
d. Arterial Blood Gases are recommended in those patients who appear ill.
(Difficulty speaking, tachypnea, altered mental status, sternocleidomastoid
accessory muscle use for example.) ABGs allow stratification of severity.
Consider ICU admission if respiratory acidosis is present.
e. Indications for hospitalization may include:
i. High risk co-morbid conditions such as pneumonia, CHF, cardiac
arrhythmias.
ii. Failed outpatient management.
iii. Unrelieved dyspnea
iv. Inability to eat or sleep due to dyspnea.
v. Progressive hypoxemia or hypercarbia
vi. Altered mental status
vii. Inability to care for oneself at home.
viii. Marked worsening from baseline
f. Indications for Intensive Care Admission may include:
i. Respiratory Failure requiring mechanical ventilation or continuous noninvasive ventilation
ii. Presence of other end organ dysfunction: shock, renal failure, coma,
myocardial infarction and so on.
iii. Hemodynamic instability.
iv. Inability to clear secretions
v. Respiratory acidosis or impending respiratory failure
g. Indications for Non-Invasive Ventilation:
i. Respiratory acidosis with pH < 7.36 and PaCO2 > 45 torr.
ii. Tachypnea with breath rate > 25/min
iii. Intact gag reflex
iv. Able to cooperate and follow commands
v. Consider ICU admission if non-invasive ventilation is initially continuous.
h. Consider the addition of ipratropium to albuterol if unrelieved tachypnea or
dyspnea.
i. Consider Pulmonary Medicine consultation if the patient fails to improve
promptly.
j. Consider other precipitating causes for COPD exacerbation (besides viral or
bacterial bronchitis) such as:
i. Congestive Heart Failure
ii. Community Acquired Pneumonia
iii. DVT/PE
k. Oxygen therapy
i. Commonly needed during exacerbations because of V/Q mismatching.
ii. Prescribe to attain SaO2 at least 88% or PaO2 at least 60 mm Hg.
l. Criteria for Discharge:
i. Symptoms returning to baseline. Patient able to eat and sleep.
ii. Hemodynamics stable.
iii. Able to ambulate (presuming ambulatory pre-hospitalization)
iv. Understands home medications.
v. Able to go at least four hours in between albuterol usages.
m. Transition of care issues:
i. Consider Outpatient Pulmonary Consult if frequent admissions or
exacerbations are occurring.
ii. See PCP within 7 days of discharge.
iii. May need short term oxygen. Re-assess after 30 days or when stable at
home.
5. Outpatient maintenance therapy
a. Smoking cessation.
i. This is the only intervention proven to change disease trajectory and
lengthen lifespan.
ii. Severely addicted patients will need adjunctive therapy.
1. The absolute best results occur with group therapy, nicotine
replacement, and bupropion. Bupropion may be needed for
several months in some individuals.
b. Frequent exacerbations:
i. One hospitalization or more per year and/or two or more exacerbations
of COPD/year = frequent.
c.
d.
e.
f.
ii. Review for possible reasons of exacerbation: CHF, poorly controlled
hypertension, bronchiectasis, continued smoking.
iii. Medical therapy:
1. Inhaled corticosteroid (Advair; Symbicort; others) with a long
acting Beta agonist OR
2. A PGE2 inhibitor such as theophylline or roflumilast (daliresp) OR
3. A macrolide such as azithromycin or erythromycin
iv. Pulmonary Medicine consultation
Corticosteroids
i. Only indicated for exacerbations and should be used in doses of 40 mg
prednisone or less over 7 to 10 days.
Vaccinations
i. Yearly influenza vaccine.
ii. Pneumovac is recommended although efficacy is in question from recent
studies.
GOLD STAGING:
i. A. Minimal symptoms, no hospitalizations in the previous year, and mild
to moderate obstruction on Spirometry.
ii. B. More symptoms. No recent hospitalizations. Mild to Moderate
obstruction on Spirometry. Dyspnea with exercise or ADLs.
iii. C. Moderate to Severe Obstruction on Spirometry. Hospitalized within
last year or 2 or more exacerbations. Minimal baseline symptoms or
Dyspnea.
iv. D. Moderate to Severe Obstruction on Spirometry. Hospitalized within
last year or 2 or more exacerbations. Quite symptomatic.
Therapy by GOLD Stage:
i. Prn Albuterol inhaler 2 puffs every four hours indicated for all groups.
ii. Some patients will benefit from addition of Ipratropium (combivent
respimat inhaler). It is unclear which patients fit this however.
iii. Groups B through D benefit significantly from Pulmonary rehabilitation.
1. PFTs do not typically improve but Quality of Life scores improve,
exacerbations and doctor visits decrease, and hospitalizations
decrease.
2. Pulmonary Rehab programs include education including tips for
self-management and graded exercise to improve flexibility and
endurance.
iv. Group B:
1. Long acting anticholinergic such as Tiotropium 18 mcg , 1 puff a
day OR
2. Long acting beta inhaler such as Formoterol or Salmeterol.
v. Group C:
1. Long acting anticholinergic such as Tiotropium 18 mcg , 1 puff a
day OR
2. Combination long acting Beta Agonist/Corticosteroid agonist such
as Advair 250/50 1 puff twice a day.
vi. Group D:
1. Long acting anticholinergic such as Tiotropium 18 mcg , 1 puff a
day AND
2. Combination long acting Beta Agonist/Corticosteroid agonist such
as Advair 500/50 1 puff twice a day.
g. Oxygen
i. Oxygen is indicated for those patients with baseline hypoxemia (PaO2 <
55 or <60 with objective erythrocytosis or right heart failure).
ii. Some patients may need oxygen with exercise or sleep. Specific testing
in those situations is needed to determine need.
h. Surgical approaches:
i. Lung Volume reduction surgery can be considered in those patients with
unrelenting symptoms, apical bullous disease, and normal diffusing
capacities.
ii. Lung transplant can be considered for those individuals with
1. Age < 65
2. GOLD D stage and an elevated BODE score.
3. No active tobacco or substance abuse
4. No significant other co-morbidities or recent malignancies.
The COPD CHASM working group consisted of:
Jim Barker, MD
David Perez, RRT, MBA
Richard Beckendorf, MD
Emran Rouf, MD, MPH
David Bonnet, MD
Sunita Varghees MD, PHD
Monica L Brown, BS, MPH student
Thu Vo, DO
Elizabeth Fomby, MD
Pam York, RRT
Christopher Grant, MD
References Used include:
1.
Treatment of Stable Chronic Obstructive Pulmonary Disease: the GOLD Guidelines by
HOBART LEE, MD; JEFFREY KIM, MD; and KARINE TAGMAZYAN, MD, Loma Linda
University School of Medicine, Loma Linda, California, Am Fam
Physician. 2013 Nov 15;88(10):655-663.
2.
Global Strategy for the Diagnosis, Management, and Prevention of Chronic
Obstructive Pulmonary Disease, GOLD Executive Summary
Jørgen Vestbo1,2, et al. Am J Respir Crit Care Med Vol 187, Iss. 4, pp. 347–365, Feb
15, 2013
3.
Global Initiative for Chronic Obstructive Lung Disease, Global Strategy for the
Diagnosis, Management, and Prevention of Chronic Obstructive Pulmonary Disease,
Feb 1, 2013. RR Roison and J Vestbo, for the GOLD Committee. GOLD website.
4.
NICE Guideline, 2013 update, National Clinical Guideline Centre, United Kingdom.
Chronic obstructive pulmonary disease: Management of chronic obstructive
pulmonary disease in adults in primary and secondary care,
http://guidance.nice.org.uk/CG101/Guidance/pdf/English
5.
Anderson B, Conner K, Dunn C, Kerestes G, Lim K, Myers C, Olson J, Raikar S, Schultz
H, Setterlund L. Institute for Clinical Systems Improvement. Diagnosis and
Management of Chronic Obstructive Pulmonary Disease (COPD). Updated March
2013.
6.
Diagnosis and Management of Stable Chronic Obstructive Pulmonary
Disease: A Clinical Practice Guideline from the American College
of Physicians
Amir Qaseem, MD, PhD, MHA; Vincenza Snow, MD; Paul Shekelle, MD, PhD;
Katherine Sherif, MD; Timothy J. Wilt, MD, MPH;
Steven Weinberger, MD; and Douglas K. Owens, MD, MS, for the Clinical Efficacy
Assessment Subcommittee of the American College of Physicians* Ann Intern Med.
2007;147:633-638.
7.
Diagnosis and Management of Chronic Obstructive Pulmonary Disease:
The Swiss Guidelines Official Guidelines of the Swiss Respiratory Society E.W. Russi a
W. Karrer d M. Brutsche e et al. Respiration 2013;85:160–174.
8.
Primary Care–Relevant Interventions for Tobacco Use Prevention and
Cessation in Children and Adolescents: A Systematic Evidence Review
for the U.S. Preventive Services Task Force.
Carrie D. Patnode, PhD, MPH; Elizabeth O’Connor, PhD; Evelyn P. Whitlock, MD,
MPH; Leslie A. Perdue, MPH; Clara Soh, MPA;
and Jack Hollis, PhD Ann Intern Med. 2013;158:253-260. www.annals.org
9.
Management of Acute Exacerbations of COPD* A Summary and Appraisal of
Published Evidence Douglas C. McCrory, MD, MHSc; Cynthia Brown, MD; Sarah E.
Gelfand, BA; and Peter B. Bach, MD CHEST 2001; 119:1190–1209
10.
COPD updates: What’s new in pathophysiology and management? Carlos Noujeim
and Pierre Bou-Khalil (Lebanon). Expert Rev. Respir. Med. 7(4), 429–437 (2013).
Tier 2 Guideline
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Date of Adoption: March, 2001
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Date of Adoption: March, 2001 Revision Dates: 02/2003, 09/2004, 08/2006, 11/2008, 10/2010
Contact Physician: Dr. Virginia Maxanne Flores, MD; S&W Department of Psychiatry
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Table 3
Me dication
methylphenidate IR (Ritalin®, Methylin®)
dextroamphetamine(Dexed rine®, DextroStat®)
dexmethylphenidate (Focalin®)
methylphenidate SR (Ritalin-SR®)
methylphenidate ER (Meta date®,ER,
Methylin® ER )
methylphenidate ER (Meta date® CD)
methylphenidate LA (Ritalin® LA)
a mphetamine-dextroamphetamine (Add erall® )
dextroamphetamine spansule (Dexedrine®
Spa nsu le®)
methylphenidate ER (Con ce rta®)
a mphetamine-dextroamphetamine XR
(Adderall XR®)
a tomoxetine (Strattera®)
dexmethylphenidate XR (Fo calin ® XR)
methylphenidate transderma l patch-extended
rele ase (Daytrana Transderma l Patch) Should
wear 9 hours with effects lasting for 3-4 hours
a fte r re moval of pa tch.
lis dexa mfetamine dimesylate (Vyvanse)
* LEGEND
MAS-Mixed Amphetamine Salts
DEX-Dextroamphetamine
NICHQ-National Initiative for
Children’s Healthcare Quality
For mular y
Effect
D uration
in Hours
Yes
Yes
No
Yes
No
3-6
1-6
6
8
8
Yes
Yes
Yes
Yes
8
1 0-12
4-6
6-8
Yes
Yes
12
12
Yes
No
Yes
24
8-12
9
Yes
12
Table 4
Alternative Non-Stimulant Medica tions
(to be conside red after failure of s tages 1-3)
buproprion (We llbutrin®)
gua nfacine (Tenex®) - short-acting
gua nfacine (Intuniv®) - long-acting
c lonidine (Catapres®)
Exc ept for guanfacine (Intuniv ®) - long-acting, these are not FDA
indicated for the treatment o f ADHD; but Child & Adolesce nt Psychiatry may
consider th ese four a lternatives if the p atient needs combination therapy or a
longer duration of action, has adverse events from stimulan ts or has co-morbid
conditions which require them. These medications are generally u sed more
often by Child and Adolesce nt Psychiatrists or Developmen tal Be havior
Ped iatricians.
Source: American Academy of Child and Adolescent Psychiatry (AACAP, 2006), The Texas Children’s Medication Algorithm Project, and the
American Academy of Pediatrics (AAP, 2001).
Developed by: Physicians from the Departments of Psychiatry & Pediatrics, Health Integrated; and the clinical Pharm D Staff.
Reviewed and Approved by: Members of the Quality Improvement Sub-committee.
** HEDIS® is a registered trademark of the National Committee for Quality Assurance (NCQA).
L:\QI\NCQA\Clinical Guidelines\Current Tier 2 INTER dept\ADHD\Current stuff\ADHD for Approval Aug 2012.docx
Asthma Guidelines
Developed by: SWHP Asthma Intervention Team
Contact Person: Felix R. Shardonofsky, M.D.
Source: NHBLI Practical Guide for the Diagnosis & Management of Asthma
Adopted: SWHP Quality Improvement Committee 11/12/2002: Revision/Approval: Quality Improvement Subcommittee 10/04, 10/06,
9/12/2008, 8/10, 10/12
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Preferred:
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Preferred:
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Preferred:
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High-dose ICS +
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possible
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at least
3 months)
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With viral respiratory infection: SABA q 4–6 hours up to 24 hours (longer with physician consult). Consider short
course of oral systemic corticosteroids if exacerbation is severe or patient has history of previous severe
exacerbations.
Caution: Frequent use of SABA may indicate the need to step up treatment. See text for recommendations on
initiating daily long term control therapy
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possible
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(and asthma is
well controlled
at least
3 months)
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treatments at 20 –minute intervals as needed. Short cause of oral systemic corticosteroids may be
needed.
Caution: Increasing use of SABA or use >2 days a week for symptom relief (not prevention of EIB)
generally indicates inadequate control and the need to step up treatment.
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Comprehensive Risk Reduction for Patients with
Atherosclerotic Cardiovascular Disease
(Tier #2 Guideline)
Purpose: To delineate periodic examination requirements for adults with Atherosclerotic Cardiovascular Disease
Patient Population: Patients who have had a ST Elevation Myocardial Infarction, Coronary Artery Bypass Graft, or Percutaneous
Transluminal Coronary Angioplasty
Developed by: Catherine J McNeal, M.D., Eugene Terry, M.D., Michael M. Hawkins, M.D. and SWHP Secondary Prevention of Coronary
Artery Disease Workgroup
Clinical Resource: The American College of Cardiology and the American Heart Association (ACC/AHA) Practice Guidelines update
December 2007.
Adopted: SWHP Quality Improvement Committee 7/21/99 Revised: February 2008, March 2012, April 2014 Reviewed: February, 2010
Treatment of Blood Cholesterol to Reduce Atherosclerotic
Cardiovascular Disease Risk in Adults: Synopsis of the 2013
ACC/AHA Cholesterol Guideline
Neil J. Stone, MD; Jennifer G. Robinson, MD, MPH; Alice H. Lichtenstein, ScD; David C. Goff Jr., MD, PhD;
Donald M. Lloyd-Jones, MD, ScM; Sidney C. Smith Jr., MD; Conrad Blum, MD; and J. Sanford Schwartz, MD,
for the 2013 ACC/AHA Cholesterol Guideline Panel*
Description: In November 2013, the American College of Cardiology and American Heart Association (ACC/AHA) released a clinical
practice guideline on the treatment of blood cholesterol to reduce
cardiovascular risk in adults. This synopsis summarizes the major
recommendations.
Methods: In 2008, the National Heart, Lung, and Blood Institute
convened the Adult Treatment Panel IV (ATP-IV) to update the
2001 ATP-III cholesterol guidelines using a rigorous process to
systematically review randomized, controlled trials (RCTs) and
meta-analyses of RCTs that examined cardiovascular outcomes. The
panel commissioned independent systematic evidence reviews on
low-density lipoprotein cholesterol and non–high-density lipopro-
A
therosclerotic cardiovascular disease (ASCVD) is the
leading cause of death, decreased quality of life, and
medical costs in the United States. Nearly 1 in 3 Americans die of heart disease and stroke (1). Most ASCVD is
preventable through a healthy lifestyle and effective treatment of cholesterol and blood pressure. The 2013 “Guideline on the Treatment of Blood Cholesterol to Reduce
Atherosclerotic Cardiovascular Risk in Adults” from the
American College of Cardiology and American Heart Association (ACC/AHA) provides an evidence-based approach to reducing ASCVD risk (2).
GUIDELINE DEVELOPMENT PROCESS
In 2008, the National Heart, Lung, and Blood Institute (NHLBI) convened the Adult Treatment Panel IV
(ATP-IV) to update the 2001 ATP-III cholesterol guidelines using a rigorous systematic process to identify and
review randomized, controlled trials (RCTs) with cardiovascular outcomes and meta-analyses of these RCTs. The
panel comprised experts and clinicians from the fields of
cardiology, epidemiology, primary care, and endocrinology
tein cholesterol goals in secondary and primary prevention and the
impact of lipid drugs on atherosclerotic cardiovascular disease
(ASCVD) events and adverse effects. In September 2013, the panel’s draft recommendations were transitioned to the ACC/AHA.
Recommendations: This synopsis summarizes key features of the
guidelines in 8 areas: lifestyle, groups shown to benefit from statins,
statin safety, decision making, estimation of cardiovascular disease
risk, intensity of statin therapy, treatment targets, and monitoring
of statin therapy.
Ann Intern Med.
www.annals.org
For author affiliations, see end of text.
(2) and received support from the Lifestyle Management
and Risk Assessment Work Groups (3, 4).
Systematic evidence reviews conducted according to
principles recommended by the Institute of Medicine (5)
were performed to answer 3 questions relevant to clinical
care. Two questions focused on the evidence supporting
low-density lipoprotein cholesterol (LDL-C) and non–
high-density lipoprotein cholesterol (HDL-C) levels as targets of treatment. One question examined the reduction in
ASCVD events and adverse effects for each cholesterollowering drug class. The panel synthesized the evidence
from these 3 reviews as well as from Lifestyle Management
and Risk Assessment Work Groups reviews (3, 4) that addressed 5 additional critical questions.
Systematic electronic searches of relevant databases of
the peer-reviewed English-language literature published
from 1 January 1995 through 1 December 2009 for each
critical question were conducted by an NHLBI-selected
independent contractor and focused on RCTs and systematic reviews and meta-analyses of RCTs assessed as fair to
good quality. In addition, RCTs with ASCVD outcomes
* For a list of the members of the 2013 ACC/AHA Cholesterol Guideline Panel, see the Appendix (available at www.annals.org).
This article was published online first at www.annals.org on 28 January 2014.
that included coronary heart disease, stroke, and cardiovascular deaths published after that date were eligible for consideration through July 2013. Evidence tables were constructed and the strength of evidence was rated according
to the NHLBI (Table 1 of the Supplement, available at
www.annals.org). Recommendations were graded according to criteria from the NHLBI (Table 2 of the Supplement) and ACC/AHA (Table 3 of the Supplement). Because of the inherent differences in grading systems and the
clinical questions driving the recommendations, alignment
between the NHLBI and ACC/AHA formats was imperfect. A complete description of the methods used and results of the evidence review are provided in the guideline
(2) and the NHLBI evidence report (www.nhlbi.nih.gov
/guidelines/cholesterol/ser/index.htm).
To help clinicians estimate CVD risk, the risk assessment working group developed the Pooled Cohort Equations using data from 5 NHLBI-sponsored longitudinal,
population-based cohorts of African American and nonHispanic white men and women to estimate risk for a first
myocardial infarction, coronary heart disease death, or fatal
or nonfatal stroke on the basis of age, sex, race, smoking
status, total cholesterol level, HDL-C level, systolic blood
pressure, antihypertensive therapy, and diabetes (4, 6).
These equations significantly advance ASCVD risk estimation by providing sex- and race-specific estimates and including stroke as an outcome. The earlier Framingham
equations calculated only coronary heart disease risk for
non-Hispanic whites.
The draft recommendations were reviewed by 23 experts and representatives of federal agencies identified by
the NHLBI. In September 2013, the recommendations
developed by the panel were transitioned to the ACC/AHA
and had additional review by 4 experts nominated by the
ACC Foundation and the AHA. The governing bodies of
the ACC and AHA approved the guideline, which also
received endorsement from the American Association of
Cardiovascular and Pulmonary Rehabilitation, American
Pharmacists Association, American Society for Preventive
Cardiology, Association of Black Cardiologists, Preventive
Cardiovascular Nurses Association, and WomenHeart:
The National Coalition for Women with Heart Disease.
RECOMMENDATIONS
The guideline focuses on treatment of blood cholesterol to reduce ASCVD risk in adults. Major recommendations are summarized here and in Table 1. The guideline
report provides a complete listing of recommendations and
supporting evidence behind each recommendation (2).
1. Encourage Adherence to a Healthy Lifestyle
A healthy lifestyle is the foundation for cardiovascular
health. The panel endorsed the 2013 ACC/AHA Lifestyle
Management Guideline (3) for a diet that is low in saturated fat, trans fat and sodium; emphasizes vegetables,
fruits, whole grains, low-fat dairy products, poultry, fish,
legumes, nontropical vegetable oils, and nuts; and limits
sweets, sugar-sweetened beverages, and red meats and engage in regular aerobic physical activity. Adults also should
maintain a healthy body weight, avoid smoking, and control hypertension and diabetes when present.
2. Statin Therapy is Recommended for Adults in Groups
Demonstrated to Benefit
Strong RCT evidence shows that reduction in
ASCVD events from statin therapy exceeds adverse events
for 4 patient groups: those with clinical ASCVD (acute
coronary syndromes, myocardial infarction, stable angina,
coronary or other arterial revascularization, stroke, transient ischemic attack, or peripheral arterial disease of atherosclerotic origin) when statins are used for secondary prevention, and those with LDL-C levels of 190 mg/dL or
greater; those aged 40 to 75 years with diabetes and
LDL-C levels of 70 to 189 mg/dL; and those aged 40 to 75
years without diabetes and with a 10-year ASCVD risk of
7.5% or greater when statins are used for primary prevention. Moderate evidence supports consideration of statin
therapy for primary prevention in individuals with a 10year ASCVD risk of 5% to less than 7.5%. Routine initiation of statin therapy is not recommended in adults with
New York Heart Association heart failure class II to IV or
those receiving maintenance hemodialysis. Randomized,
controlled trials in these groups showed no reduction in
ASCVD.
3. Statins have an Acceptable Margin of Safety when
Used in Properly Selected Individuals and Appropriately
Monitored
Strong RCT evidence supports safety of statins when
they are used as directed in conjunction with regular
follow-up assessments in properly selected patients. Adjustment of statin intensity is recommended in individuals
older than 75 years with a history of statin intolerance or
other characteristics (2) or those receiving drug therapy
that may increase statin adverse events.
Routine monitoring of hepatic aminotransferase level
or creatine kinase level is not recommended unless clinically indicated by symptoms suggesting hepatotoxicity or
myopathy. Given statin therapy’s potential for decreasing
ASCVD events and death, it is important to confirm the
relationship of muscle and other symptoms to statin treatment. Therefore, eliciting a history of muscle symptoms
before statin initiation and carefully monitoring symptoms
during statin discontinuation and rechallenge is recommended. Severe myopathy, rhabdomyolysis, and possibly
hemorrhagic stroke are rare complications of statin
therapy.
Although statin therapy modestly increases the risk for
type 2 diabetes, ASCVD risk reduction outweighs the excess risk for diabetes for high-intensity statins in secondary
prevention or for 10-year ASCVD risk of 7.5% or greater.
Similarly, ASCVD risk reduction outweighs the excess risk
for diabetes for moderate-intensity statin therapy in adults
with a 10-year ASCVD risk of 5% or greater.
Table 1. Major Recommendations for the Treatment of Blood Cholesterol to Reduce ASCVD Risk in Adults*†
Healthy lifestyle habits should be encouraged for all persons.
The appropriate intensity of statin therapy should be initiated or continued:
Clinical ASCVD‡
Persons aged ~75 y with no safety concerns: high-intensity statin (class I, level A)
Persons aged >75 y or with safety concerns: moderate-intensity statin (class I, level A)
Primary prevention: primary LDL-C level ~ 190 mg/dL
Rule out secondary causes of hypercholesterolemia
Persons aged ~21 y: high-intensity statin (class I, level B)
Achieve ~ 50% reduction in LDL-C level (class IIa, level B)
May consider LDL-C–lowering nonstatin therapy to further reduce LDL-C levels (class IIb, level C)
Primary prevention: persons with diabetes aged 40–75 y with an LDL-C level of 70–189 mg/dL
Moderate-intensity statin (class I, level A)
Consider high-intensity statin when 10-y ASCVD risk is ~ 7.5% (class IIa, level B)
Primary prevention: persons aged 40–75 y without diabetes with an LDL-C level of 70–189 mg/dL
Estimate 10-y ASCVD risk (risk calculator based on Pooled Cohort Equations recommended)§ in those not receiving a statin; estimate risk every 4–6 y (class I,
level B)
To determine whether to initiate a statin, engage in clinician–patient discussion of potential for ASCVD risk reduction, adverse effects, drug–drug interactions,
and patient preferences (class IIa, level C). Re-emphasize healthy lifestyle habits and address other risk factors. If statin therapy is chosen:
Persons with ~ 7.5% 10-y ASCVD risk: moderate- or high-intensity statin (class I, level A)
Persons with 5% to < 7.5% 10-y ASCVD risk: consider moderate-intensity statin (class IIa, level B)
Other factors may be consideredli: LDL-C level ~ 160 mg/dL, family history of premature ASCVD, lifetime ASCVD risk, high-sensitivity C-reactive protein
level of ~2.0 mg/L, coronary artery calcification score ~ 300 Agatston units, or ankle–brachial index <0.9 (class IIb, level C)
Primary prevention when LDL-C level is < 190 mg/dL and person is aged < 40 y or > 75 y or has < 5% 10-y ASCVD risk
Statin therapy may be considered in selected personsli (class IIb, level C)
Statin initiation is not routinely recommended for persons with NYHA class II–IV heart failure or those who are receiving maintenance hemodialysis.
Regularly monitor adherence to lifestyle and drug therapy with lipid and safety assessments. Nonstatin therapy can be considered in selected persons.
Assess adherence, response to therapy, and adverse effects within 4–12 wk after statin initiation or change in therapy (class I, level A)
Measure fasting lipid panel (class I, level A)
Do not routinely monitor hepatic function with ALT levels or muscle injury with CK levels unless patient is symptomatic (class IIa, level C).
Screen and treat type 2 diabetes mellitus according to current practice guidelines. Healthy lifestyle habits should be encouraged to prevent progression to
diabetes (class I, level B).
Anticipated therapeutic response: approximately ~ 50% reduction in LDL-C level from baseline for high-intensity statin and 30% to
moderate-intensity statin (class IIa, level B)
Insufficient evidence from RCTs for LDL-C or non–HDL-C treatment goals
< 50% for
For guidance in persons with unknown baseline LDL-C level, a level of < 100 mg/dL was observed in RCTs about high-intensity statin therapy.
Less-than-anticipated therapeutic response:
Reinforce improved adherence to lifestyle and drug therapy (class I, level A)
Evaluate for secondary causes of hypercholesterolemia if indicated¶ (class I, level A)
Increase statin intensity, or if patient is receiving maximally tolerated statin intensity, consider addition of nonstatin therapy shown in RCT to reduce ASCVD
events in selected high-risk persons** (class IIb, level C)
Regularly monitor adherence to lifestyle and drug therapy every 3–12 mo once statin adherence has been established. Continue to assess adherence for
optimum ASCVD risk reduction and safety (class I, level A)
In persons unable to tolerate the recommended intensity of statin therapy, use the maximally tolerated intensity of statin.
If there are muscle or other symptoms, establish their relationship to statin therapy (class IIa, level B)
Obtain a history of muscle symptoms before initiating statin therapy.
If muscle or other symptoms develop during statin therapy, discontinue the statin.
Once mild to moderate muscle or other symptoms resolve, rechallenge with the same dose of statin or lower; if muscle symptoms recur, discontinue statin
and rechallenge with progressively lower doses of the same or a different statin.
If muscle symptoms persist > 2 mo after statin discontinuation, consider other conditions that may increase the risk for muscle symptoms††
ALT = alanine aminotransferase; ASCVD = atherosclerotic cardiovascular disease; CK = creatine kinase; HDL-C = high-density lipoprotein cholesterol; LDL-C =
low-density lipoprotein cholesterol; NYHA = New York Heart Association; RCT = randomized, controlled trial.
* Adapted from reference 2. Reprinted with permission.
† For information about class and level, please see Table 3 of the Supplement.
‡ Clinical ASCVD is defined as acute coronary syndromes or a history of myocardial infarction, stable angina, coronary or other arterial revascularization, stroke, transient
ischemic attack, or peripheral arterial disease presumed to be of atherosclerotic origin.
§ Estimated 10-y “hard” ASCVD risk includes first occurrence of nonfatal myocardial infarction, death from coronary heart disease, and nonfatal and fatal stroke as used in
the Pooled Cohort Equations on the basis of age, sex, smoking status, total cholesterol level, HDL-C level, systolic blood pressure, and the use of antihypertensive therapy.
II Other factors that may influence ASCVD risk include primary LDL-C level ~160 mg/dL or other evidence of genetic hyperlipidemias; family history of premature ASCVD
with onset before age 55 yin a first-degree male relative or before age 65 yin a first-degree female relative; high-sensitivity C-reactive protein level of >2 mg/L; coronary artery
calcification score ~300 Agatston units or ~75th percentile for age, sex, and ethnicity (for additional information, see www.mesa-nhlbi.org/CACReference.aspx.); or
ankle–brachial index <0.9 or lifetime ASCVD.
¶ Common secondary causes of hypercholesterolemia include diet (saturated or trans fats, weight gain, or anorexia), drugs (diuretics, cyclosporine, glucocorticoids, or
amiodarone), diseases (biliary obstruction or nephrotic syndrome), and altered metabolism (hypothyroidism, obesity, or pregnancy).
** High-risk persons include those with clinical ASCVD; those with an untreated LDL-C level ~190 mg/dL, suggesting genetic hypercholesterolemia; or those aged 40–75 y
with diabetes.
†† Common causes of muscle ache, pain, or fatigue include hypothyroidism, reduced renal or hepatic function, rheumatologic disorders (especially polymyalgia rheumatica),
steroid myopathy, vitamin D deficiency, or primary muscle diseases.
www.annals.org
Annals of Internal Medicine
4. Engage in a Clinician–Patient Discussion Before
Initiating Statin Therapy, Especially for Primary
Prevention in Patients with Lower ASCVD Risk
Decisions to initiate statin therapy in primary prevention should be based on clinical judgment and preferences
of informed patients. In adults without clinical ASCVD or
diabetes whose LDL-C level is less than 190 mg/dL, calculating the estimated 10-year ASCVD risk should be the
start of the clinician–patient discussion and should not
automatically lead to statin initiation. As the absolute risk
for ASCVD events decreases, so does the net benefit of the
intervention. Therefore, discussion of the potential for
ASCVD event reduction, adverse effects, drug–drug interactions, and patient preferences is especially important for
lower-risk primary prevention. The discussion provides the
opportunity to encourage healthy lifestyle habits and control other risk factors.
Additional factors may be considered when a riskbased decision is uncertain, including LDL-C levels of 160
mg/dL or greater, family history of premature ASCVD,
elevated lifetime ASCVD risk, high-sensitivity C-reactive
protein level of 2.0 mg/L or greater, coronary artery calcification score greater than 300 Agatston units, and ankle–
brachial index less than 0.9. After age 75 years, comorbid
conditions, anticipated longevity, safety considerations,
and patient preferences should play a large role in decision
making.
5. Use the Newly Developed Pooled Cohort Equations
for Estimating 10-Year ASCVD Risk
The Pooled Cohort Equations are currently the best
available method for estimating 10-year ASCVD risk to
guide statin initiation (4, 6). Application of the inclusion
and exclusion criteria from RCTs is cumbersome and results in under-identifying high-risk and over-identifying
low-risk individuals for statin treatment.
The Pooled Cohort Equations were developed using
recent data from 5 NHLBI-sponsored, longitudinal,
population-based cohorts of African American and white
men and women (ARIC [Atherosclerotic Risk in Communities], CHS [Cardiovascular Health Study], CARDIA
[Coronary Artery Risk Development in Young Adults],
and the original Framingham Heart Study and its Offspring Cohorts). When the Pooled Cohort Equations were
validated in 2 independent contemporary cohorts (MESA
[Multi-Ethnic Study of Atherosclerosis] and REGARDS
[Reasons for Geographic and Racial Differences in
Stroke]), discrimination and calibration ranged from
“good” to “fair.” Some overestimation of ASCVD risk was
observed, primarily in higher-risk individuals, perhaps due
to high rates of statin initiation after baseline examinations
in these cohorts and limited duration of follow-up. Modest
overestimation of ASCVD risk generally will not affect
most decisions to recommend statin treatment for adults
Table 2. High-, Moderate-, and Low-Intensity Statin
Therapy*
Statin Therapy
Daily Dose
High-Intensity† Moderate-Intensity‡
Atorvastatin
Rosuvastatin
Simvastatin
Pravastatin
Lovastatin
Fluvastatin
Fluvastatin
Pitavastatin
4011–80 mg
20 (40) mg
–
–
–
–
–
–
Low-Intensity§
10 (20) mg
–
(5) 10 mg
–
20–40 mg¶
10 mg
40 (80) mg
10–20 mg
40 mg
20 mg
80 mg (Fluvastatin XL) 20–40 mg
40 mg**
–
2–4 mg
1 mg
FDA = U.S. Food and Drug Administration; LDL-C = low-density lipoprotein
cholesterol; XL = extended-release.
* Individual responses to statin therapy varied in randomized, controlled trials and
vary in clinical practice. A less-than-average response may have a biologic basis.
Statins and dosages in bold were reduced in major cardiovascular events in randomized, controlled trials. Statins and doses in italics were approved by the FDA
but were not tested in randomized, controlled trials.
† Daily dose decreases LDL-C levels by an average of ~50%.
‡ Daily dose decreases LDL-C levels by an average of 30% to
<50%. § Daily dose decreases LDL-C levels by an average of <30%.
II Evidence from 1 randomized, controlled trial only; down-titration if patient is
unable to tolerate atorvastatin, 80 mg.
¶ Although simvastatin, 80 mg, was evaluated in randomized, controlled trials, the
FDA recommends against initiation of or titration to 80 mg of simvastatin because
of increased risk for myopathy and rhabdomyolysis.
** Twice daily.
with a 10-year ASCVD risk of 7.5% or greater because
ASCVD event reduction exceeds adverse effects in the 10year ASCVD risk range of 5% to less than 7.5%.
Although over-prediction was reported by 1 group for
3 other cohorts (7), these cohorts of health professionals
and women screened for a clinical trial are not representative of the U.S. population (the reason the risk assessment
panel decided not to use them for derivation or validation)
and probably were subject to high rates of statin use during
the follow-up period (8).
6. Initiate the Appropriate Intensity of Statin Therapy
The appropriate intensity of statin therapy should be
used to reduce ASCVD risk and minimize adverse effects
(Table 2). On the basis of strong RCT evidence, highintensity statin therapy (LDL-C level decreased by ~50%)
is preferentially recommended for adults aged 75 years or
younger who have clinical ASCVD and no safety concerns.
Moderate-intensity statins (LDL-C level decreased by 30%
to <50%) are recommended for adults aged 75 years or
younger who have clinical ASCVD and safety concerns
and in those older than 75 years with clinical ASCVD.
High-intensity statin therapy is also recommended for
individuals with LDL-C levels of 190 mg/dL or greater. In
primary prevention in patients with LDL-C levels less than
190 mg/dL, moderate-intensity statin therapy is recommended, although high-intensity statin therapy also can be
considered for individuals with or without diabetes who
have a 10-year ASCVD risk of 7.5% or greater. When
choosing the intensity of statin therapy for primary prevention, consideration may be given to a high estimated 10-
year ASCVD risk, an LDL-C level of 160 to 189 mg/dL,
or additional factors that may influence ASCVD risk. Lowintensity statin therapy may be used when high- or
moderate-intensity statins are not tolerated.
7. Evidence is Inadequate to Support Treatment to
Specific LDL-C or Non–HDL-C Goals
Randomized, controlled trials of statins, nonstatin
drugs, or both did not compare titration to different
LDL-C goals. Thus, the panel was unable to make any
evidence-based recommendations about use of treatment
goals for guiding therapy. “Treating to goal” may result in
treatment with less-than-optimum statin intensity or adding nonstatin therapy in the absence of RCT evidence that
combination therapy improves outcomes.
8. Regularly Monitor Patients for Adherence to Lifestyle
and Statin Therapy
Randomized, controlled trials of statins regularly assessed adherence and safety. A fasting lipid panel is needed
after initiation of or changes in statin or other drug therapy. Percentage reductions in LDL-C level should not be
used as treatment goals or performance measures but
should be used to assess and provide feedback to promote
adherence to healthy lifestyle behaviors and statin therapy.
Safety measurements should be assessed as clinically
indicated.
In patients with a less-than-anticipated therapeutic response or intolerance of recommended statin therapy intensity, adherence to healthy lifestyle behaviors and medications should be re-emphasized and secondary causes of
hyperlipidemia excluded. A nonstatin LDL-C–lowering
drug, preferably one that reduced ASCVD events in RCTs,
can be considered in higher-risk adults, including those
with genetic dyslipidemias, such as familial hypercholesterolemia, if the potential for additional ASCVD risk reduction outweighs the potential for adverse effects.
SUMMARY
Millions of U.S. adults are at increased ASCVD risk—
some because they have had an ASCVD event, others because of ASCVD risk factors. Adherence to healthy lifestyle
behaviors, control of blood pressure and diabetes, and
avoidance of smoking is recommended for all adults. Statin
therapy should be used to reduce ASCVD risk in individuals likely to have a clear net benefit (those with clinical
ASCVD) or in primary prevention for adults with LDL-C
levels of 190 mg/dL or greater, those aged 40 to 75 years
with diabetes, and those with a 10-year ASCVD risk of
7.5% or greater without diabetes. A clinician–patient discussion that considers potential ASCVD risk reduction,
adverse effects, and patient preferences is needed to decide
whether to initiate statin therapy, especially in lower-risk
primary prevention.
Appropriate intensity of statin therapy based on
ASCVD risk and potential for adverse effects is recommended rather than focusing on specific LDL-C or non–
HDL-C goals. Five of 7 statins, including a high-intensity
statin, are available in the United States as low-cost
generics.
The Pooled Risk Equations, which were developed in
a geographically diverse sample of African Americans and
non-Hispanic whites, identify adults at increased risk for
an ASCVD event (including stroke as well as heart disease). They represent important steps forward in the ability
to match intensity of preventive treatment to level of
ASCVD risk. These risk equations will be reevaluated and
revised as additional information becomes available, including research assessing other potentially useful markers
of ASCVD risk and data required to develop equations
specific to other ethnic groups.
Until heart-healthy lifestyles are adopted throughout
the lifespan, the need for preventive measures using
evidence-based drug therapy will remain high. As with all
clinical guidelines, the 2013 ACC/AHA cholesterol guidelines must be implemented in conjunction with sound
clinical judgment. These evidence-based recommendations
focus statin treatment on patients likely to obtain the greatest benefit, thereby reducing the ASCVD burden in adults.
From Northwestern University, Chicago, Illinois; University of Iowa,
Iowa City, Iowa; Tufts University, Boston, Massachusetts; University of
Colorado, Aurora, Colorado; University of North Carolina, Chapel Hill,
North Carolina; Columbia University Medical Center, New York, New
York; and University of Pennsylvania, Philadelphia, Pennsylvania.
Potential Conflicts of Interest: Disclosures can be viewed at www
.acponline.org/authors/icmje/ConflictOfInterestForms.do?msNum
=M14-0126.
Corresponding Author: J. Sanford Schwartz, MD, University of Penn-
sylvania, Blockley 1101, 423 Guardian Drive, Philadelphia, PA 19104;
e-mail, [email protected].
Current author addresses and author contributions are available at
www.annals.org.
References
1.
2.
3.
4.
5.
6.
7.
8.
Go AS, Mozaffarian D, Roger VL, Benjamin EJ, Berry JD, Borden WB, et al; American Heart Association Statistics Committee and Stroke
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2013;127:e6-e245. [PMID: 23239837]
Stone NJ, Robinson J, Lichtenstein AH, Bairey Merz CN, Lloyd-Jones DM, Blum CB, et al. 2013 ACC/AHA Guideline on the Treatment of
Blood Cholesterol to Reduce Atherosclerotic Cardiovascular Risk in Adults: A Report of the American College of Cardiology/American Heart
Association Task Force on Practice Guidelines. J Am Coll Cardiol. 2013. [PMID: 24239923]
Eckel RH, Jakicic JM, Ard JD, Miller NH, Hubbard VS, Nonas CA, et al. 2013 AHA/ACC Guideline on Lifestyle Management to Reduce
Cardiovascular Risk: A Report of the American College of Cardiology/American Heart Association Task Force on Practice Guidelines. J Am
Coll Cardiol. 2013. [PMID: 24239922]
Goff DC Jr, Lloyd-Jones DM, Bennett G, Coady S, D’Agostino RB Sr, Gibbons R, et al. 2013 ACC/AHA Guideline on the Assessment of
Cardiovascular Risk: A Report of the American College of Cardiology/American HeartAssociation Task Force on Practice Guidelines.
Circulation. 2013. [PMID: 24222018]
Graham R, Mancher M, Wolman DM, Greenfield S, Steinberg E, eds; Institute of Medicine. Clinical Practice Guidelines We Can Trust.
Washington, DC: National Academies Pr; 2011.
American Heart Association. 2013 Prevention Guidelines Tools: CV Risk Calculator. Dallas, TX: American Heart Association; 2013.
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Ridker PM, Cook NR. Statins: new American guidelines for prevention of cardiovascular disease. Lancet. 2013;382:1762-5. [PMID: 24268611]
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24315619]
Current Author Addresses: Dr. Stone: Feinberg School of Medicine, Northwestern Medical Faculty Foundation, Northwestern
University, 676 North St. Clair, Suite 600 (Cardiology), Chicago, IL 60611.
Dr. Robinson: Department of Epidemiology, University of Iowa, 200 Hawkins Drive, SE 226 GH, Iowa City, IA 52242
Dr. Lichtenstein: Jean Mayer USDA Human Nutrition Research Center on Aging, Tufts University, 711 Washington Street, Boston,
MA 02111.
Dr. Goff: Colorado School of Public Health, University of Colorado, Building 500, 3rd Floor, Suite 300, Anschutz Medical Campus,
Aurora, CO 80045.
Dr. Lloyd-Jones: Department of Preventive Medicine, Northwestern University, 680 North Lake Shore Drive, Suite 1400, Chicago,
IL 60611.
Dr. Smith: UNC Health Care System, 101 Manning Drive, Chapel Hill, NC 27514.
Dr. Blum: Columbia College, P & S, 16 East 60th Street, New York, NY 10022.
Dr. Schwartz: University of Pennsylvania, Blockley 1101, 423 Guardian Drive, Philadelphia, PA 19104.
APPENDIX: 2013 ACC/AHA CHOLESTEROL
GUIDELINE PANEL
The members of the 2013 ACC/AHA Cholesterol Guideline Panel are Neil J. Stone, MD (Chair); Jennifer G.
Robinson, MD, MPH (Vice-Chair); Alice H. Lichtenstein, ScD (Vice-Chair); Donald M. Lloyd-Jones, MD, ScM (CoChair, ASCVD Risk Assessment Expert Work Group); Robert H. Eckel, MD (Co-Chair, Lifestyle Management Expert
Work Group); C. Noel Bairey Merz, MD; Conrad B. Bloom, MD; Anne C. Goldberg, MD; David Gordon, MD; Daniel
Levy, MD; Patrick McBride, MD, MPH; Susan T. Shero, MS, RN; Karol Watson, PhD; and Peter W.F. Wilson, MD.
Although he is not a member of the ACC/AHA Cholesterol Guideline Panel, David C. Goff Jr., MD, PhD, is Co-Chair of
the ASCVD Risk Assessment Expert Work Group
7LHU *XLGHOLQH
Microhematuria Without Evidence of Primary Renal Disease In Adults
(Confirmed by Microscopic Analysis)
Date of Adoption: September 14, 2010 Revision Dates: 8/2013
Contact Physician: Dr. Erin Bird, MD; S&W Department of Urology
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Diabetes Annual Assessment
Purpose: To delineate yearly examination requirements for adults with diabetes.
Patient Population: Patients, age 18 to 75, with diabetes.
Developed by: SWHP Diabetes Team 12/18/97 Contact Person: Veronica Piziak, M.D.
Adopted: 1/21/98 Date of Last Reviews: April 2004, April 2006, April 2008, and April 2010
Next Review Date: May 2016
Approved by SWHP Quality Improvement Sub-Committee: April 13, 2010, April 10, 2012, May
13, 2014
TIME FRAME FOR REQUIRED TESTS
Initial
Visit
Examination
Twice per Year
Yearly
1. Eye Exam (By Optometrist or Ophthalmologist)
X
X
2. Hemoglobin A1c Control – goal <8.0% without hypoglycemia
X
3. Urine Microalbumin (Therapy with ACE-I or ARB indicated if
elevated)
X
X
4. Foot Exam (Check for sensation, reflexes, pulses, lesions, and calluses
twice a year with a monofilament test at least once a year)
X
X
5. Lipid Panel goal–Total Cholesterol <200 mg/dL,Triglyceride <150
mg/dL, (HDL men >40 mg/dL women >50 mg/dL), and LDL <100
mg/dL ; < 70 if known vascular disease (Statin therapy should be
considered in patients over age 40.
X
X
6. Diabetes Education- (Nutritional therapy, self monitoring blood
glucose, self management skills, lifestyle changes and reducing risks
and complications.)
X
(after initial diabetes
education – refresh when
recommended by primary
care physician)
7. Blood Pressure
(Systolic < 140)
(Diastolic < 90)
ACE-I or ARB recommended as first line therapy for Hypertension
control
(See also Scott & White Treatment Guidelines for Hypertension)
X
Record BP in medical
record twice a year and if
BP > 140/90 more
frequent monitoring
recommended
8. Tobacco Cessation (Educate patient on health risks associated with
tobacco use, advise tobacco user to quit, discuss cessation medications
and cessation strategies.)
X
X
9. Weight Control
X
X
10. Exercise
X
X
11. Depression Screening (include screening for history of depression
and screening for symptoms of depression)
X
X
(more frequent screening
if clinically indicated)
Sources: American Diabetes Association Guideline and National Quality Forum (NQF) endorsed standards submitted by the
National Committee for Quality Assurance (NCQA)
Page 1 of 1
L:\QI\NCQA\Clinical Guidelines\Current Guidelines\Diabetes\Annual Assessment and Guideline 2014\Diabetes Annual Assessment-2014.docx
X
SCOTT AND WHITE HEALTH PLAN
CLINICAL PRACTICE GUIDELINES FOR DIABETES
SWHP has adopted the 2011 Clinical Practice Recommendations of the National Quality Forum
(NQF) endorsed Diabetes Standards submitted by the National Committee for Quality
Assurance (NCQA) located at the following internet website link:
http://www.qualityforum.org/Measures_List.aspx#k=Diabetes&e=1&st=&sd=549%7C798&s=&p=1
SWHP Guideline Approval Body: SWHP Quality Improvement Subcommittee
Date of Adoption: December 7, 2011
Review Dates: April 2012, April 2014, May 2016
Physician Sponsor: Veronica K. Piziak, M.D., Ph.D.
Scott &White Healthcare
Professor of Medicine and Endocrinology, Texas A&M Health Science
Center College of Medicine
Board Certification by the American Board of Internal Medicine in
Endocrinology and Metabolism
Paper Copy: A paper copy of this Guideline is available upon request by contacting the SWHP
Quality Improvement Division. Call toll free 1-800-321-7947 ext. 3516.
L/QI/NCQA/Clinical Guidelines/Current Tier 2 INTER dept/Diabetes
SCOTT AND WHITE HEALTH PLAN
CLINICAL PRACTICE GUIDELINE FOR THE TREATMENT OF
OSTEOARTHRITIS OF THE KNEE
ScottandWhiteHealthPlan(SWHP)hasadoptedthe“Treatment of Osteoarthritis of the Knee” dated
May18,2013oftheAmericanAcademyofOrthopaedicSurgeons,asaclinicalpracticeguidelinefor
SWHP’sproviders1.Theguidelineislocatedatthefollowinginternetwebsite:
http://www.aaos.org/research/guidelines/TreatmentofOsteoarthritisoftheKneeGuideline.pdf
Additional Resources for Care:
x SWHP VitalCare Shared Decision-Making Program2:
https://www.swhp.org/sites/default/files/SharedDecisioinMakingRef_FAX.pdf
x SWHP Formulary:https://swhp.org/providers/pharmacyservices/prescriptiondruglists
x Notes:
1. Specificrecommendationsforcareshouldbediscussedwithyourpatient.Allmedicationsnoted
inthisguidelinemaynotbeintheSWHPFormulary;however,sinceSWHPhasanOpen
Formulary,nonFormularymedicationsareavailablewithauthorizationatthenonFormulary
copayment.
2. SWHP’sSharedDecisionMakingprogramofferspreferencesensitiveconditionsupport.
Preferencesensitiveconditionsupportextendstoconditionsforwhicheithersciencesupports
multipleacceptabletreatmentoptions,orthereisinadequatescientificinformationaboutthe
treatmentchoices.OurHealthCoachescanhelpyourpatientmakeaninformeddecisionabout
thetreatmentheorshewouldliketoreceive.Decisionsupportforpreferencesensitive
conditionsaddressesawiderangeoftopics,includingosteoarthritis.
SWHP Guideline Approval Body:SWHPQualityImprovementSubcommittee
Date of Adoption:
Review Dates:March8.2011
Physician Sponsor:MichaelHawkins,MD
Paper Copy:Ifyouhavedifficultydownloadinginformationorwouldlikeapapercopy,pleasecontact
SWHPProviderRelationsDepartmenttollfreeat8003217947ext.3064ordirectat2542983064
Tier #1 Address the expected practice or management of a specific condition or
disease process within an organizational unit, i.e. division or department; may be
distributed outside the respective organizational unit.
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Approved: December 1999 Revised: 2/2003; 2/2007 Reviewed: 2/2005; 2/2009,12/2010, 12/2012
Source: Texas Medication Algorithm Project
Physician Contact: Dr. Virginia Maxanne Flores, M.D.
Reviewed in 2010 by: Department of Psychiatry, Scott & White Clinics
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Approved: December 1999 Revised: 2/2003; 2/2007 Reviewed: 2/2005; 2/2009, 12/2010
Source: Texas Medication Algorithm Project
Physician Contact: Dr. Virginia Maxanne Flores, M.D.
Reviewed in 2010 by: Department of Psychiatry, Scott & White Clinics
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&OLQLFDO 3UDFWLFH *XLGHOLQH IRU 0HQWDO +HDOWK 6SHFLDOLVWV 7LHU STRATEGIES FOR ALCOHOL WITHDRAWAL MANAGEMENT
$GRSWHG 5HYLHZHG 5HYLVHG 3K\VLFLDQ &RQWDFW 9LUJLQLD 0D[DQQH )ORUHV 0'
5HYLHZHG LQ E\ 'HSDUWPHQW RI 3V\FKLDWU\ 6FRWW :KLWH &OLQLFV
A. Thiamine 100 mg I.M. x 1, then 100 mg p.o. daily x 5 days
B. Folate 1 mg p.o. daily
C. Multivitamin 1 p.o. daily
D. Nurse monitors and documents Abstinence Symptom
Evaluation (ASE’s) q 4 hours.
E. Magnesium Sulfate 1 gram q 8 hours I.M. x 2, as indicated
During 1st 24 hours of
monitoring ASE scores, is ASE
score •RUGRHV$6(VFRUH
increase by 3 points between
assessments?
Patient enters inpatient
treatment facility for
alcohol withdrawal.
No
+/- Acamprosate
+/- Naltrexone
+/- Antabuse
Yes
Is there
significant hepatic
impairment?
Encourage patient to
call MH provider for
outpatient referral if
patient changes mind
Yes
72 hours (Fixed
Schedule)
No
Refer to
Outpatient Care
Yes
Will treatment
duration be 24 or
72 hours?
24 hours (FrontLoading Schedule)
Diagnosis of
alcohol
dependence?
72 hours (Fixed
Schedule)
Yes
Diazepam 20 mg p.o.
q 2 hours until ASE’s <
10 or there is
resolution of
symtoms. On average
three doses are
required.
No
Patient agrees
to Outpatient
Care?
Diazepam 10 mg p.o.
q 6 hours x 4 doses,
then
Diazepam 5 mg q 6
hours x 8 doses,
Diazepam 10 mg p.o.
q hour prn ASE • 10
Lorazepam 2 mg p.o.
q 6 hours x 4 doses,
then
Lorazepam 1 mg p.o.
q 6 hours x 8 doses,
Lorazepam 1 mg p.o.
q hour prn ASE • 10
No
Initiate
treatment within 14
days of diagnosis.
Other Diagnosis
TX
initiation
complete?
Detox
complete?
No
Yes
Explain dangers (delirium, seizures, etc.) of not
completing detox, including being released from
facility against medical advice.
Consider possibility of switching eligible patients to
Front-Loading Schedule.
Release from facility against medical advice if patient
continues to refuse detox.
Yes
No
+/- Naltrexone
+/- Antabuse
+/- Acamprosate
Engage patient in
treatment with a minimum
of 2 follow-up services
within 30 days of the initial
treatment.
Encourage patient to
initiate treatment.
* Effective August 2011 the Guideline, “Strategies for Alcohol Withdrawal Management with Front-Loading Schedule” was merged into this Guideline.
Developed by the Physicians and Staff of the Department of Psychiatry, Scott & White Clinics
Figure 1. Recommended immunization schedule for persons aged 0 through 18 years – 2013.
(FOR THOSE WHO FALL BEHIND OR START LATE, SEE THE CATCH-UP SCHEDULE [FIGURE 2]).
These recommendations must be read with the footnotes that follow. For those who fall behind or start late, provide catch-up vaccination at the earliest opportunity as indicated by the green bars in
Figure 1. To determine minimum intervals between doses, see the catch-up schedule (Figure 2). School entry and adolescent vaccine age groups are in bold.
Vaccines
Birth
Hepatitis B1 (HepB)
1st dose
Rotavirus2 (RV) RV-1 (2-dose series);
RV-5 (3-dose series)
Diphtheria, tetanus, & acellular
pertussis3 (DTaP: <7 yrs)
Tetanus, diphtheria, & acellular
pertussis4 (Tdap: >7 yrs)
1 mo
2 mos
4 mos
6 mos
9 mos
12 mos
15 mos
18 mos
19–23mos
2-3 yrs
4-6 yrs
7-10 yrs 11-12 yrs 13–15 yrs 16–18 yrs
3rd dose
2nd dose
See
1st dose
2nd dose footnote 2
1st dose
2nd dose
Haemophilus influenzae type b5 (Hib)
1st dose
See
2nd dose footnote 5
Pneumococcal conjugate6a,c (PCV13)
1st dose
2nd dose
Pneumococcal polysaccharide6b,c
(PPSV23)
Inactivated Poliovirus7 (IPV)
(<18years)
Influenza8 (IIV; LAIV) 2 doses for some :
see footnote 8
1st dose
2nd dose
3rd dose
4th dose
5th dose
(Tdap)
3rd or 4th dose,
see footnote 5
3rd dose
4th dose
3rd dose
4th dose
Annual vaccination (IIV only)
Annual vaccination (IIV or LAIV)
Measles, mumps, rubella9 (MMR)
1st dose
2nd dose
Varicella10 (VAR)
1st dose
2nd dose
Hepatitis A11 (HepA)
2 dose series, see footnote 11
Human papillomavirus12
(HPV2: females
only; HPV4: males and females)
13
Meningococcal (Hib-MenCY > 6 weeks;
MCV4-D>9 mos; MCV4-CRM > 2 yrs.)
(3-dose
series)
1st dose
see footnote 13
booster
Not routinely
Range of recommended ages during
recommended
which catch-up is encouraged and for
certain high-risk groups
This schedule includes recommendations in effect as of January 1, 2013. Any dose not administered at the recommended age should be administered at a subsequent visit, when indicated and feasible. The use of
a combination vaccine generally is preferred over separate injections of its equivalent component vaccines. Vaccination providers should consult the relevant Advisory Committee on Immunization Practices (ACIP)
statement for detailed recommendations, available online at http://www.cdc.gov/vaccines/pubs/acip-list.htm. Clinically significant adverse events that follow vaccination should be reported to the Vaccine Adverse
Event Reporting System (VAERS) online (http://www.vaers.hhs.gov) or by telephone (800-822-7967).Suspected cases of vaccine-preventable diseases should be reported to the state or local health department.
Additional information, including precautions and contraindications for vaccination, is available from CDC online (http://www.cdc.gov/vaccines) or by telephone (800-CDC-INFO [800-232-4636]).
Range of recommended
ages for all children
Range of recommended ages
for catch-up immunization
Range of recommended ages
for certain high-risk groups
This schedule is approved by the Advisory Committee on Immunization Practices (http://www.cdc.gov/vaccines/acip/index.html), the American Academy of Pediatrics (http://www.aap.org), the American
Academy of Family Physicians (http://www.aafp.org), and the American College of Obstetricians and Gynecologists (http://www.acog.org).
NOTE: The above recommendations must be read along with the footnotes of this schedule.
FIGURE 2. Catch-up immunization schedule for persons aged 4 months through 18 years who start late or who are more than 1 month behind —United States, 2013
The figure below provides catch-up schedules and minimum intervals between doses for children whose vaccinations have been delayed. A vaccine series does not need to be restarted, regardless of
the time that has elapsed between doses. Use the section appropriate for the child’s age. Always use this table in conjunction with Figure 1 and the footnotes that follow.
Persons aged 4 months through 6 years
Vaccine
Minimum
Age for
Dose 1
Minimum Interval Between Doses
Dose 1 to dose 2
Dose 2 to dose 3
Dose 3 to dose 4
Dose 4 to dose 5
6 months3
Hepatitis B1
Birth
4 weeks
8 weeks and at least 16 weeks after first dose; minimum age for
the final dose is 24 weeks
Rotavirus2
6 weeks
4 weeks
4 weeks2
Diphtheria, tetanus, pertussis3
6 weeks
4 weeks
4 weeks
6 months
6 weeks
4 weeks if first dose administered at
younger than age 12 months
8 weeks (as final dose) if first dose administered at age 12–14
months
No further doses needed if first dose administered at age 15
months or older
4 weeks5 if current age is younger than 12 months
8 weeks (as final dose)5 if current age is 12 months or older
and first dose administered at younger than age 12 months and
second dose administered at younger than 15 months
No further doses needed if previous dose administered at age
15 months or older
8 weeks (as final dose)
This dose only necessary for children
aged 12 through 59 months who received
3 doses before age 12 months
Pneumococcal6
6 weeks
4 weeks if first dose administered at younger than age 12 months
8 weeks (as final dose for healthy children) if first dose
administered at age 12 months or older or current age 24 through
59 months
No further doses needed for healthy children if first dose
administered at age 24 months or older
4 weeks if current age is younger than 12 months
8 weeks (as final dose for healthy children) if current age is 12
months or older
No further doses needed for healthy children if previous dose
administered at age 24 months or older
8 weeks (as final dose)
This dose only necessary
for children aged 12
through 59 months who received 3 doses
before age 12 months or for children at
high risk who received 3 doses at any age
Inactivated poliovirus7
6 weeks
4 weeks
4 weeks
6 months7 minimum age 4 years for
final dose
Meningococcal13
see footnote 13
see footnote 13
Haemophilus influenzae type b5
6 weeks
8 weeks13
Measles, mumps, rubella9
12 months
4 weeks
Varicella10
12 months
3 months
Hepatitis A11
12 months
6 months
Persons aged 7 through 18 years
Tetanus, diphtheria; tetanus,
diphtheria, pertussis4
7 years4
Human papillomavirus12
9 years
4 weeks
4 weeks if first dose administered at younger than age 12 months
6 months if first dose administered at 12 months or older
Routine dosing intervals are recommended12
Hepatitis A11
12 months
Hepatitis B1
Birth
4 weeks
8 weeks (and at least 16 weeks after first dose)
Inactivated poliovirus7
6 weeks
4 weeks
4 weeks7
Meningococcal13
6 weeks
8 weeks13
Measles, mumps, rubella9
Varicella10
6 months if first dose administered at
younger than age 12 months
6 months
12 months
4 weeks
12 months
3 months if person is younger than age 13 years
4 weeks if person is aged 13 years or older
NOTE: The above recommendations must be read along with the footnotes of this schedule.
6 months7
Footnotes — Recommended immunization schedule for persons aged 0 through 18 years—United States, 2013
For further guidance on the use of the vaccines mentioned below, see: http://www.cdc.gov/vaccines/pubs/acip-list.htm.
Hepatitis B (HepB) vaccine. (Minimum age: birth)
Routine vaccination:
At birth
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Doses following the birth dose
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age 6 weeks.
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the birth dose.
Catch-up vaccination:
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15 years.
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Routine vaccination:
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2. If RV-5 is used, administer a 3-dose series at ages 2, 4, and 6 months.
3. If any dose in series was RV-5 or vaccine product is unknown for any dose in the series, a total of 3 doses of RV vaccine should be
administered.
Catch-up vaccination:
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3. Diphtheria and tetanus toxoids and acellular pertussis (DTaP) vaccine. (Minimum age: 6 weeks)
Routine vaccination:
t "ENJOJTUFSBEPTFTFSJFTPG%5B1WBDDJOFBUBHFToNPOUITBOEUISPVHIZFBST5IFGPVSUIEPTFNBZCFBENJOJTUFSFE
as early as age 12 months, provided at least 6 months have elapsed since the third dose.
Catch-up vaccination:
t 5IFöGUICPPTUFS
EPTFPG%5B1WBDDJOFJTOPUOFDFTTBSZJGUIFGPVSUIEPTFXBTBENJOJTUFSFEBUBHFZFBSTPSPMEFS
t 'PSPUIFSDBUDIVQJTTVFTTFF'JHVSF
4. Tetanus and diphtheria toxoids and acellular pertussis (Tdap) vaccine. (Minimum age: 10 years for Boostrix, 11 years for
Adacel).
Routine vaccination:
t "ENJOJTUFSEPTFPG5EBQWBDDJOFUPBMMBEPMFTDFOUTBHFEUISPVHIZFBST
t 5EBQDBOCFBENJOJTUFSFESFHBSEMFTTPGUIFJOUFSWBMTJODFUIFMBTUUFUBOVTBOEEJQIUIFSJBUPYPJEDPOUBJOJOHWBDDJOF
t "ENJOJTUFSPOFEPTFPG5EBQWBDDJOFUPQSFHOBOUBEPMFTDFOUTEVSJOHFBDIQSFHOBODZQSFGFSSFEEVSJOHUISPVHIXFFLTHFTUBUJPO
regardless of number of years from prior Td or Tdap vaccination.
Catch-up vaccination:
t 1FSTPOTBHFEUISPVHIZFBSTXIPBSFOPUGVMMZJNNVOJ[FEXJUIUIFDIJMEIPPE%5B1WBDDJOFTFSJFTTIPVMESFDFJWF5EBQWBDDJOFBT
UIFöSTUEPTFJOUIFDBUDIVQTFSJFTJGBEEJUJPOBMEPTFTBSFOFFEFEVTF5EWBDDJOF'PSUIFTFDIJMESFOBOBEPMFTDFOU5EBQWBDDJOFTIPVME
not be given.
t 1FSTPOTBHFEUISPVHIZFBSTXIPIBWFOPUSFDFJWFE5EBQWBDDJOFTIPVMESFDFJWFBEPTFGPMMPXFECZUFUBOVTBOEEJQIUIFSJBUPYPJET
(Td) booster doses every 10 years thereafter.
t $IJMESFOXJUIBOBUPNJDPSGVODUJPOBMBTQMFOJBJODMVEJOHTJDLMFDFMMEJTFBTFBOEPUIFSIFNPHMPCJOPQBUIJFTDPOHFOJUBMPSBDRVJSFEBTQMFOJB
or splenic dysfunction);
t $IJMESFOXJUIJNNVOPDPNQSPNJTJOHDPOEJUJPOT)*7JOGFDUJPODISPOJDSFOBMGBJMVSFBOEOFQISPUJDTZOESPNFEJTFBTFTBTTPDJBUFEXJUI
treatment with immunosuppressive drugs or radiation therapy, including malignant neoplasms, leukemias, lymphomas and Hodgkin
disease; or solid organ transplantation, congenital immunodeficiency.
7. Inactivated poliovirus vaccine (IPV). (Minimum age: 6 weeks)
Routine vaccination:
t "ENJOJTUFSBTFSJFTPG*17BUBHFToNPOUITXJUIBCPPTUFSBUBHFoZFBST5IFöOBMEPTFJOUIFTFSJFTTIPVMECFBENJOJTUFSFE
on or after the fourth birthday and at least 6 months after the previous dose.
Catch-up vaccination:
t *OUIFöSTUNPOUITPGMJGFNJOJNVNBHFBOENJOJNVNJOUFSWBMTBSFPOMZSFDPNNFOEFEJGUIFQFSTPOJTBUSJTLGPSJNNJOFOUFYQPTVSF
to circulating poliovirus (i.e., travel to a polio-endemic region or during an outbreak).
t *GPSNPSFEPTFTBSFBENJOJTUFSFECFGPSFBHFZFBSTBOBEEJUJPOBMEPTFTIPVMECFBENJOJTUFSFEBUBHFUISPVHIZFBST
t "GPVSUIEPTFJTOPUOFDFTTBSZJGUIFUIJSEEPTFXBTBENJOJTUFSFEBUBHFZFBSTPSPMEFSBOEBUMFBTUNPOUITBGUFSUIFQSFWJPVTEPTF
t *GCPUI017BOE*17XFSFBENJOJTUFSFEBTQBSUPGBTFSJFTBUPUBMPGEPTFTTIPVMECFBENJOJTUFSFESFHBSEMFTTPGUIFDIJMETDVSSFOUBHF
t *17JTOPUSPVUJOFMZSFDPNNFOEFEGPS64SFTJEFOUTBHFEZFBSTPSPMEFS
t 'PSPUIFSDBUDIVQJTTVFTTFF'JHVSF
8. Influenza vaccines. (Minimum age: 6 months for inactivated influenza vaccine [IIV]; 2 years for live, attenuated
influenza vaccine [LAIV])
Routine vaccination:
t "ENJOJTUFSJOøVFO[BWBDDJOFBOOVBMMZUPBMMDIJMESFOCFHJOOJOHBUBHFNPOUIT'PSNPTUIFBMUIZOPOQSFHOBOUQFSTPOTBHFEUISPVHI
49 years, either LAIV or IIV may be used. However, LAIV should NOT be administered to some persons, including 1) those with asthma,
2) children 2 through 4 years who had wheezing in the past 12 months, or 3) those who have any other underlying medical conditions
UIBUQSFEJTQPTFUIFNUPJOøVFO[BDPNQMJDBUJPOT'PSBMMPUIFSDPOUSBJOEJDBUJPOTUPVTFPG-"*7TFF..83/P33
BWBJMBCMF
at http://www.cdc.gov/mmwr/pdf/rr/rr5908.pdf.
t "ENJOJTUFSEPTFUPQFSTPOTBHFEZFBSTBOEPMEFS
For children aged 6 months through 8 years:
t 'PSUIFoTFBTPOBENJOJTUFSEPTFTTFQBSBUFECZBUMFBTUXFFLT
UPDIJMESFOXIPBSFSFDFJWJOHJOøVFO[BWBDDJOFGPSUIFöSTU
UJNF'PSBEEJUJPOBMHVJEBODFGPMMPXEPTJOHHVJEFMJOFTJOUIF"$*1JOøVFO[BWBDDJOFSFDPNNFOEBUJPOT..83o
available at http://www.cdc.gov/mmwr/pdf/wk/mm6132.pdf.
t 'PSUIFoTFBTPOGPMMPXEPTJOHHVJEFMJOFTJOUIF"$*1JOøVFO[BWBDDJOFSFDPNNFOEBUJPOT
9. Measles, mumps, and rubella (MMR) vaccine. (Minimum age: 12 months for routine vaccination)
Routine vaccination:
t "ENJOJTUFSUIFöSTUEPTFPG..3WBDDJOFBUBHFUISPVHINPOUITBOEUIFTFDPOEEPTFBUBHFUISPVHIZFBST5IFTFDPOEEPTF
may be administered before age 4 years, provided at least 4 weeks have elapsed since the first dose.
t "ENJOJTUFSEPTFPG..3WBDDJOFUPJOGBOUTBHFEUISPVHINPOUITCFGPSFEFQBSUVSFGSPNUIF6OJUFE4UBUFTGPSJOUFSOBUJPOBMUSBWFM
These children should be revaccinated with 2 doses of MMR vaccine, the first at age 12 through 15 months (12 months if the child remains
in an area where disease risk is high), and the second dose at least 4 weeks later.
t "ENJOJTUFSEPTFTPG..3WBDDJOFUPDIJMESFOBHFENPOUITBOEPMEFSCFGPSFEFQBSUVSFGSPNUIF6OJUFE4UBUFTGPSJOUFSOBUJPOBM
travel. The first dose should be administered on or after age 12 months and the second dose at least 4 weeks later.
Catch-up vaccination:
t &OTVSFUIBUBMMTDIPPMBHFEDIJMESFOBOEBEPMFTDFOUTIBWFIBEEPTFTPG..3WBDDJOFUIFNJOJNVNJOUFSWBMCFUXFFOUIFEPTFTJT
weeks.
10. Varicella (VAR) vaccine. (Minimum age: 12 months)
Routine vaccination:
t "ENJOJTUFSUIFöSTUEPTFPG7"3WBDDJOFBUBHFUISPVHINPOUITBOEUIFTFDPOEEPTFBUBHFUISPVHIZFBST5IFTFDPOEEPTFNBZ
be administered before age 4 years, provided at least 3 months have elapsed since the first dose. If the second dose was administered at
least 4 weeks after the first dose, it can be accepted as valid.
Catch-up vaccination:
t &OTVSFUIBUBMMQFSTPOTBHFEUISPVHIZFBSTXJUIPVUFWJEFODFPGJNNVOJUZTFF..83</P33>BWBJMBCMFBUhttp://www.
cdc.gov/mmwr/pdf/rr/rr5604.pdf
IBWFEPTFTPGWBSJDFMMBWBDDJOF'PSDIJMESFOBHFEUISPVHIZFBSTUIFSFDPNNFOEFENJOJNVN
interval between doses is 3 months (if the second dose was administered at least 4 weeks after the first dose, it can be accepted as valid);
for persons aged 13 years and older, the minimum interval between doses is 4 weeks.
11. Hepatitis A vaccine (HepA). (Minimum age: 12 months)
Routine vaccination:
t *OJUJBUFUIFEPTF)FQ"WBDDJOFTFSJFTGPSDIJMESFOBHFEUISPVHINPOUITTFQBSBUFUIFEPTFTCZUPNPOUIT
t $IJMESFOXIPIBWFSFDFJWFEEPTFPG)FQ"WBDDJOFCFGPSFBHFNPOUITTIPVMESFDFJWFBTFDPOEEPTFUPNPOUITBGUFSUIFöSTUEPTF
t "OJOBEWFSUFOUEPTFPG%5B1WBDDJOFBENJOJTUFSFEUPDIJMESFOBHFEUISPVHIZFBSTDBODPVOUBTQBSUPGUIFDBUDIVQTFSJFT5IJTEPTF
can count as the adolescent Tdap dose, or the child can later receive a Tdap booster dose at age 11–12 years.
t 'PSPUIFSDBUDIVQJTTVFTTFF'JHVSF
Haemophilus influenzae type b (Hib) conjugate vaccine. (Minimum age: 6 weeks)
Routine vaccination:
t "ENJOJTUFSB)JCWBDDJOFQSJNBSZTFSJFTBOEBCPPTUFSEPTFUPBMMJOGBOUT5IFQSJNBSZTFSJFTEPTFTTIPVMECFBENJOJTUFSFEBUBOE
6 months of age; however, if PRP-OMP (PedvaxHib or Comvax) is administered at 2 and 4 months of age, a dose at age 6 months is not
indicated. One booster dose should be administered at age 12 through15 months.
t )JCFSJY1315
TIPVMEPOMZCFVTFEGPSUIFCPPTUFSöOBM
EPTFJODIJMESFOBHFENPOUITUISPVHIZFBSTXIPIBWFSFDFJWFEBUMFBTU
1 dose of Hib.
Catch-up vaccination:
t *GEPTFXBTBENJOJTUFSFEBUBHFTNPOUITBENJOJTUFSCPPTUFSBTöOBMEPTF
BUMFBTUXFFLTBGUFSEPTF
t *GUIFöSTUEPTFTXFSF1310.11FEWBY)*#PS$PNWBY
BOEXFSFBENJOJTUFSFEBUBHFNPOUITPSZPVOHFSUIFUIJSEBOEöOBM
dose should be administered at age 12 through 15 months and at least 8 weeks after the second dose.
t *GUIFöSTUEPTFXBTBENJOJTUFSFEBUBHFUISPVHINPOUITBENJOJTUFSUIFTFDPOEEPTFBUMFBTUXFFLTMBUFSBOEBöOBMEPTFBUBHF
12 through 15 months, regardless of Hib vaccine (PRP-T or PRP-OMP) used for first dose.
t 'PSVOWBDDJOBUFEDIJMESFOBHFENPOUITPSPMEFSBENJOJTUFSPOMZEPTF
t 'PSPUIFSDBUDIVQJTTVFTTFF'JHVSF
Vaccination of persons with high-risk conditions:
t )JCWBDDJOFJTOPUSPVUJOFMZSFDPNNFOEFEGPSQBUJFOUTPMEFSUIBOZFBSTPGBHF)PXFWFSPOFEPTFPG)JCWBDDJOFTIPVMECFBENJOJTUFSFE
to unvaccinated or partially vaccinated persons aged 5 years or older who have leukemia, malignant neoplasms, anatomic or functional
asplenia (including sickle cell disease), human immunodeficiency virus (HIV) infection, or other immunocompromising conditions.
Pneumococcal conjugate vaccine (PCV). (Minimum age: 6 weeks)
Routine vaccination:
t "ENJOJTUFSBTFSJFTPG1$7WBDDJOFBUBHFTNPOUITXJUIBCPPTUFSBUBHFUISPVHINPOUIT
t 'PSDIJMESFOBHFEUISPVHINPOUITXIPIBWFSFDFJWFEBOBHFBQQSPQSJBUFTFSJFTPGWBMFOU1$71$7
BENJOJTUFSBTJOHMF
supplemental dose of 13-valent PCV (PCV13).
Catch-up vaccination:
t "ENJOJTUFSEPTFPG1$7UPBMMIFBMUIZDIJMESFOBHFEUISPVHINPOUITXIPBSFOPUDPNQMFUFMZWBDDJOBUFEGPSUIFJSBHF
t 'PSPUIFSDBUDIVQJTTVFTTFF'JHVSF
Vaccination of persons with high-risk conditions:
t 'PSDIJMESFOBHFEUISPVHINPOUITXJUIDFSUBJOVOEFSMZJOHNFEJDBMDPOEJUJPOTTFFGPPUOPUFD
BENJOJTUFSEPTFPG1$7JG
doses of PCV were received previously, or administer 2 doses of PCV13 at least 8 weeks apart if fewer than 3 doses of PCV were received
previously.
t "TJOHMFEPTFPG1$7NBZCFBENJOJTUFSFEUPQSFWJPVTMZVOWBDDJOBUFEDIJMESFOBHFEUISPVHIZFBSTXIPIBWFBOBUPNJDPSGVODUJPOBM
asplenia (including sickle cell disease), HIV infection or an immunocompromising condition, cochlear implant or cerebrospinal fluid leak.
See MMWR 2010;59 (No. RR-11), available at http://www.cdc.gov/mmwr/pdf/rr/rr5911.pdf.
t "ENJOJTUFS1147BUMFBTUXFFLTBGUFSUIFMBTUEPTFPG1$7UPDIJMESFOBHFEZFBSTPSPMEFSXJUIDFSUBJOVOEFSMZJOHNFEJDBMDPOEJUJPOT
(see footnotes 6b and 6c).
Pneumococcal polysaccharide vaccine (PPSV23). (Minimum age: 2 years)
Vaccination of persons with high-risk conditions:
t "ENJOJTUFS1147BUMFBTUXFFLTBGUFSUIFMBTUEPTFPG1$7UPDIJMESFOBHFEZFBSTPSPMEFSXJUIDFSUBJOVOEFSMZJOHNFEJDBMDPOEJUJPOT
(see footnote 6c). A single revaccination with PPSV should be administered after 5 years to children with anatomic or functional asplenia
(including sickle cell disease) or an immunocompromising condition.
Medical conditions for which PPSV23 is indicated in children aged 2 years and older and for which use of PCV13 is
indicated in children aged 24 through 71 months:
t *NNVOPDPNQFUFOUDIJMESFOXJUIDISPOJDIFBSUEJTFBTFQBSUJDVMBSMZDZBOPUJDDPOHFOJUBMIFBSUEJTFBTFBOEDBSEJBDGBJMVSF
DISPOJDMVOHEJTFBTF
(including asthma if treated with high-dose oral corticosteroid therapy), diabetes mellitus; cerebrospinal fluid leaks; or cochlear implant.
t 'PSBOZQFSTPOBHFEZFBSTBOEPMEFSXIPIBTOPUBMSFBEZSFDFJWFEUIF)FQ"WBDDJOFTFSJFTEPTFTPG)FQ"WBDDJOFTFQBSBUFECZUP
18 months may be administered if immunity against hepatitis A virus infection is desired.
Catch-up vaccination:
t 5IFNJOJNVNJOUFSWBMCFUXFFOUIFUXPEPTFTJTNPOUIT
Special populations:
t "ENJOJTUFSEPTFTPG)FQ"WBDDJOFBUMFBTUNPOUITBQBSUUPQSFWJPVTMZVOWBDDJOBUFEQFSTPOTXIPMJWFJOBSFBTXIFSFWBDDJOBUJPO
programs target older children, or who are at increased risk for infection.
12. Human papillomavirus (HPV) vaccines. (HPV4 [Gardasil] and HPV2 [Cervarix]). (Minimum age: 9 years)
Routine vaccination:
t "ENJOJTUFSBEPTFTFSJFTPG)17WBDDJOFPOBTDIFEVMFPGBOENPOUITUPBMMBEPMFTDFOUTBHFEZFBST&JUIFS)17PS)17
may be used for females, and only HPV4 may be used for males.
t 5IFWBDDJOFTFSJFTDBOCFTUBSUFECFHJOOJOHBUBHFZFBST
t "ENJOJTUFSUIFTFDPOEEPTFUPNPOUITBGUFSUIFfirst dose and the third dose 6 months after the first dose (at least 24 weeks after the
first dose).
Catch-up vaccination:
t "ENJOJTUFSUIFWBDDJOFTFSJFTUPGFNBMFTFJUIFS)17PS)17
BOENBMFT)17
BUBHFUISPVHIZFBSTJGOPUQSFWJPVTMZWBDDJOBUFE
t 6TFSFDPNNFOEFESPVUJOFEPTJOHJOUFSWBMTTFFBCPWF
GPSWBDDJOFTFSJFTDBUDIVQ
13. Meningococcal conjugate vaccines (MCV). (Minimum age: 6 weeks for Hib-MenCY, 9 months for Menactra [MCV4-D], 2
years for Menveo [MCV4-CRM]).
Routine vaccination:
t "ENJOJTUFS.$7WBDDJOFBUBHFoZFBSTXJUIBCPPTUFSEPTFBUBHFZFBST
t "EPMFTDFOUTBHFEUISPVHIZFBSTXJUIIVNBOJNNVOPEFöDJFODZWJSVT)*7
JOGFDUJPOTIPVMESFDFJWFBEPTFQSJNBSZTFSJFTPG.$7
with at least 8 weeks between doses. See MMWR 2011; 60:1018–1019 available at: http://www.cdc.gov/mmwr/pdf/wk/mm6030.pdf.
t 'PSDIJMESFOBHFENPOUITUISPVHIZFBSTXJUIIJHISJTLDPOEJUJPOTTFFCFMPX
Catch-up vaccination:
t "ENJOJTUFS.$7WBDDJOFBUBHFUISPVHIZFBSTJGOPUQSFWJPVTMZWBDDJOBUFE
t *GUIFöSTUEPTFJTBENJOJTUFSFEBUBHFUISPVHIZFBSTBCPPTUFSEPTFTIPVMECFBENJOJTUFSFEBUBHFUISPVHIZFBSTXJUIB
minimum interval of at least 8 weeks between doses.
t *GUIFöSTUEPTFJTBENJOJTUFSFEBUBHFZFBSTPSPMEFSBCPPTUFSEPTFJTOPUOFFEFE
t 'PSPUIFSDBUDIVQJTTVFTTFF'JHVSF
Vaccination of persons with high-risk conditions:
t 'PSDIJMESFOZPVOHFSUIBONPOUITPGBHFXJUIBOBUPNJDPSGVODUJPOBMBTQMFOJBJODMVEJOHTJDLMFDFMMEJTFBTF
BENJOJTUFSBOJOGBOU
series of Hib-MenCY at 2, 4, 6, and 12-15 months.
t 'PSDIJMESFOBHFEUISPVHINPOUITXJUIQFSTJTUFOUDPNQMFNFOUDPNQPOFOUEFöDJFODZBENJOJTUFSFJUIFSBOJOGBOUTFSJFTPG)JC.FO$:
at 2, 4, 6, and 12 through 15 months or a 2-dose primary series of MCV4-D starting at 9 months, with at least 8 weeks between doses.
'PSDIJMESFOBHFEUISPVHINPOUITXJUIQFSTJTUFOUDPNQMFNFOUDPNQPOFOUEFöDJFODZXIPIBWFOPUSFDFJWFEBDPNQMFUFTFSJFT
of Hib-MenCY or MCV4-D, administer 2 primary doses of MCV4-D at least 8 weeks apart.
t 'PSDIJMESFOBHFENPOUITBOEPMEFSXJUIQFSTJTUFOUDPNQMFNFOUDPNQPOFOUEFöDJFODZPSBOBUPNJDPSGVODUJPOBMBTQMFOJBJODMVEJOH
sickle cell disease), who have not received a complete series of Hib-MenCY or MCV4-D, administer 2 primary doses of either MCV4-D
or MCV4-CRM. If MCV4-D (Menactra) is administered to a child with asplenia (including sickle cell disease), do not administer MCV4-D
until 2 years of age and at least 4 weeks after the completion of all PCV13 doses. See MMWR 2011;60:1391–2, available at http://www.
cdc.gov/mmwr/pdf/wk/mm6040.pdf.
t 'PSDIJMESFOBHFENPOUITBOEPMEFSXIPBSFSFTJEFOUTPGPSUSBWFMFSTUPDPVOUSJFTJOUIF"GSJDBONFOJOHJUJTCFMUPSUPUIF)BKKBENJOJTUFS
an age appropriate formulation and series of MCV4 for protection against serogroups A and W-135. Prior receipt of Hib-MenCY is not
sufficient for children traveling to the meningitis belt or the Hajj. See MMWR 2011;60:1391–2, available at http://www.cdc.gov/mmwr/
pdf/wk/mm6040.pdf.
t 'PSDIJMESFOXIPBSFQSFTFOUEVSJOHPVUCSFBLTDBVTFECZBWBDDJOFTFSPHSPVQBENJOJTUFSPSDPNQMFUFBOBHFBOEGPSNVMBUJPOBQQSPQSJBUF
series of Hib-MenCY or MCV4.
t 'PSCPPTUFSEPTFTBNPOHQFSTPOTXJUIIJHISJTLDPOEJUJPOTSFGFSUPhttp://www.cdc.gov/vaccines/pubs/acip-list.htm#mening.
1.
5.
6a.
6b.
6c.
Additional information
t 'PSDPOUSBJOEJDBUJPOTBOEQSFDBVUJPOTUPVTFPGBWBDDJOFBOEGPSBEEJUJPOBMJOGPSNBUJPOSFHBSEJOHUIBUWBDDJOFWBDDJOBUJPOQSPWJEFST
should consult the relevant ACIP statement available online at http://www.cdc.gov/vaccines/pubs/acip-list.htm.
t 'PSUIFQVSQPTFTPGDBMDVMBUJOHJOUFSWBMTCFUXFFOEPTFTXFFLTEBZT*OUFSWBMTPGNPOUITPSHSFBUFSBSFEFUFSNJOFECZDBMFOEBS
months.
t *OGPSNBUJPOPOUSBWFMWBDDJOFSFRVJSFNFOUTBOESFDPNNFOEBUJPOTJTBWBJMBCMFBUhttp://wwwnc.cdc.gov/travel/page/vaccinations.htm.
t 'PSWBDDJOBUJPOPGQFSTPOTXJUIQSJNBSZBOETFDPOEBSZJNNVOPEFöDJFODJFTTFF5BCMFi7BDDJOBUJPOPGQFSTPOTXJUIQSJNBSZBOE
secondary immunodeficiencies,”in General Recommendations on Immunization (ACIP), available at http://www.cdc.gov/mmwr/preview/
mmwrhtml/rr6002a1.htm; and American Academy of Pediatrics. Passive immunization. In: Pickering LK, Baker CJ, Kimberlin DW, Long
44FET3FECPPLSFQPSUPGUIF$PNNJUUFFPO*OGFDUJPVT%JTFBTFTUIFE&ML(SPWF7JMMBHF*-"NFSJDBO"DBEFNZPG1FEJBUSJDT
FIGURE 3. Catch-up immunization schedule for persons aged 4 months through 18 years who start late or who are more than 1 month behind —
#)O:!!-O!:)!:!!:)'^:!!
does not need to be restarted, regardless of the time that has elapsed between doses. Use the section appropriate for the child’s age. Always use this table in
conjunction with the accompanying childhood and adolescent immunization schedules (Figures 1 and 2) and their respective footnotes.
Persons aged 4 months through 6 years
Minimum Age
for Dose 1
Vaccine
Minimum Interval Between Doses
Dose 1 to dose 2
Dose 2 to dose 3
Hepatitis B
Birth
4 weeks
Rotavirus1
6 weeks
4 weeks
4 weeks1
Diphtheria, tetanus, pertussis2
6 weeks
4 weeks
4 weeks
4 weeks
6 weeks
Dose 4 to dose 5
6 months
6 months2
4 weeks3
if current age is younger than 12 months
type b3
Dose 3 to dose 4
8 weeks
3
!
administered at younger than age 12 months and second
dose administered at younger than 15 months
No further doses needed
No further doses needed
This dose only necessary
for children aged 12
months through 59 months
who received 3 doses
before age 12 months
if previous dose administered at age 15 months or older
4 weeks
4 weeks
if current age is younger than 12 months
!
Pneumococcal4
6 weeks
!
!
age 24 through 59 months
if current age is 12 months or older
No further doses needed
No further doses needed
for healthy children if previous dose administered at
age 24 months or older
!
age 24 months or older
Inactivated poliovirus5
Meningococcal6
7
6 weeks
4 weeks
9 months
8 weeks6
Measles, mumps, rubella
12 months
4 weeks
Varicella8
12 months
3 months
Hepatitis A
12 months
6 months
4 weeks
This dose only necessary
for children aged 12
months through 59 months
who received 3 doses
before age 12 months or
for children at high risk
who received 3 doses at
any age
6 months5
minimum age 4 years for
Persons aged 7 through 18 years
4 weeks
Tetanus, diphtheria/ tetanus,
diphtheria, pertussis9
7 years9
Human papillomavirus10
9 years
4 weeks
6 months
Routine dosing intervals are recommended10
Hepatitis A
12 months
6 months
Hepatitis B
Birth
4 weeks
6 weeks
4 weeks
4 weeks5
Inactivated poliovirus5
6
Meningococcal
9 months
Measles, mumps, rubella7
12 months
6 months
younger than
age 12 months
8 weeks
6 months5
6
8 weeks
4 weeks
3 months
Varicella8
12 months
if person is younger than age 13 years
4 weeks
if person is aged 13 years or older
1.
2.
3.
4.
Rotavirus (RV) vaccines (RV-1 [Rotarix] and RV-5 [Rota Teq]).
" #$
%
%&'(!!)
initiated for infants aged 15 weeks, 0 days or older.
" *+(-
!%
indicated.
Diphtheria and tetanus toxoids and acellular pertussis (DTaP) vaccine.
" #!
years or older.
type b (Hib) conjugate vaccine.
" Hib vaccine should be considered for unvaccinated persons aged 5 years or
:!!%%!!:
(HIV) infection, or anatomic/functional asplenia.
" *>+>-?@>>:$C*EF:$
%
be administered at age 12 through 15 months and at least 8 weeks after the
second dose.
" *G
%
!
months.
Pneumococcal vaccines. (Minimum age: 6 weeks for pneumococcal conjugate
:!!K>F(LO!!!O!!:!!K>>Q(L
" For children aged 24 through 71 months with underlying medical conditions,
administer 1 dose of PCV if 3 doses of PCV were received previously, or
administer 2 doses of PCV at least 8 weeks apart if fewer than 3 doses of
PCV were received previously.
" A single dose of PCV may be administered to certain children aged 6 through 18
!!'Q-O!!!'
" Administer PPSV to children aged 2 years or older with certain underlying
medical conditions. See MMWR 2010:59(No. RR-11), available at http://
www.cdc.gov/mmwr/pdf/rr/rr5911.pdf.
5.
Inactivated poliovirus vaccine (IPV).
" A fourth dose is not necessary if the third dose was administered at age 4
years or older and at least 6 months after the previous dose.
" *%:
recommended if the person is at risk for imminent exposure to circulating
poliovirus (i.e., travel to a polio-endemic region or during an outbreak).
" IPV is not routinely recommended for U.S. residents aged 18 years or older.
6. Meningococcal conjugate vaccines, quadrivalent (MCV4). (Minimum age:
Z@!K@F(-[L@:K@F(-F+@L
" See Figure 1 (“Recommended immunization schedule for persons aged 0
through 6 years”) and Figure 2 (“Recommended immunization schedule for
persons aged 7 through 18 years”) for further guidance.
7. Measles, mumps, and rubella (MMR) vaccine.
" Administer the second dose routinely at age 4 through 6 years.
8. Varicella (VAR) vaccine.
" Administer the second dose routinely at age 4 through 6 years. If the
!%!)
accepted as valid.
9. Tetanus and diphtheria toxoids (Td) and tetanus and diphtheria toxoids
and acellular pertussis (Tdap) vaccines.
" For children aged 7 through 10 years who are not fully immunized with the
childhood DTaP vaccine series, Tdap vaccine should be substituted for
#:!!!!-O
needed, use Td vaccine. For these children, an adolescent Tdap vaccine
dose should not be given.
" An inadvertent dose of DTaP vaccine administered to children aged 7
through 10 years can count as part of the catch-up series. This dose can
count as the adolescent Tdap dose, or the child can later receive a Tdap
booster dose at age 11–12 years.
10. Human papillomavirus (HPV) vaccines (HPV4 [Gardasil] and HPV2 [Cervarix]).
" Administer the vaccine series to females (either HPV2 or HPV4) and males
(HPV4) at age 13 through 18 years if patient is not previously vaccinated.
" \!::!!!!-O]
2 (“Recommended immunization schedule for persons aged 7 through 18 years”).
F!!:::!!)O(!!^:_:+OQ(^_+Qhttp://www.vaers.hhs.gov) or by
telephone (800-822-7967). Suspected cases of vaccine-preventable diseases should be reported to the state or local health department. Additional information, including precautions and
contraindications for vaccination, is available from CDC online (http://www.cdc.gov/vaccines) or by telephone (800-CDC-INFO [800-232-4636]).
Post Natal Depression (PND) Prevention Program Guideline
Adopted: Feb. 2005 Revised: Feb. 2007 Reviewed: June 2011
Physician Contact: Dr. Virginia Maxanne Flores, M.D.
During the postpartum period, between 30 and 85% of women will experience symptoms of depression. These are usually
limited to the “baby blues” and can be treated with education and reassurance. However, 13 to 18% of women will develop
major depression. These women require specific treatment for depression.
I. Screening
A. Recommend that all women be routinely assessed during the antenatal period for a history of depression or other mental health
history.
B. Patients should be screened for the symptoms of depression in the postnatal period as a part of a screening program for PND.
II. Management
A. PND should be managed in the same way as depression at any other time, but with additional considerations regarding the use of
antidepressants when breast-feeding and in pregnancy. (See Scott & White Health Plan (SWHP) Tier 2 Clinical Practice Guideline
“Pharmacological Management of Major Depressive Disorder, Non-Psychotic.”)
B. Psychosocial interventions should be considered when deciding on treatment options for a mother diagnosed as suffering from
PND.
Note: Patients with bipolar or psychotic symptoms should be referred to Psychiatry. Also suicidal patients should be evaluated for
admission, as well as patients who express fears of hurting their baby.
III. Prescribing
A. Establish a clear indication for drug treatment.
B. Use treatments in the lowest effective dose.
C. Drugs with a better evidence base (generally more established drugs) are preferable.
D. Assess the benefit/risk ratio of the illness and treatment for both mother and baby/fetus, including consideration of:
2X increased risk of congenital heart defects with paroxetine
30% risk of neonatal abstinence syndrome after Selective Serotonin Reuptake Inhibitors (SSRI) exposure in late
pregnancy
6X increased risk to neonate of persistent pulmonary hypertension with SSRI exposure after 20 weeks
E. The risks of stopping tricyclic or SSRI antidepressant medication should be carefully assessed in relation to the mother’s mental
state and previous history. There is no indication to stop tricyclic or SSRI antidepressant medication (EXCEPT PAROXETINE) as a
matter of routine in early pregnancy.
F.
There is no clinical indication for women treated with TCA’s, paroxetine, sertraline, or fluoxetine to stop breast feeding, provided the
infant is healthy and its progress monitored. Other modern antidepressants are probably also safe during lactation.
Antidepressant Drug information:
Rating for use in
Adverse effects on breast-fed infants
Medication
Dosage range (mg per day)+
pregnancy *
(NA=Information not available)
Selective Serotonin reuptake
inhibitors (SSRI)
fluoxetine (Prozac)
C
Gastrointestinal effects, irritability, insomnia
20-40
paroxetine (Paxil)
D
NA
20 to 50
sertraline (Zoloft)
C
None
50-200
citalopram (Celexa)
C
Somnolence, decreased feeding, weight loss
20 to 60
escitalopram (Lexapro)
C
NA
10 to 20
Tricyclics (tertiary)
amitryptyline (Elavil)
C
None
75 to 300
imipramine (Tofranil)
D
None
75 to 300
Tricyclics (secondary)
desipramine (Norpramin)
C
None
75 to 300
nortriptyline (Pamelor)
D
None
25-150
protriptyline (Vivactil)
C
NA
15-60
Miscellaneous
Bupropion (Wellbutrin)
C
None
200-450
mirtazapine (Remeron)
C
NA
15 to 45
trazodone (Desyrel)
C
NA
150 to 600
venlafaxine (Effexor XR)
C
NA
75 to 225
Duloxetine (Cymbalta)
C
NA
40-60
*--U.S. Food and Drug Administration drug rating for use of drugs in pregnancy: A=No risk in controlled human studies B=no evidence of risk to fetus; C=risk to
fetus cannot be ruled out; D=evidence of risk to human fetus; + Adult daily dosages are adapted from AHCPR and women may need lower daily dosages.
Guideline based on Recommendations of the Royal College of Physicians, Scotland; US Preventive Health Task Force; and other expert recommendations from
the American Academy of Family Physicians. Scott and White Physicians from Dept. of Psychiatry, OB-GYN, and Family Medicine participated in the
development and review of this guideline. 2007 reviewed by OB-GYN and Family Medicine physicians of the Scott and White Health Plan Prenatal Team. 2009
reviewed by OB-GYN and Family Medicine physicians of the SWHP Prenatal Team, as well as Dept. of Psychiatry, Scott & White Clinics and Health Integrated, Inc.
OB-GYN Postpartum Dictation Reminder
Demographics:
?"9(@1?
Name of Primary Care Physician:
Chief Complaint:
Allergies:
Subjective or History of Presenting Illness:
0(
1
A
A("
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9(9&
(
&(" 0%&
B
!
6
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6
" Evaluation of Mood: " "( '/
%((
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Medications-;% &>
Past Medical History
Family Medical History
Objective:
Vital Signs:66%CD
General:"%
Physical:
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% Assessment
Plan
Courtesy Copy Postpartum Visit note to primary care
physicians that have no access to the electronic record.
Scott & White Health Plan Prenatal / Perinatal Guidelines for Normal Pregnancy
Tier 2 Guideline
Purpose: To recommend prenatal / perinatal management of uncomplicated pregnancy
Patient Population: Uncomplicated Pregnancy patients
Originally Developed / Endorsed by: SWMH Obstetrics Quality Assurance Committee Adopted: Dec. 16, 1998 Contact Physician: Dr. Richard Jones
Revised Dates: Feb. 1999; March 1999; Dec. 2000; Feb. 2001; April 2003; Feb. 2005; Feb. 2007; Feb. 2009; Dec. 2011; July 2013 Date to be reviewed:
: Dec.
: 2015
Frequency of visits and care rendered should be determined by a woman’s individual needs and risk factors.
SERVICES
Obstetrical
Evaluations
FIRST TRIMESTER
(WEEKS 0 to 13)
An initial evaluation should be performed
prior to 13 weeks including:
- Comprehensive health history, including
previous history of depression and/or
postpartum depression*
- Family & Social history
- Pregnancy history
- Genetics screening and counseling about
testing options, including information about
optional aneuploidy, cystic fibrosis, and
hemoglobinopathy screening
- Physical exam, including height, weight, &
blood pressure
- Ultrasonography to confirm or establish
gestational dating if indicated
- Screening for gestational diabetes if patient
is at high risk (and repeat late 2nd TM if
negative during first TM)
- advise ideal weight gain in pregnancy for
patient’s BMI
- Psychosocial screening
- Tobacco cessation mgmt plan if indicated
SECOND TRIMESTER
(WEEKS 14 to 28)
-Between 16 to 19 weeks:
Ultrasonography (if clinically indicated)
-Between 15 to 18 weeks: perform
maternal serum screening for aneuploidy
and/or neural tube defect if desired.
-Between 24 to 28 weeks: glucose
tolerance screening (unless no risk
factors), and hematocrit.
THIRD TRIMESTER
(WEEKS 29 to 42)
POSTPARTUM
(3 to 8 WEEKS AFTER
DELIVERY)
At 35-37 weeks gestational age: vaginal
culture for Group B streptococcus and
HIV test.
Administer Tdap vaccine during 3rd TM
(regardless of patient’s prior
vaccination history).
-At 28 weeks: If patient is Rh negative
and unsensitized, and Rh of baby’s father
is positive or unknown, repeat antibody
testing and administer Rhogam. Testing
urine at 28 weeks or as needed.
-Lab work to be obtained and reviewed by early second trimester: urine culture,
hemogram, platelets (optional), blood type & Rh, antibody screen, hepatitis B surface
antigen, rubella titer, syphilis screening, cervical cytology, hemoglobinopathy screening (if
indicated), gonorrhea & chlamydia screening (unless considered extremely low risk), and
HIV testing (offered with counseling & explanation of possible consequences and benefits)
-Multiparous patients do not require repeat rubella titer if previously documented as
immune, or repeat blood type & Rh.
Routine Office
Visits
Every 4 to 6 weeks: Blood pressure, weight, screen for significant edema, fundal height,
documentation of fetal heart activity (after approximately 10 weeks), and urine dipstick for
albumin and glucose.
All women who will be pregnant during the influenza season (Oct – May) should be
vaccinated, regardless of trimester.
Every 2 to 4 weeks until 36 weeks
gestation, then weekly until delivery:
-Blood pressure, weight, screen for
significant edema, fundal height,
documentation of fetal heart activity
and fetal presentation, urine dipstick for
Follow-up on or between 21
and 56 days after delivery:
-Evaluation of weight, blood
pressure, breasts, abdomen and
a pelvic exam.
-Screening for postpartum
Patient Education
Information
Presented
Regarding:
-Nutrition, exercise, sexual activity, work
activity
-Tobacco, alcohol, and drug restriction
-Postpartum Depression
-Preparation for childbirth (Refer to
classes)
-Vaginal Birth After Cesarean
(if indicated by patient’s history)
-Breast feeding versus bottle-feeding
-Family Planning
*See also the Post Natal Depression Prevention Program Guideline
Resources: Schedule is based on recommendations from: American College of Obstetricians and Gynecologists (ACOG)
albumin and glucose
depression.*
-Breast feeding
-Onset of labor, rupture of
membranes, abnormal bleeding
-Fetal activity
-Nutrition and exercise
-Review Family Planning
anticipatory guidance
Colorectal Cancer Screening
Tier 2 Guideline
Purpose: To delineate screening for colorectal cancer.
Patient Population:
Low Risk – Age < 50 or > 83 with no major co-morbidities, risk factors, non-operative candidate, or
life expectancy < 3 years.
2. Average Risk – Age 50 to 80 with no risk factors.
3. High Risk - First degree relative < 70 with colon cancer, first degree relative < 60 with polyps, two first
degree relatives with polyps and/or colon cancer, familial multiple cancer syndrome, or longstanding
inflammatory bowel disease.
1.
Developed by: Physicians representative of the S&W Departments: Gastroenterology, Family Medicine,
Internal Medicine and Surgery .
Source: American Cancer Society, American College of Gastroenterology (ACG); American
Gastroenterological Association (AGA) and the American Society of Gastrointestinal
Endoscopy (ASGE).
Contact Person: Dr Andrejs Avots-Avotins (Department of Medicine, Division of Gastroenterology).
SWHP Quality Improvement Committee Approved: June 1999.
Date of Last Review: June 2004, August 2004, August 2006, August 2008, August 2010, and
August 2012
Scheduled Review Date: August 2016
INITIATION OF SCREENING AND SUBSEQUENT SURVEILLANCE EXAMS IN
PATIENTS WITH INCREASED RISK
First degree relative with polyps < age 60 or colon cancer < age 70
Colonoscopy at age 50 or 10 years younger than the youngest affected family member,
whichever is earlier. Colonoscopy to be performed at 5 year intervals.
Hereditary Non-Polyposis Colorectal Cancer Syndrome - HNPCC
Colonoscopy beginning at age 25 or 5 years younger than the age at diagnosis of the youngest affected
relative, whichever is earlier. Colonoscopy to be performed every 2 years and then annually after age 40.
Genetic testing available.
Familial Adenomatous Polyposis - FAP
Annual sigmoidoscopy beginning at age 10-12 years with colectomy when polyps identified.
After age 40 sigmoidoscopy every 3-5 yrs if polyps have not been identified. Genetic testing
available.
Pancolonic inflammatory bowel disease
Surveillance begins after 10 years of disease duration with colonoscopy every 2 years with systematic
biopsies to detect dysplasia.
Left sided or segmental colitis
Surveillance begins after 15 years of disease duration with colonoscopy every 2 years with systematic
biopsies to detect dysplasia.
Page 1 of 2
Colorectal Cancer Screening
NO SCREENING
• Age < 50 & no
risk factors
• Age > 80 with moderate
of severe co-morbidities or
age 83-86 with no major
co-morbidities
•Non-operative
candidate
• Life expectancy < 3yrs
NOTE
Patients with fe def anemia
or patients with NON-anal
outlet bleeding
be referred for GI
consultation
AVERAGE RISK
• Age >50 & no risk factors
Colonoscopy q 10 yr
or
Flex Sig and BE q 5 yr
or
**FIT q 1 yr + Flex Sig q 5
yr
or
Flex Sig q 5 yr
or
**FIT q 1 yr
(**Fecal Immunochemical Testing
(FIT)
3 card specimen)
Significant
Findings:
Polyp > 0.5cm
or ANY + FOBT
HIGH RISK
st
• 1 degree relative < 70 with
colon cancer
• 1st Degree Relative < 60 with polyps
• Two 1st degree relatives with polyps
and/or colon cancer
• Familial multiple cancer syndrome
• Longstanding inflammatory bowel
disease
Complete Colon Exam
Colonoscopy beginning at age 50
or 10 yr younger than the youngest
affected family member
OR FOR
Longstanding inflammatory bowel diseaseColonoscopy beginning 10 yr after disease
onset
Colorectal Cancer Surveillance
LOW RISK
No polyps or hyperplastic
rectosigmoid polyps on last
surveillance colonoscopy
INCREASED RISK
• High risk family history of colon cancer or polyps with
previously negative colonoscopy > 4 years ago
• Multiple polyps (3 or more regardless of size)
• Polyp > 1cm
• CA in situ or low risk Duke’s A cancer in pedunculated polyp
• Hx of colon cancer (assuming negative colonoscopy within
12 mo of cancer resection)
• Serrated adenoma of any site
NO Screening for 5 yr then
AVERAGE RISK - usually 10
year follow-up unless
other risk factors present
COLONOSCOPY warranted: Interval from last
colonoscopybe determined by endoscopist (usually 1-5 years)
References: Guidelines for Colonoscopy Surveillance After Screening and Polypectomy: A Consensus Update by the US
Multi-Society Task Force on Colorectal Cancer Gastroenterology 2012;143-844-857. And - Colorectal Cancer Screening Be
Considered in Elderly Persons without Previous Screening? A Cost Effectiveness Analysis Annals Int Med 2014-160 (11):
750-759 - possibly with hyperlinks.
Page 2 of 2
CLINICAL PRACTICE GUIDELINES FOR COLORECTAL CANCER SCREENING
Scott and White Health Plan (SWHP) has adopted American Cancer Society Guidelines for the Early
Detection of Cancer located at the following internet website link:
http://www.cancer.org/docroot/PED/content/PED_2_3X_ACS_Cancer_Detection_Guidelines_36.asp
and
American Society for Gastrointestinal Endoscopy (ASGE) guideline: colorectal cancer screening and
surveillance, Gastrointestinal Endoscopy Volume 63, No. 4 ; 2006 located at the following internet
website link:
http://www.asge.org/WorkArea/showcontent.aspx?id=3334
and
American College of Gastroenterology Guidelines for Colorectal Cancer Screening 2008 located
at the following internet website link:
http://www.acg.gi.org/physicians/pdfs/CCSJournalPublicationFebruary2009.pdf
SWHP Guideline Approval Body: SWHP Quality Improvement Subcommittee
Date of Adoption: August 10, 2010
Physician Sponsor:
Dr. Andrejs Avots-Avotins, M.D., Scott & White Healthcare
Department of Medicine, Division of Gastroenterology.
Board Certification American Board of Internal Medicine, (ABIM) and
Gastroenterology, (ABIM)