PRACTICE
GUIDELINES
GUIDELINE
ISSUED: APRIL 1998
UPDATE: FEBRUARY 2000
CLINICAL
PRACTICE GUIDELINE for
MANAGEMENT of DIABETES MELLITUS
ENDORSED
BY:
CHIEFS OF
ENDOCRINOLOGY
CHIEFS OF
MEDICINE
INTRODUCTION
This is an update of the
Clinical Practice Guidelines
for the Management of Diabetes Mellitus
intended to incorporate the
results of clinical trials
that have been published since the April 1998
release of the guideline.
Additional
issues important to the management of
diabetes
mellitus are thoroughly discussed in
the April 1998 guideline.
These include: management of
type I diabetes, patient education and
behavior change, psychosocial
issues, nutrition, physical
activity, aspirin prophylaxis, lower
extremity complications,
adverse outcomes of pregnancy,
and psychiatric complications. For more
detailed information see the
Kaiser Permanente Northern
California Clinical Practice Guidelines
for the management of Diabetes
Mellitus, April 1998.
Key
points
* Glycemic control, regardless of the way it is
achieved,
will reduce microvascular
complications
in patients with
type 2 diabetes. The therapeutic
goal for glycemic control is a
HbAlc of < 7.0%.
*Monotherapy and
combination drug therapies have
changed (both standard and optional
therapies).
* Blood pressure (BP) control
reduces macrovascular and
microvascular morbidity and
mortality.
The target blood
pressure should be < 130/85
mm Hg for all patients with diabetes
mellitus. If there are early
signs of nephropathy, the
patient with diabetes should have a target
BP of 125/75 mm Hg or lower,
if tolerated.
*
Hyperlipidemia is a common
comorbidity associated with
diabetes. For a given level of
cholesterol, patients with
diabetes have a much greater
frequency of cardiovascular events;
therefore, aggressive therapy
of diabetic dyslipidemia
is indicated.
Goals:
LDL < 100 mg/dL
with vascular disease; LDL
< 130 mg/dL no vascular disease:
HDL > 50 mg/dL;
triglycerides < 200 mg/dL.
SCREENING
& DIAGNOSIS
A
fasting plasma glucose (no food or beverage for
at least
8 hours prior to the test) remains the test
of choice for diagnosing
diabetes mellitus. While glycosylated
hemoglobin (HbAlc) has proven to
be a very valuable tool for
monitoring treatment, further
studies continue to discourage its use for
screening or diagnosis. This
is due to both the lack
of standardization as well as poor
reproducibility in healthy
adult populations. One meta-analysis
concluded that a HbAlc level of
7 % or higher (or > 1 %
above upper limit assay) has
sufficiently high sensitivity for identifying
diabetes that requires
treatment. Unfortunately, at this
level, cases of impaired fasting glucose
(IFG) or impaired glucose
tolerance (IGT), as well as
some cases of diabetes will be missed.
The
prevalence of IGT and type 2 diabetes in women
with
polycystic ovarian syndrome (PCOS)
is substantially higher than
expected when compared with
age and weight matched populations of
women without PCOS. There is
also a higher conversion
from IGT or IFG to type 2 diabetes each
year. It is estimated that 35%
of PCOS patients have
IGT, and 10% will be diagnosed with diabetes
before reaching the fourth
decade. Therefore, this group
of women should be included as a high-risk
group that is appropriate for
diabetes screening. Blood
pressure and lipids should be aggressively
managed in this group.
Recommendations
* Screening for type I diabetes, outside of a
research
environment, is not recommended.
Community screening
in the general population for
type 2 diabetes is not recommended
due to its low yield.
* Screening of high-risk
groups for type 2 diabetes is
reasonable based on current
evidence.
The major risk
factors for type 2 diabetes
are
<>
Obesity
(>120% of desired
body weight or a BMI
>27 kg/m)
0
<>A first degree
relative with diabetes
<>
African-American, Hispanic, Native American, Pacific
Islander
<>
Delivery of a
baby > 9 pounds or a previousdiagnosis
of gestational diabetes
<>
Hypertension
(³140/90
mm Hg)
<>
HDL-C
£ 35 mg/dL
or a triglyceride >250mg/dL
<> History of
impaired glucose tolerance (IGT) or
impaired fasting glucose (IFG)
<> Women with
polycystic ovarian syndrome (PCOS)
The
available data are currently insufficient to
make
an evidence-based recommendation
concerning optimal screening
intervals among high-risk
groups; however, it is the consensus
of the Diabetes Guidelines
Team that annual screening
by fasting blood glucose level of
patients with a history of
gestational diabetes, IGT,
and PCOS should be done.
For
additional information on screening and
diagnosis,
see pages 5-6 in the Kaiser Permanente
Northern California Clinical
Practice Guidelines for
the Management of Diabetes Mellitus,
April 1998.
MANAGEMENT OF
TYPE 2 DIABETES
Glycemic Control
The
United Kingdom Prospective Diabetes Study
(UKPDS)
evaluated 3867 patients with
newly diagnosed type 2
diabetes over 10 years. Tighter
glucose control with insulin,
metformin or sulfonylureas was
compared to conventional
treatment. Average HbAlc over
10 years was 7% in the
intensively treated group and
7.9% in the conventionally treated group.
Despite this minimal
difference, there were fewer microvascular
complications and a trend
towards
reduced macrovascular
diabetes complications
in the intensively treated patients.
HIGHLIGHTS
OF THE UKPDS
*Type
2 diabetes is
progressive and additional oral medication
and/or insulin are likely
needed
to maintain adequate
glycemic control.
*No
advantage or disadvantage was observed with
any particular
agent in attaining
glycemic
control.
* Obese patients taking metformin had
fewer diabetes-related
complications along with less
weight gain and fewer
hypoglycemic episodes.
Mortality
and stroke in these
obese patients were decreased
in the intensive therapy group
who received metformin. For
these reasons, it is the
consensus of the Diabetes Guideline
Team that metformin
is the drug of choice in most
overweight type 2 diabetes patients
without
contraindications (e.g., heart failure, renal
or hepatic insufficiency, or
hypoxic states).
*
Even small decreases in average blood glucose
resulted
in decreased microvascular
complications.
GLYCEMIC CONTROL MEASURES
The recommendation of the
Diabetes Guideline Team is
that the therapeutic goal for glycemic
control is < 7.0% (see
table below) based on the results
of the UKPDS and the recommendation
of the American Diabetes
Association. However, at this
point, this value differs from the goals set
for glycemic control using the
Quality Indicators for
the APC Population Management Diabetes
Management Program and for
HEDIS. The Quality Indicators
for the APC Diabetes Management
Program measures good control
as HbAlc < 8.0 and fair
control as HbAlc < 10.0%
(in 2001, HbAlc <
9.5%). In contrast, HEDIS
does not have a measure for good glycemic
control, but does set a
measure for poorly controlled
diabetes as HbAlc of >9.5%.
CLINICAL
CONSIDERATIONS
*
After a new drug is initiated or when the dosage of
a medication is adjusted, follow up
(e.g.,
by telephone appointment visit [TAV]) with the
patient. Ask about glycemic control
and
hvpoglycemic symptoms.
*
Consider one of the following if glycemic
control is
suboptimal or unstable before
concluding that drug therapy
has failed:
<>
Occult
infections (e.g., urinary tract infections)
<> New onset
endocrinopathy (e.g., hyper- or hypothyroidism,
Cushing's Syndrome,
adrenal
insufficiency)
<>
Overeating to
compensate for hypoglycemia
<>
Dosing
intervals and dosages may need adjusting
regularly, using self-monitoring
of blood glucose as well as
symptom monitoring.
*
When adding an insulin sensitizer (e.g.,
metformin or
thiazolidinediones), watch for
hypoglycemia. Reducing the
dose of insulin or sulfonylurea
is a desired effect of adding
the insulin sensitizers.
Warning patients of hypoglycemia
and having an action plan can
improve compliance.
SELF-MONITORING
OF BLOOD GLUCOSE (SMBG)
Frequency
and timing of SMBG
in Type I and Type 2 patients
should be a collaborative
decision between the provider
and the patient, based
on the patient's individual needs, intensity
of management and goals of
treatment plan to help patient
adjust therapy.
The
frequency of testing should be adjusted to
both motivate
patients and enhance their
glycemic
control and
lifestyle. Patients who do not adjust
their insulin dosage based on their
blood glucose readings may not
benefit from as frequent
testing.
Suggested minimal frequency and timing of SMBG in
diabetes
can be viewed online in the
Regional
Diabetes Mellitus CPG
section on the Kaiser
Permanente Northern California intranet
website at http://cl.kp.org
IMMUNIZATIONS
INFLUENZA - all patients with
diabetes should be immunized
for influenza annually, if no
contraindications exist.
PNEUMOCOCCAL VACCINE - current
CDC recommendations are
*All
people with
diabetes above the age of two
should be immunized with pneumococcal
vaccine.
* Revaccinate patients
³
65 years of age, if the person received his/her first vaccination
before age 65 and if more than
5 years have elapsed since
the first dose.
MEDICATION
FOOTNOTES
'Sulfonylureas
Sulfonylurcas
remain a cost
effective and successful
treatment for many Type 2 diabetes
patients. The UKPDS has
alienated concerns about long-term
cardiovascular safety. Sulfonylureas
have been used in combination
therapies with synergistic
effects on blood glucose lowering.
2Biguanides
Metformin
(Glucophage®)
continues to be the only drug in this class currently available in the
United States. A subgroup of
overweight diabetes patients
in the UKPDS treated with metformin had
fewer macrovascular
complications, and its use was associated
with less weight gain and fewer
hypoglycemic attacks. For
these reasons, it is the consensus
of the Diabetes Guideline Team that
metformin is the drug of
choice in most overweight Type
2 diabetes patients without
contraindications
(e.g., heart
failure, renal or hepatic
insufficient or hypoxic states).
3Insulin
Protocols for insulin
adiustment can be viewed online
in the Regional Diabetes Mellitus CPG
section on the Kaiser
Permanente Northern California
intranet website at http://cl.kp.org
Lispro
insulin (Humalog®)
is designed for very rapid release and shorter duration of action. This
insulin can be useful in
multi-dose regimens to provide
more intensive control of blood sugar with
less hypoglycemia.
4Thiazolidinediones
Two new medications in this
class have recently been
released in the United States - rosiglitazone
(Avandia®,
non-formulary) and pioglitazone (Actos®).
Both appear to have a better safety
profile than troglitazone
(Rezulin®,
non-formulary), with similar effectiveness. The new
medications currently require
bimonthly monitoring of
liver function for the first year, and
periodic monitoring
thereafter. Rosiglitazone is dosed
at 4 and 8 mg daily, while pioglitazone is
dosed at 15,30, and 43 mg
daily. It may take 4 - 6 weeks
before a glycemic effect is seen. Expect some
weight gain and volume
expansion with these medications.
Allow one week "washout" when
switching from troglitazone to
the newer medications.
5Alpha-Glucosidase
Inhibitors
Two preparations
are currently
available in the United
States - acarbose (Precose®,
non-
formulary)
and miglitol
(Glyset®).
The two medications are similar in action, effectiveness,
and side effects. However,
miglitol has near-complete
absorption after oral doses, and is
excreted unchanged in the
urine. In clinical trials,
miglitol was not associated with elevations in
serum transaminase levels.
Unlike acarbose, routine monitoring
of liver enzymes is not
recommended
with miglitol
therapy. Although there has
been some suggestion for avoidance of
miglitol in renal
insufficiency, no systemic toxicity
has been demonstrated. However, avoid using
miglitol or acarbose if serum
creatinine > 2.0 mg/dL.
There are more drug interactions with
miglitol than with acarbose.
The consensus of the Guideline
Team is that these drugs should not be
used as first-line therapy.
They should be considered
for the subgroup of patients with high
postprandial glucose levels.
6Repaglinide
(non-formulary)
Repaglinide
(Prandin®)
lowers blood glucose levels by stimulating the release of insulin from
the pancreas in patients with
Type 2 diabetes. Repaglinide
is taken before meals to lower the
postprandial increase in blood
glucose. The consensus
of the Guideline Team is that this drug
should not to be used as first
line therapy. It should
be considered for the subgroup of patients with
high postprandial glucose
levels or those who have genuine
sulfonylurea allergies.
Medication
tables can be viewed online in the
Regional
Diabetes Mellitus CPG section on the
Kaiser Permanente Northern
California intranet website
at http://cl.kp.org
PREVENTION AND
TREATMENT OF COMPLICATIONS
Beneficial Effects of ACE Inhibitors
ACE
inhibitors decrease
mortality in post-MI patients
and heart failure patients.
Retinopathy
and nephropathy
may be delayed. Recent evidence
in the HOPE study
suggests
that the ACE
inhibitor, ramipril, has beneficial
effects on cardiovascular
endpoints
in patients with
diabetes who are over the
age of 55. Current evidence is still
insufficient to recommend
universal use of these agents
in patients with diabetes.
Hypertension
Blood pressure
control reduces macrovascular and microvascular
morbidity and
mortality in patients with diabetes.
Hypertension
markedly increases the risk of
macrovascular
complications (MI, stroke,
and
peripheral vascular
disease) and microvascular complications
(retinopathy
and
nephropathy) in patients
with diabetes. Prompt and
continuous control of blood
pressure
decreases the risk of
these complications. The
target blood pressure
should
be < 130/85 mm
Hg for all patients with diabetes
mellitus. If there are early
signs of nephropathy
(albumin/creatinine ratio > 30 mcg/mg
Cr), the patient with
diabetes
should have a target
BP of 125/75 mm Hg or lower,
if tolerated.
In
the Hypertension Optimal Treatment (HOT) study,
patients
were randomized to
one
of three groups (diastolic
BP <80 or <85or<90mmHg).
A long-acting
calcium
channel blocker was
used as initial therapy:
beta-blockers, ACE inhibitors and
diuretics were added as
needed. Cardiovascular events
and mortality were
decreased
with lower blood
pressure in patients with
diabetes, with further
improvements
in patients with
target diastolic blood
pressure < 80 mm Hg.
Decreases
in cardiovascular
events and mortality were
proportional to reductions in
diastolic blood pressure.
The
United Kingdom Prospective Diabetes Study
(UKPDS)
showed that tight control of
BP (144/82) with either
captopril or atenolol reduced
the risk of heart failure by
56%, stroke by 44%, and death
from diabetes by 32% compared
to patients with BP
154/87.
The risk of renal
damage and progression of retinopathy
also was
decreased
by improved BP
control. Previous studies (SHEP
and HDS) had shown
improvements
in outcome with
diuretics as first-line
treatment.
With reduction of macrovascular and microvascular
complications
of Type 2
diabetes as the goal,
it appears that lowering the
blood pressure is more
important than the
choice of antihypertensive medication
used.
For
additional
information on the treatment of hypertension
in patients with diabetes, see
pages 28 - 29 in the
Kaiser Permanente Northern California
Clinical Practice
Guidelines for the
Management of Diabetes Mellitus,
April 1998 and page 5 in the Kaiser
Permanente Northern
California Clinical Practice Guideline
for Screening, Evaluation
and Management of
Adult Hypertension, January-1999.
Lipids
Hyperlipidemia is a
common comorbidity associated
with diabetes. For a given level
of cholesterol,
patients with diabetes have a much
greater frequency of cardiovascular
events: therefore,
aggressive therapy of diabetic
dyslipidemia is indicated.
A common abnormal lipid
pattern in Type 2 diabetes is
increased triglyceride/very-low-density
lipoprotein (VLDL), decreased
HDL, and an LDL fraction
that contains a greater
proportion
of small, dense
atherogenic LDL particles.
Initial therapy for all diabetes
patients, regardless of lipid
levels, should include
a low-fat, low-cholesterol diet,
regular physical activity, and
optimal glycemic control.
Initial
drug therapy for the majority of people
with
diabetes and hyperlipidemia
is a HMG CoA
reductase inhibitor [e.g., lovastatin
(Mevacor®), simvastatin
(Zocor®)].
Higher doses or combination therapy may be needed to achieve goals.
With these changes,
additional monitoring for side
effects (e.g., rhabdomyolysis) is
needed.
Drug
therapy should be directed first at lowering
LDL.
For diabetes patients with pre-
existing vascular disease, the
goal is to
reduceLDL to < 100 mg/dL. For diabetes
patients without
known vascular disease, the
goal
for LDL is < 130
mg/dL. Some experts recommend
that all patients with diabetes
have an LDL < 100
because of their risk for increased
cardiovascular events, especially
those with additional risk
factors such as tobacco use,
hypertension, or
microalbuminuria.
Further
reductions of LDL below 100
lead to reduction of
atherosclerotic
plaque.
Isolated low HDLs (< 50) also
should be treated aggressively.
For
additional information on the treatment of
hyperlipidemia
in diabetes, see pages 30 -
31
in the Kaiser Pemianente
Northern California Clinical
Practice Guidelines for
the
Management of Diabetes
Mellitus, April 1998. and
page 12 in the Kaiser Permanente
Northern California Clinical
Practice Guidelines for
Adult Cholesterol
Management,
November 1998.
Peripheral
Neuropathy
Control of pain in
diabetic
peripheral neuropathy continues
to be challenging. A
recent
randomized control
trial showed that gabapenlin
(Neurontin®) (titrated
from
900 to 3600
mg/day or maximum
tolerated dosage) appeared
to be efficacious. Limiting
side
effects included
dizziness, somnolence, abdominal
pain, and memory loss.
Gabapentin
is not FDA approved
for this use.
A
separate Veterans Administration Hospital study
concluded
that gabapentin may be an
alternative
for treating
diabetic peripheral neuropathy
pain, yet does not appear to
offer considerable advantage
over amitriptyline and is
more expensive.
Autonomic
Neuropathy
GASTROINTESTINAL MANIFESTATIONS
Dietary
modifications include
reductions in fat (<40
gm) and fiber. Four to six small
meals are recommended. The use
of agents that may slow
gastric emptying such as
calcium
channel blockers,
tricyclic antidepressants,
anticholinergic agents
should
be minimized.
Optimization of glucose control
will further improve gastric
motility.
Prokinetic
agents include erythromycin,
metoclopromide,
or cisapride. Intravenous
metoclopramide
(Reglan®)
10 mg IV qid for up to 10 days or erythromycin (3 mg/kg
IV q8 hours) may be used for
patients who cannot tolerate
oral medications.
Cisapride
(Propulsid®)
10-20 mg po may be used 30 minutes before each meal and at
bedtime. Important changes
have been made in the cisapride
labeling. These
changes
include
recommendations for performing diagnostic
tests prior to any use
of cisapride. There have been
continuing reports of heart
rhythm disorders and deaths
associated
mostly in people
who are either taking certain
other medications or who
have
certain underlying
conditions that are known risk
factors. Review the new
information
prior to starting
cisapride. Domperidone
remains investigational.
MALE
IMPOTENCE
Sildenafil
(Viagra®),
a type 5 phosphodiesterase inhibitor, is effective in
50-60%
of diabetic males with erectile dysfunction. The
medication should be
ingested
approximately one hour before intended intercourse.
The most common
side
effects include headache, flushing, rhinitis, dyspepsia
and altered vision. Side
effects
are typically mild and transient. Sildenafil
is absolutely contraindicated for
men
receiving any forms of nitrates. Relative contraindications
include patients
with
CVA, MI, or life threatening arrhythmia within the
prior six months, resting
hypotension
(< 90/50), hypertension (> 170/110), CHF,
unstable angina, or
retinitis
pigmentosa. Patients who are physically
inactive with multiple
cardiovascular
risk factors may be appropriate candidates
for non invasive CAD
screening
prior to prescribing sildenafil.
A
starting dose of 50 mg is appropriate for most
patients
and can be increased to 100
mg
if the drug is ineffective.
However, patients using
inhibitors of P450
cytochrome
system (cimetidine,
erythromycin, ketoconazole,
itraconazole)
or
protease inhibitors should
begin with a 25 mg dose.
Likewise, patients older than
65 years or with hepatic or
severe renal disease should
begin with the 25 mg dose.
Because
of comparable or superior efficacy and
ease of
use, sildenafil can be considered
the pharmacologic treatment of
choice for patients with
erectile dysfunction.
For
additional information on peripheral and
autonomic
neuropathies, see pages 34 -
37 in the KP Northern
California Clinical Practice Guidelines
for the Management of
Diabetes
Mellitus, April 1998.
Nephropathy
There are adequate data that
ACE inhibitors, calcium
channel blockers, and angiotensin-
II blockers can reduce the
amount of microalbuminuria,
but only ACE inhibitors
have
been shown to slow or
halt the progression of renal
disease. Therefore, ACE
inhibitors
should be the first
line choice, and if intolerance
develops to one drug,
other
ACE inhibitors should be
tried first.
Ideally, screening microalbumin is best done on a
first
void morning urine (to avoid the
effect of physical activity).
If there is an albumin/creatinine
ratio > 30 mcg/mg Cr,
a urinalysis should be
obtained to rule out pyuria or
hematuria. These should be
treated
first. Tight glycemic
control and treatment of
hypertension, if present, should
be initiated. Repeat urine
microalbumin within 3 - 6
months is recommended before
initiating ACE inhibitor
treatment for confirmed microalbuminuria.
Data
are still insufficient in this area to advise
on
titration of ACE inhibitor dosage
in normotensive patients with
microalbuminuria. The value
of following
microalbuminuria
once therapy
is established has not
been determined in the
literature.
However, some
experts believe that tight
glycemic control and treatment of
hypertension improve
microalbumin; and, therefore following
microalbuminuria once
therapy
has been established
may be appropriate.
For
additional information on nephropathy, see
pages 33
- 34 in the Kaiser Permanente
Northern California Clinical
Practice Guidelines for
the Management of Diabetes
Mellitus,
April 1998.
SELECTED
REFERENCES
GENERAL
American Diabetes
Association:
Clinical Practice Recommendations
1999. Diabetes Care
1999;22(suppl
l):SI-Sll4.
Kaiser Permanente Care Management
Institute. CMI
Diabetes
Guidelines 1999.
DIAGNOSIS/SCREENING
Ehrmann DA, Bames RB,
Rosenfield RL, et al.
Prevalence
of impaired glucose
tolerance and diabetes
in women with polycystic ovary
syndrome. Diabetes Care
1999:22:141-146.
Kilpatrick
ES, Maylor PW, Keevil BG. Biological
variation
of glycated hemoglobin: implications
for diabetes screening and
monitoring. Diabetes Care
1998:21:261-264.
Peters
AL, Davidson MB, Schriger DL, et al. A
clinical
approach for the diagnosis of diabetes mellitus:
an analysis using glycosylated
hemoglobin levels. JAMA
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UK
PROSPECTIVE DIABETES STUDY (UKPDS)
TRIALS
UK Prospective
Diabetes Study
(UKPDS) Group.
Intensive
blood glucose
control with sulfonylureas or
insulin compared with
conventional
treatment and
risk of complications in patients
with Type 2 diabetes
(UKPDS
33).Lancet
1998;352:832-853.
UKPDS
Group. Effect of intensive blood-glucose
control
with metformin on complications in overweight
patients with type 2 diabetes
(UKPDS 34). Lancet 1998;352:854-65.
UKPDS
Group. Tight blood pressure control and risk
of
macrovascular and microvascular complications
in type 2 diabetes: UKPDS 38.
Brit Med J. 1998;317:703-712.
UKPDS
Group. Efficacy of atenolol and captopril in
reducing
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microvascular
complications in
tvpe 2 diabetes:UKPDS
38. Brit Med J. 1998;317:713-720.
UKPDS
Group. Cost effectiveness analysis of
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40. Brit Med J. 1998;317:720-726.
ACE
INHIBITORS
The
Heart Outcomes Prevention
Evaluation (HOPE)
Study
Investigators. Effects
of an angiotensin-
converting-enzyme
inhibitor,
ramipril, on death
from
cardiovascular causes,
myocardial
infarction,
and stroke in
high-risk patients.
NEngljMed
2000:342:145-53.
UPDATE ON TWO
DRUGS MENTIONED IN GUIDEUNE:
1. Trogirtazone (Rezulin) has been withdrawn
from the market (3/21/2000).
2. Cisapride (Propulsid) is available only through a
limited-access program (7/14/2000).
HYPERTENSION
Hansson L, Zanchetti A,
Camithers SG, et al. Effects
of intensive blood-pressure lowering and low-dose
aspirin in patients with
hypertension: principal results
of the Hypertension Optimal Treatment (HOT)
randomised trial. Lancet
1998;351:1755-62.
LIPIDS
Downs JR, Clearfield M, Weis
S, et al. Primary prevention
of acute coronary events with lovastatin in men and
women with average cholesterol
levels: results of AFW\PS/TexCAPS.JAMA
1998;279:1615-22.
Haffner
S. Management of
dyslipidemia in adults with
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PNEUMOCOCCAL
VACCINE
American Diabetes
Association:
Clinical Practice Recommendations
2000. Diabetes Care 2000;23
(suppi
1):S91-S93.
Prevention
of pneumococcal
disease: recommendations of
the Advisory Committee on Immunization Practices
(ACIP).MMWR 1997:46;1-24.
PERIPHERAL
NEUROPATHY
Backonja M,
Beydoun A, Edwards
KR et al. Gabapentin for
the symptomatic treatment of painful neuropathy in
patients with diabetes
mellitus: a randomized controlled
trial.JAMA 1998;250:1831-1836.
Morello
CM, Leckband SG, Stoner CP et al.
Randomized double-blind
study comparing the efficacy of
gabapentin with amitriptyline
on diabetic peripheral
neuropathv pain.Arch Intern Med 999;159:1931-
1937.
AUTONOMIC
NEUROPATHY
Koch KL. Diabetic
gastropathy:
gastric neuromuscular
dysfunction in diabetes mellitus: a review of
symptoms, pathophysiology, and
treatment. Dig Dis Sci
1999;44:106l-75.
Kong
MF. Horowitz M. Gastric emptying in diabetes
mellitus;
relationship to blood-glucose control.
Clinical Geriatric Medicine
1999;15:321-38.
Patterson
D, Abell T, Rothstein R, et al. A
double-blind
multicenter comparison of domperidone and
metoclopramide in the
treatment of diabetic patients
with svmptoms of gastroparesis. Am J Gastroenterol
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SILDENAFIL
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ACKNOWLEDGMENTS
Clinical Leader
Barbara
Livermore, MD;
Endocrinology, Sacramento
Guideline Team
Bill Caplan, MD,
Endocrinology, Martinez
Richard
Kanter, MD,
Endocrinology, San Francisco
Jerry Minkoff, MD,
Endocrinology, Santa Rosa
Project
Management
Julie Lenhart,
RPh, MS; TPMG
Department of Quality &
Utilization
David
St. Pieire, MHROD; TPMG
Department of Quality &
Utilization
Data
Analysis
Ralph Vogel, PhD,
TPMG
Department of Quality and Utilization
Patricia Kipnis, PhD, TPMG
Department of Quality and
Utilization
Reviewers
Robert Alloo, MD; Medicine,
Santa Clara/Campbell
Antonis
Antoniou, MD;
Medicine, Fresno
Tim
Corfman, MD; Medicine,
Walnut Creek
John
Tamor Citron; MD,
Endocrinology, Walnut Creek
Rick
Diott. MD; Endocrinology,
Martinez
Laurie
Doyle, MPH; Regional
Health Education
Bruce
Ettinger, MD; Division
of Research
Paul
Feigenbaum, MD; Medicine,
San Francisco
Robert
Goldfien, MD; Medicine,
Richmond
Fred
Horn, MD; Endocrinology,
Fremont
Mare
Jaffe, MD; Endocrinology,
South San Francisco
Pamela
Kershner, MD;
Endocrinology, Walnut Creek
Kevin
Kobalter, MD;
Endocrinology, San Rafael
Pansy
Kwong, MD; Medicine,
Oakland
Nancy
Moline, RN, MEd, CDE;
Regional Health Education
Elia
Racah, MD; Medicine, Park
Shadelands
Craig
Sadur, MD;
Endocrinology, Pleasanton
Edgar
Schoen, MD;
Genetics/Pediatrics, Oakland
Craig Smith, MD; Medicine,
South Sacramento
John
Takakuwa, MD; Medicine,
Rancho Cordova
David
Williams, MD; Medicine,
Vallejo
Jeannie
Tip, MD; Medicine,
Oakland
Editing
& Graphic Design
Linda
Bine; TPMG Communications
Gail
Holan; Curvey Graphic
Design
CONTACT
INFORMATION
Kaiser
Permanente Northern California TPMG Department
of Quality and Utilization
1800
Harrison Street, 4th Floor
Oakland.
CA 94612
510-987-2950
or tie-line 8-427-2950
To
obtain more information about KPRC Clinical Practice
Guidelines, printed copies.
or
permission to reproduce any portion, please contact
the TPMG Dept. of Quality &
Utilization,
or send an e-mail message to clinical .guidelines@kp.
org
KPNC
Clinical Practice Guidelines can be viewed on-line
on the Kaiser Permanente
Northern
California intranet at http://cl.kp.org
This
website is accessible only from the Kaiser Permanente
computer network.
Disclaimer
The
Permanente Medical Group (TPMG) Clinical Practice
Guidelines have been
developed
to assist clinicians by providing an analytical
framework for the evaluation and
treatment
of selected common problems encountered in
patients. These guidelines are
not
intended to establish a protocol for all patients
with a particular condition. While
the
guidelines provide one approach to evaluating a problem,
clinical conditions
may
vary significantly from individual to individual.
Therefore, the clinician must
exercise
independent judgment and make decisions based
upon the situation presented.
While
great care has been taken to assure the accuracy
of the information presented, the
reader
is advised that TPMG cannot be responsible for
continued currency of the
information,
for any errors or omissions in this guidelines,
or for any consequences
arising
from its use.
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