**CA Guidelines

Breast q2 years 40-74. NO SBE or beyond 10 years life expenctancy..

Cervical q3 years 21+ regardless of sexual hx. 30 yo choice q3 years or cytology + HPV
q5 years, stop at age 65 if neg.
Colorectal 50-75 through FOBT or FIT yearly, sigmoidoscopy q5 years, FOBT or FIT +
sigmoidoscopy q5 years, or colonoscopy q 10 years
o Cologuard new DNA stool test need more studies
o Stop if life expectancy < 10 years
Ovarian CA 125. Dont screen
Prostate 50-69, discuss 1st

**Depression
Rx and nonpharm and St. Johns Wort equally effectiveDepressed mood/lost of
pleasure, change in wt or appetite, insomnia or hypersomnia, psychomotor agitation or
retardation, fatigue/loss of energy, feelings of worthlessness or excessive guilt,
indecisiveness or decreased concentration, death/SI
Dysthymia less severe, 2+ years
Acute (6-12 wks, continuation (4-9 mos), maintenance (1+ yr)
Psychotherapy
o acceptance and commitment therapy overcome negative thoughts and accept
difficulties
o cognitive therapy correct false self-beliefs and neg thoughts
o CBT activity scheduling, HW
o Interpersonal therapy relationships and how to address them
o Psychodynamic therapy conscious and unconscious feelings and past
experiences
o Third-wave CBT targets thought processes to help with awareness and
acceptance
CAM (complementary and alternative medicine acupuncture, meditation, w-3 fatty
acids, SAMe, St. Johns Wort, yoga), exercise
SGA 2nd gen antidepressants ADRs constipation, diarrhea, dizziness, h/a, insomnia,
nausea, sexual adverse events, somnolence
St. Johns Wort ADRs GI sx, dizziness/confusion, fatigue/sedation, skin rxn, dry mouth,
cytochrome p450 and dec fx OCP and immunosuppressants, NOT with MAO or SSRI,
better tolerated than SGAs but not regulated by USFDA
Buproprion les sexual adverse fx
Citalopram incc QT prolongation and torsades if >40mg/day
Fluoxetine least discontinuation syndrome
Paroxetine worst for sexual dysfunction, wt gain, d/c syndrome
Sertraline higher diarrhea
Venlafaxine higher n/v

**DM
 Lifestyle Therapy
o Nutrition optimal wt, plant-based diet, high polyunsaturated and
monounsaturated fatty acids, avoid trans and limit saturated, counseling
o Physical Activity 150min/wk moderate exertion and strength training, med
clearance
o Sleep 7 hrs/night, OSA screen, home sleep study and refer if needed
o Behaiorial Support moderate ETOH, behaviorial therapy
o Smoking Cessation quit, replace, structured program
Wt Mgmt
o Lifestyle
o Medical Tx if BMI > 27 phentermine, orlistat, lorcaserin,
phentermine/topiramate ER, naltrexone/buproprion, liraglutide 3 mg
o Surgical Tx BMI > 35
Pre-DM Algorithm FPG > 100, 2-hour PG > 140
o Tx low risk meds Metformin and Acarbose
o Caution with TZD and GLP-1 RA if fail the above
ASCVD RF Algorithm
o If TG > 500 try statin therapy like fibrates, omega-3, niacin
o If statin intolerant, lower dose/freq or add non-statin, repeat lipid panel
o Goals High Risk DM <40, Very High DM + ASCVD (HTN, FHx, low HDL, smoker,
CKD 3/4), Extreme DM + Clinical CVD
LDL - < 100, 70, 55. Tx statin, ezetimibe, PCK9i, colesevelam, niacin. If
Familial Hypercholesterolemia tx statin + PCSK9i
Non-HDL - <130, 100, 80. Tx statin and/or omega 3, fibrate, or niacin
TG - < 150. Tx statin and/or omega 3, fibrate, and/or niacin
Apo B - <90, 80, 70. Tx statin and/or ezetimibe, PCSK9i, colesevelam,
and/or niacin
o HTN Mgmt Goal < 130/80
If initial BP > 150/100 Dual Tx ACEI/ARB + CCB, BB, or Thiazide
Not at goal 2-3 months add BB, CCB, Thiazide

Not at goal 2-3 Add A-Blockers, Aldosterone Antagonist, Central Agent,
Vasodilator
Glycemic Control Algorithm
o A1c < 6.5% - w/o serious illness, low risk
o A1c > 6.5% - serious illness, risk hypoglycemia
o Entry A1C < 7.5%
Monotherapy metformin, AGi, DPP-4i, GLP-1 RA, SGLT-2i, Caution
SU/GN and TZD
Not at goal in 3 months proceed to dual tx
o Entry A1C < 7.5%
Dual Therapy MET + AGi, Bromocriptine QR, Colesevalm, DPP-4i, GLP-1
RA, SGLT-2i, Caution Basal Insulin, SU/GN and TZD
Not at goal in 3 months proceed to triple tx
 Triple Therapy - MET + DOC + AGi, Bromocriptine QR, Colesevalm, DPP-4i,
GLP-1 RA, SGLT-2i, Caution Basal Insulin, SU/GN and TZD
Not at goal in 3 months proceed to intensified insulin therapy
o Entry A1C > 9.0%
No sx dual or triple tx
Sx Insulin + other
Insulin Algorithm
o Start Basal (Long-Acting) A1C <8% TDD 0.1-0.2 U/kg vs AIC >8% TDD 0.2-0.3 U/kg
q2-3 days to reach goal.
FBG > 180 +20% TDD
FBG 140-180 +10% TDD
FBG 110-139 +1 unit
FBG <70 -10-20%
FBG <40 -20-40%
Consider d/c or dec SU after starting Basal Insulin (Basal > NPH)
Goal < 7% most people, fasting and premeal <110
o Intensify (Prandial Control) if above fails
Add GLP-1 RA or SGLT-2i or DPP-4i
Add Prandial Insulin
Basal Plus 1, Plus 2, Plus 3 Start 10% basal dose or 5 units, Titrate
q2-3 days
o Prandial Insulin before largest meal
o Not at goal injections before 2-3 meals
Basal Bolus - Start 50% TDD in 3 doses before meals, Titrate q2-3
days
o Prandial Insulin before each meal
o 2-h postprandial or premeal > 140 +10%
o BG < 70 TDD basal and/or prandial 10-20%
o BG < 40 - TDD basal and/or prandial 20-40%
o Meds ADRs
AGi moderate GI
BCR-QR- moderate GI
COLSVL mild GI, benefit ASCVD
GLP-1 RA weight loss, CrCl < 30 NO exenatide, ?benefit liraglutide, ?CV
benefit
Insulin mod-sev hypoglycemia, wt gain, more CHF risk
Metformin slight wt loss, NO if eGFR <30, mod GI
PRAML wt loss, moderate GI sx
SGLT-2i reduce SBP, wt loss, NOT eGFR < 45, genital mycotic infections,
renal and cardiac benefits empagliflozin, canaglifozin bone warning, DKA
SU/GLN hypoglycemia, weight gain, CHF risk
TZD wt gain, moderate cardiac (HF) and fx risk
Wt loss metformin slight, GLP-1 RA, SGLT-2i, PRAML
Wt gain SU, TZD
**GERD

**Hematuria
Refer to urology if gross hematuria consider renal function testing, cystoscopy, and
imaging
o Refer to nephro if proteinuria, erythrocyte morphology, etc
If microscopically refer urology for cystoscopy
Confirm heme +dipstick with microscopic UA that shows 3+ erythrocytes
CA gross and painless
DDx infection, menses, recent urology procedures
RF M, >50, smoker hx, chemical/dye exposure, analgesic abuse, gross hematuria, uro
d/o, irritative voiding sx, pelvic irradiation, chronic UTI, carcinogenic agents/chemo,
chronic indwellining FB

**HTN
General
o > 60 BP goal <150/90
o < 60 BP goal < 140/90
DM or CKD
o All ages DM, CKD - < 140/90
o CDK initiate ACEI or ARB +/- additional
Nonblack DOC are ACEI, ARB, CCB, Thiazide
Black CCB, Thiazide
Tx dual therapy or combo pill if BP >20/10 above goal
Not at Goal in 1 Month
o Lifestyle DASH, no ETOH, Na <2400mg, mod-vigours exercise 3-4 days/wk for
40 min
o Titrate max or add ACEI, ARB, CCB, Thiazide
o Titrate max or add BB, Aldosterone Antagonist, others
o Titrate max or add another med and/or refer HTN specialist
Conditions
o Beta-1 Selective BB safer in COPD, asthma, DM, PVD are metoprolol,
bisoprolol, betaxolol, and acebutolol
o HF ACEI/ARB + BB + Diuretic + Spironolactone (K+ sparing diuretic)
o Post-MI or clinical CAD ACEI/ARB + BB
o CAD ACEI, BB, CCB, Diuretic
o DM ACEI, CCB, Diuretic
o CKD ACEI/ARB
o Recurrent Stroke Prevention ACEI, Diuretic
o Pregnancy Labetalol DOC, Nifedipine, Methyldopa
Meds
o ACEI/ARB
 ADR ACEI cough, ACEI angioedema, hyperkalemia
Losartan lowers uric acid
Candesartan prevents migraines
o BB
ADR fatigue, bradycardia, fx glucose mask hypoglycemic awareness
NOT DOC for post-MI and CHF

o CCB
ADR edema, Non-DHP reduce HR and proteinuria
DHP amlodipine, nifedipine
Non-DHP diltiazem, verapamil
o Centrally-Acting Agents Clonidine, Guanfacine
Resistant HTN Clonidine weekly patch
o Diuretics Chlorthalidone, Triamterene
ADR Hypokalemia, Sprinolactone gynecomastia and hyperkalemia
GFR < 40ml/min use Loop diuretics
Best with ACEI
o Vasodilator Hydralazine, Minoxidil, Terazodin, Doxazozin
ADR Hydralazine and Minoxidil reflex tachycardia and fluid retention
(may need diuretic + BB), Alpha-Blocker cause orthostatic hypotension

**Ischemic Heart Disease

Tx stop smoking, wt loss (<35cm F <40 M start 5-10% loss), physical activity (30-60 min
5 days/wk), diet, antiplatelet agents, lipid-lowerign agents (statins) and BB, ACEI esp if
LV dysfunction and DM. Tight glucose control doesnt really help
Guideline for Tx
o Angina > sublingual NTG -> BB (if no contraindications like prior MI or HF) vs
contraindications can add/sub CCB and/or long-acting nitrate vs ranolazine
If fail then revascularization coronary artery bypass graft if LAD > 50&
stenosis (dont do PCI if unfavorable anatomy for PCI) or >70% diameter
stenosis in 3 major coronary arteries or proximal LAD + other major
coronary artery or SCD >70%
o Do ASA daily. Contraindication then clopidogrel 75 mg daily or desensitization
o Mod-High dose statin, ADR or contraindication then add bile sequestrant or
niacin
o HTN and DM control
F/U ECHO
Exercise EKG if worsening or new sx with moderate physical functioning no disabling
comorbidity and interpretable EKG
Radionuclide myocardial perfusion imaging or ECHO if new/worse sx not consistent with
unstable angina + moderate physical function or no comorbidity and uninterpretable
EKG
 Stress imaging with radionuclide myocardial perfusion or ECHO if new/worse sx, no
moderate physical, disabling comorbidity

**NEPHROLITHIASIS
Inc fluids so UOP 2 L/day
Tx thiazide, citrate, or allopurinol to prevent. Lower doses monotherapy is best

**PELVIC EXAM FEMALE

Routine exam (bimanual and speculum) provides no benefit
Ovarian CA - No longer does bimanual pelvic exam bc doesnt help. CA-125 and
transvaginal U/S best
BV criteria thin homogenous, pH > 4.5, clue cells on microscope, amine odor after
adding a base

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Dm meds, htn, hld