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Philippine Clinical Practice Guidelines for the Diagnosis and Management of Type 2 Diabetes Mellitus
1. Philippine Practice Guidelines for the
Diagnosis & Management of
Type 2 Diabetes Mellitus
Iris Thiele Isip Tan MD, MSc, FPCP, FPSEM
Chief, Medical Informatics Unit
Associate Professor IV, UP College of Medicine
Adapted from the presentation of Dr. Cecilia Jimeno
Tuesday, April 23, 13
2. UNITE FOR DIABETES PHILIPPINES
Diabetes Philippines
Institute for Studies on Diabetes Foundation, Inc.
Philippine Society of Endocrinology & Metabolism
Philippine Center for Diabetes Education Foundation, Inc.
Tuesday, April 23, 13
3. Goals & Areas of
Collaboration
Establishment of a
national diabetes
database
Encourage best diabetes practices -
development of a unified CPG
Spearhead the fight
for patients’ rights &
safety - vigilance on
false claims
UNITE FOR DIABETES
PHILIPPINES
Tuesday, April 23, 13
4. Objectives for the
Clinical Practice
Guideline
UNITE FOR DIABETES
PHILIPPINES
To develop clinical practice guidelines on the
screening, diagnosis and management of diabetes
which reflect the current best evidence and
which incorporate local data into the
recommendations, in view of aiding clinical
decision making for the benefit of the
Filipino patient
GUIDELINES THAT ARE SUITED FOR LOCAL REALITIES
Tuesday, April 23, 13
5. Organizations in the Consensus Panel
Diabetes Philippines
Institute for Studies on Diabetes Foundation, Inc.
Philippine Society of Endocrinology & Metabolism
Philippine Center for Diabetes Education Foundation, Inc.
23 other specialty, subspecialty organizations
lay representatives of persons with diabetes
UNITE FOR DIABETES
PHILIPPINES
Tuesday, April 23, 13
6. Scope of the Philippine
CPG development
Outpatient
setting
Screening and diagnosis
Screening for complications
Prevention and treatment
Special groups: GDM, elderly
Tuesday, April 23, 13
8. UNITE PHILIPPINE CPG
FOR DIABETES MELLITUS
Statement 2.1
All individuals being seen at any physician’s
clinic or by any healthcare provider should be
evaluated annually for risk factors
for type 2 diabetes.
(Table 1) [Grade D, Level 5]
Tuesday, April 23, 13
9. UNITE PHILIPPINE CPG
FOR DIABETES MELLITUS
Statement 2.2
Universal screening using laboratory
tests is NOT recommended as it would
identify very few individuals who are at risk.
[Grade D, Level 5]
Tuesday, April 23, 13
10. UNITE PHILIPPINE CPG
FOR DIABETES MELLITUS
Table 1. Demographic and Clinical Risk Factors
for Type 2 Diabetes
Testing should be considered in all
adults >40 years old.
Tuesday, April 23, 13
11. UNITE PHILIPPINE CPG
FOR DIABETES MELLITUS
Consider earlier testing if with at least
one other risk factor as follows:
•history of IGT or IFG
•history of GDM or delivery of a baby weighing 8 lbs
or above
•polycystic ovary syndrome (PCOS)
•overweight (BMI >23 kg/m2
) or obese (BMI >25
kg/m2
)
•waist circumference >80 cm (♀) and >90 cm (♂)
or waist-hip ratio (WHR) >1 (♂) and >0.85 (♀)
Tuesday, April 23, 13
12. UNITE PHILIPPINE CPG
FOR DIABETES MELLITUS
Consider earlier testing if with at least one
other risk factor as follows (con’t):
•first-degree relative with type 2 diabetes
•sedentary lifestyle
•hypertension (BP >140/90 mm Hg)
•diagnosis or history of any vascular diseases including
stroke, peripheral arterial occlusive disease, coronary
artery disease
Tuesday, April 23, 13
13. UNITE PHILIPPINE CPG
FOR DIABETES MELLITUS
Consider earlier testing if with at least one
other risk factor as follows (con’t):
•acanthosis nigricans
•schizophrenia
•serum HDL <35 mg/dL (0.9 mmol/L) and/or
•serum triglycerides >250 mg/dL (2.82 mmol/L)
Tuesday, April 23, 13
14. Which of the following
will you NOT screen for diabetes?
a.42/F on follow-up for hypertension
b.35/M consulting for cough
c.45/M with tuberculosis
d.28/F diagnosed with PCOS
Tuesday, April 23, 13
15. Why 40?
Recommendation
from other guidelines
ADA
2010
CDA
2008
AACE
2007
IDF 2005
All >45 y (B)
Earlier if BMI
>25 kg/m2
and with >1
risk factor(s)
(B)
All > 40 y
Earlier if with
risk factors
>30 y with
risk factor
(B)
Target high
risk people
by risk
factor
assessment
Tuesday, April 23, 13
16. Why 40?
NNHeS 2008
Age (y)
Prevalence of Diabetes MellitusPrevalence of Diabetes MellitusPrevalence of Diabetes MellitusPrevalence of Diabetes Mellitus
Age (y) Based on
FBSa
Based on 2h
postprandial
glucose
Based on DM
questionnaire
True
Diabetes
20-29 0.4 0.4 0.5 0.9
30-39 3.2 1.1 1.4 3.8
40-49 5.7 3.9 4.2 8.2
50-59 9.0 5.0 8.1 13.0
60-69 9.1 5.9 9.5 15.9
>70 4.4 5.5 7.1 11.8
Overall 4.8 3.0 4.0 7.2
a Based on FBS >125 mg/dL
b Based on 2h-PPG > 200 mg/dL
c Based on DM questionnaire (previous diagnosis by nurse or physician or on medication)
d True diabetes (positive in any of the three assessment methods
Tuesday, April 23, 13
17. You screen the 42 y.o. hypertensive.
FBS is 5.2 mmol/L. What next?
a.Reassure patient she is not diabetic. There is
no need to repeat the test.
b.Repeat FBS after 1 year.
c.Order an OGTT after 6 months.
d.Ask for an HbA1c after 3 months.
Tuesday, April 23, 13
18. If initial test(s) are negative, when
should repeat testing be done?
Repeat testing should ideally be done
annually for Filipinos with risk factors owing to the
significant prevalence and burden of diabetes in our
country. (Level 5, Grade D)
Tuesday, April 23, 13
19. CANDI Manila
Fojas MC, Lantion-Ang FL, Jimeno CA, Santiago D, Arroyo M, Laurel A, Sy H, See J.
Complications and cardiovascular risk factors among newly-diagnosed type 2 diabetics in
Manila. Phil. J. Internal Medicine, 47: 99-105, May-June, 2009
Local study: newly-diagnosed diabetics in Manila
20% peripheral neuropathy
42% proteinuria
2% diabetic retinopathy
COMPLICATIONS FOUND AT DIAGNOSIS!
Tuesday, April 23, 13
20. UNITE PHILIPPINE CPG
FOR DIABETES MELLITUS
Recommended tests for diagnosing diabetes:
•Fasting plasma glucose (FPG) - 8-14 hours
•Random plasma glucose (RPG)
•2-h plasma glucose in 75-g OGTT
Tuesday, April 23, 13
21. UNITE PHILIPPINE CPG
FOR DIABETES MELLITUS
Criteria for diagnosis of diabetes (Level 2, Grade B)
•FPG >126 mg/dL (7.0 mmol/L)
•Random plasma glucose >200 mg/dL (11.1 mmol/L)
in a patient with classic symptoms of hyperglycemia
(weight loss, polyuria, polyphagia, polydipsia) or with signs
and symptoms of hyperglycemic crisis
•2-h plasma glucose in 75-g OGTT >200 mg/dL (11.1
mmol/L)
Tuesday, April 23, 13
22. UNITE PHILIPPINE CPG
FOR DIABETES MELLITUS
Fasting plasma glucose (FPG) is the preferred
test due to its wide availability, lower cost and
better reproducibility (Level 3, Grade B)
•If the FPG falls within the impaired fasting glucose
range (5.6-6.9 mmol/L) then a 75-g OGTT is
recommended (Level 3, Grade B)
•Symptomatic patients - random or FPG
Tuesday, April 23, 13
23. UNITE PHILIPPINE CPG
FOR DIABETES MELLITUS
Among asymptomatic individuals with positive
results, any of the three tests should be
repeated within two weeks for confirmation
(Level 4, Grade C).
Tuesday, April 23, 13
24. UNITE PHILIPPINE CPG
FOR DIABETES MELLITUS
Diabetes can be diagnosed when any of the
three tests are positive in a symptomatic
patient (weight loss, polyuria, polyphagia, polydipsia).
Tuesday, April 23, 13
25. UNITE PHILIPPINE CPG
FOR DIABETES MELLITUS
A 75-g OGTT is preferred as the first test for the
following (Level 3, Grade B):
•Previous FBS showing IFG 100-125 mg/dL (5.6-6.9
mmol/L)
•Previous diagnosis of CVD (CAD, stroke, peripheral
arteriovascular disease) or who are at high risk of CVD
•A diagnosis of Metabolic Syndrome
Tuesday, April 23, 13
26. UNITE PHILIPPINE CPG
FOR DIABETES MELLITUS
At the present time, we cannot recommend the
routine use of the following tests in the
diagnosis of diabetes (Level 3, Grade C):
•HbA1c
•Capillary blood glucose
•Fructosamine
•Urinalysis (Level 3, Grade B)
• Plasma insulin (Level 3, Grade B)
Tuesday, April 23, 13
27. UNITE PHILIPPINE CPG
FOR DIABETES MELLITUS
•HbA1c
•Capillary blood glucose
•Fructosamine
•Urinalysis
Interpret an available result with caution and
confirm with any of the three standard tests
(Level 2, Grade B).
Tuesday, April 23, 13
28. Why NOT Hba1C?
Until standardization has been done in the
Philippines, use HbA1c only as a tool for
monitoring control among those with
established DM.
•HbA1c not readily available in some areas
•NGSP certification not easily verified in laboratories
•Studies needed to determine effect of ethnicity
Tuesday, April 23, 13
29. You screen the 42 y.o. hypertensive.
FBS is 5.2 mmol/L. What next?
a.Reassure patient she is not diabetic. There is
no need to repeat the test.
b.Repeat FBS after 1 year.
c.Order an OGTT after 6 months.
d.Ask for an HbA1c after 3 months.
Tuesday, April 23, 13
30. Screen for risk factors for
DM, prediabetes and MetS
Algorithm for Screening Diabetes
Among Asymptomatic Individuals
Tuesday, April 23, 13
31. Screen for risk factors for
DM, prediabetes and MetS
Algorithm for Screening Diabetes
Among Asymptomatic Individuals
Risk factors
(Table 1)
YES
Tuesday, April 23, 13
32. Screen for risk factors for
DM, prediabetes and MetS
Algorithm for Screening Diabetes
Among Asymptomatic Individuals
Risk factors
(Table 1)
YES
Lab testing using FBS, RBS, OGTT (Fig 3)
YES
Tuesday, April 23, 13
33. Screen for risk factors for
DM, prediabetes and MetS
Algorithm for Screening Diabetes
Among Asymptomatic Individuals
Risk factors
(Table 1)
YES
Lab testing using FBS, RBS, OGTT (Fig 3)
YES
Age
>40 y
NO
YES
Tuesday, April 23, 13
34. Screen for risk factors for
DM, prediabetes and MetS
Algorithm for Screening Diabetes
Among Asymptomatic Individuals
Risk factors
(Table 1)
YES
Lab testing using FBS, RBS, OGTT (Fig 3)
YES
Age
>40 y
NO
YES
No further testing;
re-evaluate annually
for risk factors
NO
Tuesday, April 23, 13
35. Age >40 y
Age <40 y with risk factors for DM
No 3 P’s or weight loss
(asymptomatic)
No known CAD, PAD,
CVD, No MetS
Diagnosed CAD, PAD,
CVD or with MetS
Symptomatic (polyuria,
polydipsia, polyphagia,
weight loss)
Tuesday, April 23, 13
36. Age >40 y
Age <40 y with risk factors for DM
No 3 P’s or weight loss
(asymptomatic)
No known CAD, PAD,
CVD, No MetS
Diagnosed CAD, PAD,
CVD or with MetS
Symptomatic (polyuria,
polydipsia, polyphagia,
weight loss)
Fasting plasma
glucose
<100
mg/dL
100-125
mg/dL
>126
mg/dL
No
diabetes
Repeat
testing
after 1 y
75-g
OGTT
Diabetes
Tuesday, April 23, 13
37. Age >40 y
Age <40 y with risk factors for DM
No 3 P’s or weight loss
(asymptomatic)
No known CAD, PAD,
CVD, No MetS
Diagnosed CAD, PAD,
CVD or with MetS
Symptomatic (polyuria,
polydipsia, polyphagia,
weight loss)
Fasting plasma
glucose
<100
mg/dL
100-125
mg/dL
>126
mg/dL
No
diabetes
Repeat
testing
after 1 y
75-g
OGTT
Diabetes
75-g oral glucose
tolerance test
(OGTT)
FBS
<100 &
2h <140
mg/dL
FBS
100-125
or 2h
140-199
mg/dL
FBS
>126
mg/dL
or 2h
>200
No
diabetes
Repeat
testing
after 1 y
IFG or
IGT
Repeat
after 6
mos
Diabetes
Tuesday, April 23, 13
38. Age >40 y
Age <40 y with risk factors for DM
No 3 P’s or weight loss
(asymptomatic)
No known CAD, PAD,
CVD, No MetS
Diagnosed CAD, PAD,
CVD or with MetS
Symptomatic (polyuria,
polydipsia, polyphagia,
weight loss)
Fasting plasma
glucose
<100
mg/dL
100-125
mg/dL
>126
mg/dL
No
diabetes
Repeat
testing
after 1 y
75-g
OGTT
Diabetes
75-g oral glucose
tolerance test
(OGTT)
FBS
<100 &
2h <140
mg/dL
FBS
100-125
or 2h
140-199
mg/dL
FBS
>126
mg/dL
or 2h
>200
No
diabetes
Repeat
testing
after 1 y
IFG or
IGT
Repeat
after 6
mos
Diabetes
Random plasma
glucose
<140
mg/dL
140-199
mg/dL
>200
mg/dL
No
diabetes
Repeat
testing
after 1 y
75-g
OGTT
Diabetes
Tuesday, April 23, 13
40. UNITE PHILIPPINE CPG
FOR DIABETES MELLITUS
Initial evaluation - comprehensive medical history
and PE
•Coronary heart disease risk assessment
•Foot evaluation: assess risk for foot ulcer (identify
high-risk feet)
•Eye exam: fundoscopy on diagnosis
•Dental history or oral health history
Tuesday, April 23, 13
41. RED FLAGS
of dental disease
tooth ache
pain when chewing
sensitivity to
cold/hot drinks
badly broken teeth
swelling of gums
bad breath
Tuesday, April 23, 13
42. Prevalence among T2DM
68% (SLMC, n =192)
Bitong et al PJIM 2010
PERIODONTITIS
gum bleeding
on brushing
swelling and
redness of gums
looseness or
mobility of teeth
teeth that fall
off in adults
Tuesday, April 23, 13
43. Which of the following will you NOT request
as initial tests for a person with diabetes?
a.Fasting blood glucose, HbA1c
b.Complete lipid profile
c.Blood uric acid, 12-lead ECG
d.ALT, AST, serum creatinine
Tuesday, April 23, 13
44. UNITE PHILIPPINE CPG
FOR DIABETES MELLITUS
Minimal initial tests to be requested
• Fasting blood glucose, complete lipid profile
• HbA1c
• Liver function tests
• Urinalysis; spot urine albumin-to-creatinine ratio
• Serum creatinine and calculated GFR
Tuesday, April 23, 13
45. UNITE PHILIPPINE CPG
FOR DIABETES MELLITUS
Optional tests
• ECG and TET
• TSH in type 1 diabetes, dyslipidemia or women
over age 50 y
Tuesday, April 23, 13
46. Which of the following will you NOT request
as initial tests for a person with diabetes?
a.Fasting blood glucose, HbA1c
b.Complete lipid profile
c.Blood uric acid, 12-lead ECG
d.ALT, AST, serum creatinine
Tuesday, April 23, 13
47. Which of the following statements is true
about monitoring diabetes?
a. Monitor Hba1c ideally twice a year.
b. Check FBS and postprandial blood sugar
every 2-4 weeks.
c. Estimate trends in blood sugar control by
checking CBGs once a week.
d. Achieve glycemic goals within three months.
Tuesday, April 23, 13
49. Glycemic targets
Individualize targets.
FBS <6 mmol/L
2h PPG <8 mmol/L
Newly diagnosed
Relatively young (age <60 y)
No complications
No risk factors for hypoglycemia
HbA1c <6.5%
Tuesday, April 23, 13
50. Ideally, HbA1c every 3-6 months;
2x a year if controlled on stable therapy
FBS, postprandial sugar every 2-4 weeks
Capillary blood glucose
2x a week to estimate trends
Tuesday, April 23, 13
51. Glycemic targets should be
achieved within 6 months of
diagnosis or first prescription.
Tuesday, April 23, 13
52. Which of the following statements is true
about monitoring diabetes?
a. Monitor Hba1c ideally twice a year.
b.Check FBS and postprandial blood sugar
every 2-4 weeks.
c. Estimate trends in blood sugar control by
checking CBGs once a week.
d. Achieve glycemic goals within three months.
Tuesday, April 23, 13
54. Which of the following statements is true
about reducing CV risk in diabetes?
a. Statins should be given regardless of baseline
lipid levels.
b. There is insufficient evidence to recommend
aspirin for primary prevention in men <60 y.
c. Give clopidogrel 75 mg/day for those with
diabetes and a history of CVD.
d. The goal BP for most persons with diabetes is
<140/80 mm Hg.
Tuesday, April 23, 13
55. UNITE PHILIPPINE CPG
FOR DIABETES MELLITUS
The goal BP for most persons with diabetes is
<140/80 mm Hg.
•Lifestyle therapy alone for 3 months if
pre-hypertensive (SBP 130-139 mm Hg or
DBP 80-89 mm Hg)
•Pharmacologic + lifestyle therapy if SBP>140 mm Hg
or DBP >90 mm Hg, or pre-hypertensive uncontrolled
with lifestyle therapy alone
Tuesday, April 23, 13
56. Weight loss if overweight
DASH-style dietary pattern
(reduce Na, increase K,
moderation of alcohol,
increased physical activity).
Lifestyle therapy
Tuesday, April 23, 13
57. UNITE PHILIPPINE CPG
FOR DIABETES MELLITUS
Statement 7.3
ACE inhibitors & ARBs are generally recommended
as initial therapy. If one class is not tolerated,
the other should be substituted.
Multiple drug therapy (>2 agents at maximal
doses) is generally required to achieve BP targets.
Thiazide-type diuretics, calcium channel blockers and
B-blockers may be given as additional agents.
Tuesday, April 23, 13
58. UNITE PHILIPPINE CPG
FOR DIABETES MELLITUS
Recommendations are consistent with Philippine
Practice Guidelines for the Treatment of
Dyslipidemia.
•LDL is the primary target for dyslipidemia
management in persons with diabetes.
Tuesday, April 23, 13
59. UNITE PHILIPPINE CPG
FOR DIABETES MELLITUS
Statement 8.1.1
Statin therapy should be added to lifestyle
therapy, regardless of baseline levels for diabetics
•with overt CVD (A)
•without CVD who are >40 y and have >1more
other CVD risk factors (A)
Tuesday, April 23, 13
60. UNITE PHILIPPINE CPG
FOR DIABETES MELLITUS
Statement 8.1.2
For patients at lower risk (e.g. without overt
CVD and <40 y), statin therapy should be
considered in addition to lifestyle therapy if -
•LDL-C remains >100 mg/dL
•those with multiple risk factors (hypertension, familial
hypercholesterolemia, LVH, smoking, family history of premature CAD,
male sex, age >55 y, proteinuria, albuminuria, BMI>25)
Tuesday, April 23, 13
61. UNITE PHILIPPINE CPG
FOR DIABETES MELLITUS
The 100-70 rule
•Without overt CVD, goal is LDL-C <100 mg/
dL (2.6 mmol/L) [A]
•With overt CVD, goal is LDL-C <70 mg/dL
(1.8 mmol/L). Use of high dose statin is an
option. [B]
Tuesday, April 23, 13
62. UNITE PHILIPPINE CPG
FOR DIABETES MELLITUS
Recommendation 9.2
Insufficient evidence to recommend aspirin for
primary prevention in lower risk individuals
•Men < 50 y
•Women <60 y
* Clinical judgement if with multiple risk factors
Tuesday, April 23, 13
63. UNITE PHILIPPINE CPG
FOR DIABETES MELLITUS
Recommendation 9.3
Use aspirin therapy for secondary prevention
strategy in those with DM and a history of CVD
[A].
•For patients with CVD and documented aspirin
allergy, clopidogrel (75 mg/day) should be
used.
Tuesday, April 23, 13
64. UNITE PHILIPPINE CPG
FOR DIABETES MELLITUS
Recommendation 9.4
Combination therapy of ASA (75-162 mg/day)
and clopidogrel (75 mg/day) is reasonable up to
a year after an acute coronary syndrome [B].
Tuesday, April 23, 13
65. Which of the following statements is true
about reducing CV risk in diabetes?
a. Statins should be given regardless of baseline
lipid levels.
b. There is insufficient evidence to recommend
aspirin for primary prevention in men <60 y.
c. Give clopidogrel 75 mg/day for those with
diabetes and a history of CVD.
d.The goal BP for most persons with
diabetes is <140/80 mm Hg.
Tuesday, April 23, 13
67. Newly diagnosed T2DM
Initiation of Drug Therapy among Newly
Diagnosed Type 2 Diabetes Patients
HbA1c <9%
FBS < 250
HbA1c >9%
FBS > 250
Tuesday, April 23, 13
68. Newly diagnosed T2DM
Initiation of Drug Therapy among Newly
Diagnosed Type 2 Diabetes Patients
HbA1c <9%
FBS < 250
HbA1c >9%
FBS > 250
Mono-
therapy
Option for
combination
therapy
Tuesday, April 23, 13
69. Newly diagnosed T2DM
Initiation of Drug Therapy among Newly
Diagnosed Type 2 Diabetes Patients
HbA1c <9%
FBS < 250
HbA1c >9%
FBS > 250
Mono-
therapy
Option for
combination
therapy
Combination
therapy
Insulin
therapy
Tuesday, April 23, 13
70. UNITE PHILIPPINE CPG
FOR DIABETES MELLITUS
Statement 10.1
Initiate treatment with metformin for
monotherapy unless with contraindications or
intolerance of its ADE’s -
• diarrhea
• severe nausea
• abdominal pain
Tuesday, April 23, 13
71. UNITE PHILIPPINE CPG
FOR DIABETES MELLITUS
When optimization of therapy is needed, choose
the second drug according to the following -
•degree of HbA1c lowering
•hypoglycemia risk
•weight gain
•patient profile (dosing complexity, renal/hepatic
problems, other contraindications and age)
Tuesday, April 23, 13
72. Adapted from AACE Diabetes Mellitus Guidelines Endocr Pract 2007
Drug Therapy HbA1c reduction (%)
MONOTHERAPYMONOTHERAPY
Sulfonylureas 0.9 to 2.5
Biguanide (Metformin) 1.1 to 3.0
Thiazolidinedione 1.5 to 1.6
Alpha-glucosidase inhibitors 0.6 to 1.3
DPP-4 inhibitors 0.8
NON-INSULIN INJECTABLENON-INSULIN INJECTABLE
Exenatide 0.8 to 0.9
COMBINATION THERAPYCOMBINATION THERAPY
SU + Metformin 1.7
SU + Pioglitazone 1.2
SU + Acarbose 1.3
Repaglinide + Metformin 1.4
Pioglitazone + Metformin 0.7
DPP-4 inhibitor + Metformin 0.7
DPP-4 inhibitor + Pioglitazone 0.7
Tuesday, April 23, 13
75. UNITE PHILIPPINE CPG
FOR DIABETES MELLITUS
Since HbA1c reduction is the overriding goal, the
precise combination used may not be as important
as the glucose level achieved.
•There is no evidence that a specific combination is any
more effective in lowering glucose levels or preventing
complications than another.
SU + Pio = SU + Metformin (Hanefield et al, 2004 & Nagasaka et al, 2004)
SU + Met = SU + DPP-IV inhibitors (?)
Tuesday, April 23, 13
76. UNITE PHILIPPINE CPG
FOR DIABETES MELLITUS
Statement 10.4.2
The following patients must be referred to
internists or diabetes specialists (endocrinologists
or diabetologists) -
• Type 1 diabetes
• Moderate to severe hyperglycemia
• Co-morbid conditions (infections, acute CV events i.e. CHF or
acute MI)
• Significant hepatic and renal impairment
• Women with diabetes who are pregnant
Tuesday, April 23, 13
77. Clinical practice guidelines aim to help physicians
and patients reach the best healthcare decisions.
Steinbrook R. NEJM 2007
Tuesday, April 23, 13
78. “If you write it, and
it is good, then they
will follow.”
Keefer JH. Clin Chem 2001
Tuesday, April 23, 13