Initiate therapy with SSRI - ! fluoxetine 20 mg (10 -80 mg) or citalopram 20 mg (10 -60 mg) Exercise, Pt education: response expectations, followup ~ 1 week, at least 4 total contacts/12 weeks, referral options

PHQ9 Assess (including suicide risk & bipolar MDQ ref), select and initiate therapy A. Mild / Moderate - Pharmacotherapy or psychotherapy (PHQ9 10-19)B. Major - Pharmacotherapy with psychotherapy (PHQ9 > 20)

! Reassess suicide risk, Not for Bipolar patients, Consider lower dosages for elderly

Adult (>18) Depression

4-6 weeks followup

Clearly better: PHQ decrease > 5 or more

Somewhat better: PHQ decrease 2-4

Not better: PHQ decrease < 1

Continue Therapy, reassess ~ 4-12 weeks

Full Symptom Remission? (PHQ < 10)

Continue Treatment Total ~ 6-9 months

Full Symptom Remission? (PHQ < 10)

Discontinue Treatment, Educate re: relapse,

or maintenance if > 3 total depressive episodes

B

Adjust therapyIncrease dose and/or

psychotherapy changeReassess 1-6 weeks

Adjust therapy, assess adherenceMaximize dose , consider psychotherapy

change, reassess 1-6 weeks

Add medication bupropion 200-450 mg/day or

change to venlafaxine 150-375 mg/day ??

Consider referral

Better

Better

Not Better

Not Better

Not Better

MU FCM

8/17/07

Version 1

A

Osteoarthritis

! – Caution with long term use/liver ds

Knee – consider intra-articular Synvisc 2 ml weekly X 3 weeks

Specialist referral

Non- Pharmacologic methods: Self management, Exercise or Physical therapy, Weight loss

Pain & functional assessment each visit

Acetaminophen up to 1 gm po QID !

Knee - Consider Orthotics (lateral wedge [podiatry], taping [PT]), consider trial of glucosamine 1500 mg/d Hands – splint for thumbs

Consider topical Capsaicin – 0.025 % cream to skin TID/QID

Knee - If knee joint effusion present, consider aspiration and intra-articular corticosteroids 40 mg Triamcinolone

NSAID: Naproxen 250 - 500 mg po BID or Naproxen Sodium 220-550 mg po BID or Salsalate 1500 mg po BID

If GI risk factors (Age > 65, Hx PUD/GI Bleed, Steroid, ASA, or warfarin use, smoker, EtOH use) may add omeprazole 20 mg po daily

If renal ds, no response, or age > 65, consider Tramadol 50 mg daily to QID, or Opiates: Acetaminophen/codeine 30 mg QID or Acetaminophen/hydrocodone 5 mg 1-2 tabs QID

MU FCM

8/17/07

Version 1

A

If no response, consider change of NSAID (Diclofenac 50 mg BID) or EC Aspirin 650 mg TID or COX 2 inhibitor (Celecoxib 200 mg daily)

Still in draft, obviously....

COPD (FEV1/FVC < 70%)Smoking Cessation, Education (activities, MDI, SX, breathing), Immunizations

Mild FEV1 pred>80 %

If dyspnea: Albuterol 2-4 puffs q 4 hrs orAtrovent 2-3 puffs q 4 hrs or Combivent 1-2 puffs q 4 hrs

Moderate 60-80% If Sx uncontrolled, addSpiriva 1 cap q day orSerevent 1 q 12 hrsConsider pulm rehab referral

Severe 30-60% Add: Flovent HFA 220 2-4 puffs BID or Advair 250/50 or 500/50 1 cap BID (stop serevent)

Very Severe

<30 or < 60 if resp failure

Oxygen if resting PO2 < 88, titrate to > 90 continuousConsider pulmonary referral

Ref: ACP and Gold