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Kaiser Diagnostic and Treatment Documents


Kaiser Permanente Clinical Practice Guideline for Management of Diabetes Mellitus




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
* 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.


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.


* 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) 
<>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.

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.

*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

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%.

* 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.

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

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
* 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.
Kaiser Permanente Recommendations for Glycemic Control (Type2)
Kaiser Permanente Stepwise Approach to Glycemic Control

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.

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).

Protocols for insulin adiustment can be viewed online in the Regional Diabetes Mellitus CPG
section on the Kaiser Permanente Northern California intranet website at

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.

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

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.

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.

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

Drug therapy should be directed first at lowering LDL. For diabetes patients with pre-
existing vascular disease, the goal is to
Kaiser Permanente Diabetes Goal

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
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

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.


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.

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.

American Diabetes Association: Clinical Practice Recommendations 1999. Diabetes Care
1999;22(suppl l):SI-Sll4. Kaiser Permanente Care Management Institute. CMI
Diabetes Guidelines 1999.

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 1996:276:1246-1252.

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 risk of macrovascular and
microvascular complications in tvpe 2 diabetes:UKPDS 38. Brit Med J. 1998;317:713-720.

UKPDS Group. Cost effectiveness analysis of improved blood pressure control in hypertensive patients
with type 2 diabetes: UKPDS 40. Brit Med J. 1998;317:720-726.

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.

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).

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.

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 diabetes. Diabetes Care 1998;21:160-78.

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.

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-

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

Kloner RA,JarowJP Erectile dysfunction and sildenafil citrate and cardiologists..Amer J Cardiol 1999;83:

Lipshultz LI, Kim ED. Treatment of erectile dysfunction in men with diabetes. JAMA 1999;281:465-6.
Price DE, Gingell JC, Gepi-Attee S, et al. Sildenafil: study of a novel oral treatment for erectile dysfunction in
diabetic men. Diabetic Medicine 1998;15:821-825.

Rendell MS, Rajifer J, Wicker PA, et al. Sildenafil for treatment of erectile dysflinction in men with
diabetes: a randomized controlled trial. JAMA 1999;281:421-6.

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

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

Kaiser Permanente Northern California TPMG Department of Quality and Utilization
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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 &
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KPNC Clinical Practice Guidelines can be viewed on-line on the Kaiser Permanente
Northern California intranet at
This website is accessible only from the Kaiser Permanente computer network.

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.