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## Complete Summary

#### GUIDELINE TITLE

HIV drug - drug interactions.

#### BIBLIOGRAPHIC SOURCE(S)

New York State Department of Health. HIV drug-drug interactions. New
York (NY): New York State Department of Health; 2008 Mar. 48 p. \[32
references\]

#### GUIDELINE STATUS

This is the current release of the guideline.

This guideline updates a previous version: New York State Department of
Health. HIV drug-drug interactions. New York (NY): New York State
Department of Health; 2007 Feb. 44 p.

### \*\* REGULATORY ALERT \*\*

#### FDA WARNING/REGULATORY ALERT

**Note from the National Guideline Clearinghouse**: This guideline
references a drug(s) for which important revised regulatory information
has been released.

-   [March 12, 2008, Prezista
    (darunavir)](http://www.fda.gov/medwatch/safety/2008/safety08.htm#Prezista):
    The U.S. Food and Drug Administration (FDA) and Tibotec Therapeutics
    notified healthcare professionals of changes to the WARNINGS section
    of the prescribing information for Prezista (darunavir) tablets
    regarding the risk of hepatotoxicity, specifically, drug induced
    hepatitis in patients receiving combination therapy with
    Prezista/ritonavir.

-   [October 18, 2007, PDE5 inhibitors, Viagra (sildenafil citrate),
    Levitra (vardenafil HCL), Cialis
    (tadalafil)](http://www.fda.gov/medwatch/safety/2007/safety07.htm#PDE5):
    The PRECAUTION and updated Adverse Reactions Sections of the
    approved product labeling for Viagra, Levitra, and Cialis were
    revised in response to reports of sudden decreases or loss of
    hearing.

### COMPLETE SUMMARY CONTENT

 \*\* REGULATORY ALERT \*\*\
 SCOPE\
 METHODOLOGY - including Rating Scheme and Cost Analysis\
 RECOMMENDATIONS\
 EVIDENCE SUPPORTING THE RECOMMENDATIONS\
 BENEFITS/HARMS OF IMPLEMENTING THE GUIDELINE RECOMMENDATIONS\
 CONTRAINDICATIONS\
 IMPLEMENTATION OF THE GUIDELINE\
 INSTITUTE OF MEDICINE (IOM) NATIONAL HEALTHCARE QUALITY REPORT
CATEGORIES\
 IDENTIFYING INFORMATION AND AVAILABILITY\
 DISCLAIMER

### SCOPE

#### DISEASE/CONDITION(S)

-   Human immunodeficiency virus (HIV) infection

-   Conditions associated with drug interactions encountered in
    HIV-infected patients using highly active antiretroviral therapy
    (HAART) as well as therapy for comorbid conditions and for
    prophylaxis of opportunistic infections

#### GUIDELINE CATEGORY

Counseling\
Management\
Prevention\
Risk Assessment

#### CLINICAL SPECIALTY

Allergy and Immunology\
Family Practice\
Infectious Diseases\
Internal Medicine\
Pharmacology\
Preventive Medicine

#### INTENDED USERS

Advanced Practice Nurses\
Health Care Providers\
Pharmacists\
Physician Assistants\
Physicians\
Public Health Departments

#### GUIDELINE OBJECTIVE(S)

-   To provide an overview of known and potential drug interactions
    encountered with the use of highly active antiretroviral therapy
    (HAART)

-   To provide recommendations for prevention and management of these
    drug interactions

#### TARGET POPULATION

Human immunodeficiency virus (HIV)-infected patients

#### INTERVENTIONS AND PRACTICES CONSIDERED

1.  Thorough medication history at each visit including prescription
    medications, over-the-counter medications, recreational drugs, and
    herbal and alternative therapies

2.  Classification of common substrates, inducers, and inhibitors of the
    cytochrome P-450 (CYP450) system to predict significant drug
    interaction

3.  Identification of dietary restrictions with antiretroviral (ARV)
    drugs to avoid food-drug interactions

4.  Provision of detailed list of drugs contraindicated with the use of
    highly active antiretroviral therapy (HAART)

5.  Avoidance of certain drug combinations (refer to the original
    guideline document for details)

6.  Dose adjustments during HAART regimens

#### MAJOR OUTCOMES CONSIDERED

Morbidity/adverse effects associated with drug-drug interactions

### METHODOLOGY

#### METHODS USED TO COLLECT/SELECT EVIDENCE

Hand-searches of Published Literature (Primary Sources)\
Hand-searches of Published Literature (Secondary Sources)\
Searches of Electronic Databases

#### DESCRIPTION OF METHODS USED TO COLLECT/SELECT THE EVIDENCE

Not stated

#### NUMBER OF SOURCE DOCUMENTS

Not stated

#### METHODS USED TO ASSESS THE QUALITY AND STRENGTH OF THE EVIDENCE

Expert Consensus (Committee)

#### RATING SCHEME FOR THE STRENGTH OF THE EVIDENCE

Not applicable

#### METHODS USED TO ANALYZE THE EVIDENCE

Review

#### DESCRIPTION OF THE METHODS USED TO ANALYZE THE EVIDENCE

Not stated

#### METHODS USED TO FORMULATE THE RECOMMENDATIONS

Expert Consensus

#### DESCRIPTION OF METHODS USED TO FORMULATE THE RECOMMENDATIONS

AIDS Institute clinical guidelines are developed by distinguished
committees of clinicians and others with extensive experience providing
care to people with HIV infection. Committees\* meet regularly to assess
current recommendations and to write and update guidelines in accordance
with newly emerging clinical and research developments.

The Committees\* rely on evidence to the extent possible in formulating
recommendations. When data from randomized clinical trials are not
available, Committees rely on developing guidelines based on consensus,
balancing the use of new information with sound clinical judgment that
results in recommendations that are in the best interest of patients.

\* Current committees include:

-   Medical Care Criteria Committee

-   Committee for the Care of Children and Adolescents with HIV
    Infection

-   Dental Standards of Care Committee

-   Mental Health Committee

-   Women\'s Health Committee

-   Substance Use Committee

-   Physician\'s Prevention Advisory Committee

-   Pharmacy Committee

#### RATING SCHEME FOR THE STRENGTH OF THE RECOMMENDATIONS

Not applicable

#### COST ANALYSIS

A formal cost analysis was not performed and published cost analyses
were not reviewed.

#### METHOD OF GUIDELINE VALIDATION

External Peer Review

#### DESCRIPTION OF METHOD OF GUIDELINE VALIDATION

All guidelines developed by the Committee are externally peer reviewed
by at least two experts in that particular area of patient care, which
ensures depth and quality of the guidelines.

### RECOMMENDATIONS

#### MAJOR RECOMMENDATIONS

The clinician should conduct a thorough medication history at each visit
that includes prescription medications, including those prescribed by
other providers, over-the-counter medications, recreational drugs, and
herbal/alternative therapies.

The clinician should classify common substrates, inducers, and
inhibitors of the cytochrome P-450 (CYP450) system used in highly active
antiretroviral therapy (HAART) to accurately predict drugs that may lead
to significant drug interactions (refer to Table below titled \"Select
CYP450 Inducers, Inhibitors, and Substrates\").

Refer to Appendix B in the original guideline document for information
on routes of elimination of HAART and the effect on CYP450.

The clinician should identify dietary restrictions with antiretroviral
(ARV) drugs so that food-drug interactions can be avoided.

**Key Points**:

-   Clinicians should instruct their patients to notify them of any new
    medication the patient is taking.

-   Providing patients with a detailed list of drugs that are
    contraindicated with HAART may help the patient to identify
    significant drug interactions.

**Classification of Drug Interactions**

**Key Point**:

Induction can be problematic during HAART due to concerns for virologic
failure when protease inhibitors (PI) and/or non-nucleoside reverse
transcriptase inhibitor (NNRTI) drug concentrations are reduced.

  --------------------------------------------------------------------------------------------
  **Table\                                                                  
  Select CYP450                                                             
  Inducers,                                                                 
  Inhibitors, and                                                           
  Substrates**                                                              
  ---------------- ------------------- ---------------- ------------------- ------------------
  ** **            **1A2**             **2C19**         **2D6**             **3A4**

  **Inducers**     ritonavir\          rifampin\        rifampin\           efavirenz\
                   rifampin\           carbamazepine\   phenytoin\          nevirapine\
                   phenytoin\          ritonavir\       phenobarbital\      rifampin\
                   omeprazole\         efavirenz        carbamazepine       phenytoin\
                   phenobarbital\                                           phenobarbital\
                   nicotine                                                 carbamazepine\
                                                                            glucocorticoids\
                                                                            St. John\'s Wort\
                                                                            ritonavir\
                                                                            etravirine

  **Inhibitors**   fluoroquinolones\   cimetidine\      ritonavir\          protease
                   cimetidine\         ketoconazole\    paroxetine\         inhibitors (PIs)
                   ticlopidine\        omeprazole\      sertraline\         (in order of
                   fluvoxamine\        fluoxetine\      fluoxetine\         potency:\
                   amiodarone\         lansoprazole\    cimetidine\         ritonavir,
                   atazanavir          paroxetine\      celecoxib\          indinavir,
                                       etravirine       amiodarone\         nelfinavir,
                                                        quinidine\          amprenavir,
                                                        methadone           atazanavir,
                                                                            saquinavir)\
                                                                            delavirdine\
                                                                            fluconazole\
                                                                            ketoconazole\
                                                                            itraconazole\
                                                                            amiodarone\
                                                                            diltiazem\
                                                                            fluvoxamine\
                                                                            nefazodone\
                                                                            fluoxetine\
                                                                            clarithromycin\
                                                                            erythromycin\
                                                                            posaconazole\
                                                                            grapefruit juice\
                                                                            Seville orange
                                                                            juice

  **Substrates**   haloperidol\        nelfinavir\      metoprolol\         clarithromycin\
                   theophylline\       lansoprazole\    carvedilol\         cyclosporine\
                   zileuton\           omeprazole\      codeine\            erythromycin\
                   amitriptyline\      pantoprazole\    dextromethorphan\   alprazolam\
                   cyclobenzaprine     diazepam\        tramadol\           midazolam\
                   olanzapine          phenytoin\       venlafaxine         triazolam\
                                       voriconazole\                        simvastatin\
                                       etravirine                           lovastatin\
                                                                            atorvastatin\
                                                                            nifedipine\
                                                                            nisoldipine\
                                                                            felodipine\
                                                                            PIs\
                                                                            nevirapine\
                                                                            efavirenz\
                                                                            delavirdine\
                                                                            sertraline\
                                                                            bepridil\
                                                                            propafenone\
                                                                            amiodarone\
                                                                            flecainide\
                                                                            irinotecan\
                                                                            pimozide\
                                                                            ergotamine\
                                                                            etravirine\
                                                                            maraviroc
  --------------------------------------------------------------------------------------------

**HAART-Related Drug Interactions**

**Anticonvulsants**

Clinicians should monitor anticonvulsant levels in patients taking
concurrent HAART and anticonvulsant therapy.

Clinicians should avoid prescribing carbamazepine, phenobarbital, and
phenytoin for patients receiving non-nucleoside reverse transcriptase
inhibitors (NNRTIs) or PIs. Valproic acid or levetiracetam may be
considered.

**Antifungal Drugs**

Clinicians should not prescribe voriconazole for patients taking
ritonavir (400 mg every 12 hours). Clinicians should avoid or use
caution when combining voriconazole with the other NNRTIs or unboosted
PIs.

**Antimycobacterial Drugs**

Clinicians should not use rifampin with any PI. Consider rifabutin with
proper dose adjustment.

+--------------------------------+-------------------------------------+
| With proper dose adjustments,  |                                     |
| **rifampin** can be safely     |                                     |
| used with the following drugs: |                                     |
+--------------------------------+-------------------------------------+
| -   Nucleotide reverse         | -   Efavirenz + nucleoside reverse  |
|     transcriptase inhibitors   |     transcriptase inhibitors        |
|     (NtRTIs)                   |     (NRTIs) or NtRTIs               |
|                                |                                     |
| -   Enfuvirtide                |                                     |
|                                |                                     |
| -   Maraviroc                  |                                     |
+--------------------------------+-------------------------------------+
| With proper dose adjustments,  |                                     |
| **rifabutin** can be safely    |                                     |
| used with the following drugs: |                                     |
+--------------------------------+-------------------------------------+
| -   NRTIs                      | -   Lopinavir + ritonavir           |
|                                |                                     |
| -   NtRTIs                     | -   Maraviroc                       |
|                                |                                     |
| -   Amprenavir                 | -   Nelfinavir                      |
|                                |                                     |
| -   Atazanavir                 | -   Raltegravir (no data; may be    |
|                                |     considered with close           |
| -   Darunavir + ritonavir      |     monitoring)                     |
|                                |                                     |
| -   Enfuvirtide                | -   Ritonavir                       |
|                                |                                     |
| -   Etravirine                 | -   Efavirenz when used with 2      |
|                                |     NRTIs                           |
| -   Fosamprenavir              |                                     |
|                                | -   Nevirapine when used with 2     |
| -   Indinavir                  |     NRTIs                           |
|                                |                                     |
|                                | -   Saquinavir + ritonavir          |
|                                |                                     |
|                                | -   Tipranavir + ritonavir          |
+--------------------------------+-------------------------------------+

**Erectile Dysfunction Agents**

The following is generally recommended when erectile dysfunction agents
are combined with PIs:

*Sildenafil* - use reduced initial dose of 25 mg every 48 hours and
monitor for adverse effects

*Tadalafil* - use initial dose of 5 mg, and do not exceed a single dose
of 10 mg in 72 hours

*Vardenafil* - use initial dose of 2.5 mg, and do not exceed a single
2.5-mg dose in 72 hours

**Ergot Alkaloids**

Clinicians should not prescribe ergotamine derivatives in patients
receiving concurrent PI therapy. Alternative medications should be
considered.

**Herbal Therapy**

In the setting of PI- or NNRTI-based HAART, supplemental garlic and St.
John\'s Wort are contraindicated.

All herbal products should be used with caution until further data are
available regarding their effects with concurrent HAART.

**Key Point**:

Because most providers cannot accurately predict which patients use
herbal therapy, it is important to discuss ARV/herbal drug interactions
with all patients.

**Hydroxymethyl Glutaryl Coenzyme A (HMG-CoA) Reductase Inhibitors**

Clinicians should not prescribe simvastatin or lovastatin for patients
taking PIs.

**Key Points**:

-   Lovastatin and simvastatin are contraindicated with all PIs and
    delavirdine (DLV).

-   Pravastatin is the safest drug for treating hyperlipidemia during
    concurrent PI therapy.

-   Atorvastatin can be used cautiously at lower doses (5 to 10 mg) with
    careful titration.

-   Rosuvastatin can be used at lower doses (5mg) with careful
    titration.

**Oral Contraceptives**

Clinicians should use caution when prescribing oral contraceptives for
patients receiving HAART because of the variations in effect on ethinyl
estradiol levels.

Clinicians should advise women who are taking efavirenz, nevirapine,
lopinavir/ritonavir, nelfinavir, ritonavir, tipranavir/ritonavir,
darunavir/ritonavir, or saquinavir to use alternate or additional forms
of birth control.

**Psychotropic Therapies**

Drug interactions with most psychotropic therapies are summarized in
Table 3 in the original guideline document.

**Sedative/Hypnotics**

Clinicians should not prescribe alprazolam, midazolam, or triazolam for
patients receiving PIs. Lorazepam or oxazepam may be considered.

#### CLINICAL ALGORITHM(S)

None provided

### EVIDENCE SUPPORTING THE RECOMMENDATIONS

#### TYPE OF EVIDENCE SUPPORTING THE RECOMMENDATIONS

The type of evidence supporting the recommendations is not specifically
stated.

### BENEFITS/HARMS OF IMPLEMENTING THE GUIDELINE RECOMMENDATIONS

#### POTENTIAL BENEFITS

Identification of risk, prevention, and appropriate management of human
immunodeficiency virus (HIV) drug-drug interactions

#### POTENTIAL HARMS

Refer to the \"Major Recommendations\" field above and to Appendix A in
the original guideline document for specific cautions concerning various
drug combinations.

### CONTRAINDICATIONS

#### CONTRAINDICATIONS

Refer to the \"Major Recommendations\" field above and to Appendix A in
the original guideline document for specific contraindicated drug
combinations.

### IMPLEMENTATION OF THE GUIDELINE

#### DESCRIPTION OF IMPLEMENTATION STRATEGY

The AIDS Institute\'s Office of the Medical Director directly oversees
the development, publication, dissemination and implementation of
clinical practice guidelines, in collaboration with The Johns Hopkins
University, Division of Infectious Diseases. These guidelines address
the medical management of adults, adolescents and children with HIV
infection; primary and secondary prevention in medical settings; and
include informational brochures for care providers and the public.

**Guidelines Dissemination**

Guidelines are disseminated to clinicians, support service providers and
consumers through mass mailings and numerous AIDS Institute-sponsored
educational programs. Distribution methods include the HIV Clinical
Resource website, the Clinical Education Initiative, the AIDS
Educational Training Centers (AETC) and the HIV/AIDS Materials
Initiative. Printed copies of clinical guidelines are available for
order from the NYSDOH Distribution Center for providers who lack
internet access.

**Guidelines Implementation**

The HIV Clinical Guidelines Program works with other programs in the
AIDS Institute to promote adoption of guidelines. Clinicians, for
example, are targeted through the Clinical Education Initiative (CEI)
and the AIDS Education and Training Centers (AETC). The CEI provides
tailored educational programming on site for health care providers on
important topics in HIV care, including those addressed by the HIV
Clinical Guidelines Program. The AETC provides conferences, grand rounds
and other programs that cover topics contained in AIDS Institute
guidelines.

Support service providers are targeted through the HIV Education and
Training initiative which provides training on important HIV topics to
non-physician health and human services providers. Education is carried
out across the State as well as through video conferencing and audio
conferencing.

The HIV Clinical Guidelines Program also works in a coordinated manner
with the HIV Quality of Care Program to promote implementation of HIV
guidelines in New York State. By developing quality indicators based on
the guidelines, the AIDS Institute has created a mechanism for
measurement of performance that allows providers and consumers to know
to what extent specific guidelines have been implemented.

Finally, best practices booklets are developed through the HIV Clinical
Guidelines Program. These contain practical solutions to common problems
related to access, delivery or coordination of care, in an effort to
ensure that HIV guidelines are implemented and that patients receive the
highest level of HIV care possible.

#### IMPLEMENTATION TOOLS

Personal Digital Assistant (PDA) Downloads

For information about
[availability](#identifying-information-and-availability), see the
\"Availability of Companion Documents\" and \"Patient Resources\" fields
below.

### INSTITUTE OF MEDICINE (IOM) NATIONAL HEALTHCARE QUALITY REPORT CATEGORIES

#### IOM CARE NEED

Living with Illness\
Staying Healthy

#### IOM DOMAIN

Effectiveness\
Patient-centeredness\
Safety

### IDENTIFYING INFORMATION AND AVAILABILITY

#### BIBLIOGRAPHIC SOURCE(S)

New York State Department of Health. HIV drug-drug interactions. New
York (NY): New York State Department of Health; 2008 Mar. 48 p. \[32
references\]

#### ADAPTATION

Not applicable: The guideline was not adapted from another source.

#### DATE RELEASED

2004 (revised 2008 Mar)

#### GUIDELINE DEVELOPER(S)

New York State Department of Health - State/Local Government Agency
\[U.S.\]

#### SOURCE(S) OF FUNDING

New York State Department of Health

#### GUIDELINE COMMITTEE

Medical Care Criteria Committee

#### COMPOSITION OF GROUP THAT AUTHORED THE GUIDELINE

*Chair*: Jessica E Justman, MD, Columbia University, New York, New York

*Vice-Chair*: Barry S Zingman, MD, Montefiore Medical Center, Bronx, New
York

*Members*: Judith A Aberg, MD, New York University School of Medicine,
New York, New York; Bruce D Agins, MD, MPH, New York State Department of
Health AIDS Institute, New York, New York; Barbara H Chaffee, MD, MPH,
Binghamton Family Care Center, Binghamton, New York; Steven M Fine, MD,
PhD, University of Rochester Medical Center, Rochester, New York;
Barbara E Johnston, MD, Saint Vincent\'s-Manhattan Comprehensive HIV
Center, New York, New York; Jason M Leider, MD, PhD, North Bronx
Healthcare Network of Jacobi and North Central Bronx Hospitals, Bronx,
New York; Joseph P McGowan, MD, FACP, Center for AIDS Research &
Treatment, North Shore University Hospital, Manhasset, New York; Samuel
T Merrick, MD, New York-Presbyterian Hospital/Weill Cornell Medical
Center, New York, New York; Rona M Vail, MD, Callen-Lorde Community
Health Center, New York, New York

*Liaisons*: Sheldon T Brown, MD, Liaison to the Department of Veterans
Affairs Medical Center, Bronx Veteran Affairs Medical Center, Bronx, New
York; Douglas G Fish, MD, Liaison to the New York State Department of
Corrections, Albany Medical College; Albany, New York; Peter G Gordon,
MD, Liaison to the HIV Quality of Care Advisory Committee, Columbia
University College of Physicians and Surgeons, New York, New York;
Fabienne Laraque, MD, MPH, Liaison to the New York City Department of
Health and Mental Hygiene, Treatment and Housing Bureau of HIV/AIDS
Prevention and Control, New York, New York; Joseph R Masci, MD, Liaison
to New York City Health and Hospitals Corporation, Elmhurst Hospital
Center; Elmhurst, New York

*AIDS Institute Staff Physician*: Charles J Gonzalez, MD, New York State
Department of Health AIDS Institute, New York, New York

*Principal Investigator*: John G Bartlett, MD, The Johns Hopkins
University, Baltimore, Maryland

*Principal Contributor*: Paul Pham, PharmD, The Johns Hopkins
University, Baltimore, Maryland

#### FINANCIAL DISCLOSURES/CONFLICTS OF INTEREST

Not stated

#### GUIDELINE STATUS

This is the current release of the guideline.

This guideline updates a previous version: New York State Department of
Health. HIV drug-drug interactions. New York (NY): New York State
Department of Health; 2007 Feb. 44 p.

#### GUIDELINE AVAILABILITY

Electronic copies: Available from the [New York State Department of
Health AIDS Institute Web
site](http://www.hivguidelines.org/Content.aspx?pageID=257).

#### AVAILABILITY OF COMPANION DOCUMENTS

The following are available:

-   Appendix A: drug interactions between antiretrovirals and other
    drugs. New York (NY): New York State Department of Health; 2008 Mar.
    Electronic copies: Available from the [New York State Department of
    Health AIDS Institute Web
    site](http://hivguidelines.org/Content.aspx?PageID=311&guideLineID=12&guideParent=257&vType=text&pGuideLineID=12,).

-   Appendix B: routes of elimination of HAART and the effect on CYP450.
    New York (NY): New York State Department of Health; 2008 Mar.
    Electronic copies: Available from the [New York State Department of
    Health AIDS Institute Web
    site](http://hivguidelines.org/Content.aspx?PageID=312&guideLineID=12&guideParent=257&vType=text&pGuideLineID=12,).

This guideline is also available as a Personal Digital Assistant (PDA)
download from the [New York State Department of Health AIDS Institute
Web
site](http://hivguidelines.org/GuideLine.aspx?pageID=257&guideLineID=12&vType=pda).

#### PATIENT RESOURCES

None available

#### NGC STATUS

This NGC summary was completed by ECRI on January 17, 2005. This summary
was updated on April 15, 2005 following the withdrawal of Bextra
(valdecoxib) from the market and the release of heightened warnings for
Celebrex (celecoxib) and other nonselective nonsteroidal
anti-inflammatory drugs (NSAIDs). This summary was updated by ECRI on
June 16, 2005, following the U.S. Food and Drug Administration (FDA)
advisories on Sustiva (efavirenz) and COX-2 selective and non-selective
non-steroidal anti-inflammatory drugs (NSAIDs). This summary was updated
by ECRI on July 15, 2005 following the FDA advisory on Cialis, Levitra,
and Viagra. This NGC summary was updated by ECRI Institute on September
18, 2007. This summary was updated by ECRI Institute on November 6,
2007, following the updated U.S. Food and Drug Administration advisory
on Viagra, Cialis, Levitra, and Revatio. This summary was updated by
ECRI Institute on March 28, 2008, following the FDA advisory on Prezista
(darunavir). This NGC summary was updated most recently by ECRI
Institute on June 5, 2008.

#### COPYRIGHT STATEMENT

This NGC summary is based on the original guideline, which is
copyrighted by the guideline developer. See the [New York State
Department of Health AIDS Institute Web
site](http://www.hivguidelines.org/Content.aspx?pageID=451) for terms of
use.

### DISCLAIMER

#### NGC DISCLAIMER

The National Guideline Clearinghouse™ (NGC) does not develop, produce,
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<http://www.guideline.gov/about/inclusion.aspx> .

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Readers with questions regarding guideline content are directed to
contact the guideline developer.

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© 1998-2008 National Guideline Clearinghouse

Date Modified: 11/3/2008