Timmy Global Health Medical ProtocolsDominican Republic

Table of Contents1. Medication Usage

2. Parasites

3. Malnutrition, Stunting, & Growth Charts

4. Chronic Disease4.1 Hypertension4.2 Diabetes

5. Parasite Therapy Quick Reference Guide

Using Medications on Timmy Brigades

Introduction:During Timmy Global Health’s week-long brigades, medical providers will see a large number of patients and prescribe a significant amount of medication. To ensure consistent adherence to proper protocols as well as local norms, the below sets out relevant procedures for the provision of medications to patients on brigades.

Protocols:

Formulary: Timmy Global Health supplies all of the medications using a formulary (which can be found at the end of this document). Please review the formulary prior to the trip so that you are familiar with the available medications. This medication list is extensive and will cover all or most of the pathologies you will encounter during the week. However, if there is a medication which is medically necessary and not on the formulary, you may instruct the patient to purchase it at a pharmacy. Please first consult with our local physician, Dr. Miguel Garcia, so he can specify a reliable brand. Not all pharmaceutical laboratories in Latin America adhere to quality standards and Dr. Garcia will be able to direct you to which brands are most reliable here in the Dominican Republic. While in almost all cases patients do not need a formal prescription in order to purchase medication at a pharmacy, you must still clearly write out the medication name, brand, and dosing instructions to ensure that the patient receives the proper medicines from the pharmacist. Additionally, prior to prescribing any medications for patient purchase, you must ask one of the local medical providers or in-country Timmy Global Health staff if this medication is readily available and affordable for the patients (as it does little good to prescribe a medication that the patient will not be able to readily obtain.)

Access to medicine: As noted above, except for specific controlled substances, patients do not need a prescription to obtain medications. Therefore, self-medication is a more prominent concern than in the United States. Additionally, patients have been conditioned to expect medication in response to any medical issue. As such the expectation for receiving medication here is very high, even for conditions that do not require medication. While it can be difficult when a patient is specifically requesting medication, Timmy asks that you adhere to the same standards for dispensing medicines that you would use in your practice at home. Specifically, Timmy policy is not to dispense medication unless it is necessary. (Vitamins are an exception as all brigade patients receive vitamins to compensate for potential dietary limitations) Given that patients don’t need a prescription to purchase medicines, it is also important that you take the time to explain why you are choosing not to prescribe medication so that the patients don’t simply purchase it for themselves at the pharmacy. This is especially important when it comes to antibiotics as they are widely overused in the Dominican Republic (in fact, they are even sold at the local markets).

Antibiotic Resistance: As noted above, antibiotics are very often improperly used in the Dominican Republic. As such, antibiotic resistance is a problem and should be

considered if it is deemed necessary to dispense an antibiotic. Initially with the widespread use of antibiotics, people used Tetracyclines as the first line medication. However, the pathogens developed resistance to this class of antibiotics and people changed to Trimethoprim-sulfamethoxazole (Bactrim/Septra). Again, widespread resistance developed and people are now buying Amoxicillin in pharmacies. Now there are several examples of Amoxicillin-resistant pathogens (including a case of Group A Strep). While this does not preclude us from using such medications, it is important to keep in mind when choosing a specific antibiotic to administer (type of infection, previous antibiotic exposure, etc.)

Vitamins: Vitamins will be distributed to all patients according to the following age guidelines:

Infants ages 0-2: Infant vitamins Males ages 2-14: Children vitamins Males ages 15 and older: Adult vitamins Females ages 2-14: Children’s vitamins Females ages 15-30: Prenatal vitamins Females ages 30-45: Determine whether patient is considering becoming

pregnant or breastfeeding; if so, give prenatal vitamins. If not, adult vitamins Females ages 45 and older: Adult vitamins

If a parent is accompanied by children who were not seen during the brigade, the children may also be given vitamins. Like all other medication, vitamins should never be given directly to children. Additionally, parents should be clearly instructed as to the dose (one per day) and to keep the vitamins in a place where children can not access them to avoid overdose. (Remember, they taste good so children seek them out!)

Choosing medications: Medications should always be chosen according to what is best for the patient. However, as in the US where you might choose a medication based on cost considerations (for example depending on the insurance coverage of the patient), cost and availability should be taken into account when deciding which medication to use. Timmy Global Health works to acquire medications in the most economical manner possible. However, there are specific medications that continue to be expensive and/or difficult to obtain. Therefore, while these should always be used when medically necessary, we ask that you consider whether another medication would be a suitable substitute for the medicines listed below:

o Omeprazole/Lansoprazole—Symptoms of Gastritis/GERD are very common here in the Dominican Republic (largely due to diet). While PPIs are now often used as the first-line treatment for Gastritis/GERD in the US, many patients here have only mild symptoms and should be trialed on Calcium Antacids and/or H2-antagonists prior to the initiation of PPIs (which are expensive).

o GERD Packs—Similarly, GERD packs should be reserved for patients with more severe symptoms of GERD and/or H Pylori infection. (GERD packs consist of Omeprazole, Amoxicillin, and Clarithromycin)

o Augmentin—While this antibiotic is frequently used in the US, it should be

reserved here for infections in which another antibiotic would not be efficacious. The oral suspension form is particularly expensive.

o Naproxen—Osteoarthritis is another diagnosis commonly seen here and Naproxen is a good medication to use to control the pain. However, for patients with only very mild, intermittent, or short-term symptoms, Ibuprofen can often work just as well and is significantly less expensive.

o Cephalexin Oral Suspension—This should be reserved for clinical situations in which specific coverage is needed (e.g. Staph.) If Amoxicillin is as appropriate a choice of antibiotic (and there is no worry of antibiotic resistance), please use Amoxicillin instead.’

o Prednisone taper— NOT RECCOMENDED FOR USE IN THE DR While this medication can be a good choice for patients with severe inflammation, the instructions for proper usage are often confusing and very difficult to follow, especially for an illiterate patient. The medication should be avoided whenever possible since it is very unlikely that patients will be able to follow the instructions correctly.

o Permethrin: Scabies is a very common skin disease seen in the communities in which we work. Permethrin is a well-known and effective treatment of this disease. Unfortunately, it is also an expensive remedy. A less well-known, but much more economical treatment is Ivermectin. Studies have shown than two doses of Ivermectin given at least one week apart are an effective treatment of scabies1. Therefore, for patients seen with classic scabies, the treatment protocol is as follows:

Children less than 15kg: Permethrin cream Children greater than 15kg and adults: 200 mcg/kg/dose x 2

doses given approximately 10 days apart. Ivermectin should be taken with food as significantly

increases drug penetration into epidermis Severe cases (crusted scabies) can require multiple doses of

Ivermectin and should be treated with Permethrin concomitantly.1

The same dose of Ivermectin (200 mcg/kg/dose x 2 doses given one week apart for patients greater than 15kg) can be used in the treatment of lice

Quality of locally available pharmaceuticals: Please note that proper standards do not always exist at all pharmaceutical laboratories in Latin America. When prescribing a medication that the patient will need to obtain locally, please consult with Dr. Miguel Garcia, our local counterpart and Dominican physician. He will orient you to which laboratory brands are trustworthy and uphold standards like those that are followed in the US.

1

1 Bart J. Currie, F.R.A.C.P., and James S. McCarthy, F.R.A.C.P. Permethrin and Ivermectin for ScabiesN Engl J Med 2010; 362:717-725

Patients use of medication: Latino culture is largely centered on community and the sharing of what is

available. This pertains to resources, including medication. A medication that gives symptom relief for one family member may very well be shared within the extended family or with neighbors and friends. Medications that are NOT suitable for familial use should be specified and cautioned. It is crucial to stress the importance of completing a course of antibiotics as compliance seems to be low. Also, details about which excess medications after treatment is complete should be stored versus thrown out needs to be conveyed in the pharmacy.

There have been multiple reports of patients splitting chronic medications into halves or even fourths to make them last longer despite the brigade ticket priority given to patients on the chronic list. Always reassure patients on chronic medications that we will be back in two months to provide a prescription refill and remind them that the medication will not be effective unless taken daily and at the proper dosage.

Protocol for Use of Anti-Parasite Medicine for Intestinal Parasitic Infections on Timmy Brigades

Overview of epidemiology of Soil-Transmitted Helminth infections in the Dominican RepublicParasitic infections are a significant problem in the developing world, including in the Dominican Republic. The soil-transmitted helminthiases--ascariasis, hookworm, and trichuriasis--are among the most prevalent infections worldwide and thus the central focus of this protocol. The WHO recognizes that in the Dominican Republic these infections are a significant issue and require preventive chemotherapy treatment. 2i Given that school children tend to have the highest disease burden and morbidity as a result of soil-transmitted heminth (STH) infections, the treatment protocol focuses largely on the pediatric population.

The approach to diagnosis and treatment of children with suspected STH infections is difficult, especially as the large majority of patients are asymptomatic. Therefore, this protocol is intended to provide a guideline for treating brigade patients according to WHO standards.

Symptoms of common STH infections:Ascaris Lumbricoides: The large majority of patients infected with this worm are asymptomatic. Symptoms can occur with moderate to heavy worm burdens and affect various organ systems. Transient pulmonary symptoms (including cough, dsypnea, and wheezing,) can occur during the larval migration stage (1-2 weeks after infection.) Gastrointestinal symptoms including abdominal pain, anorexia, nausea, and diarrhea have been attributed to ascarisias, but are not specific. Malabsorption can lead to steatthorea and micronutrient deficiencies. In severe cases, intestinal obstruction can occur. Pancreatic and Hepatobiliary—migration of worms to the pancreatic and hepatobiliary tracts can cause abdominal pain, cholecystitis, jaundice, and pancreatitis. Finally, heavy infections have also been shown to be associated with impaired growth and cognitive development in school children.

Trichiuris Trichiuria (Whipworm): The large majority of patients infected with this worm are asymptomatic. Symptoms can occur with moderate to heavy worm burdens, including loose stools (which may contain mucous and/or blood), rectal prolapse, and impaired growth/cognition.

Hookworm (Necator Americanus): These are less common in the Dominican Republic. The large majority of patients are asymptomatic. Following skin penetration (mode of transmission for Hookworm), patients may have pruritic rash at site of penetration. 2i Preventive chemotherapy in human helminthiasis, Coordinating use of anthelminthic drugs in control interventions: A manual for health professionals and programme managers (World Health Organization, Geneva) 2006

Gastrointestinal symptoms may include abdominal pain (often midepigastric), vomiting, diarrhea, and flatulence. Finally infection with hookworm may result in iron deficiency anemia secondary to blood loss.     3. Summary   of WHO recommendations: For countries that categorized as requiring preventive chemotherapy treatment for soil transmitted helminthic infections, the WHO recommends the following therapy guidelines:

Category Prevalence of STH infection among

school-aged children

Action to be taken

High Risk Community

>50% Treat all school age children (enrolled and not-enrolled) twice each year

Also treat: Preschool children Woman of

childbearing age including pregnant women in second and third trimester, lactating women,

Adults at high risk in certain occupations (e.g. tea pickers and miners)

Low Risk Community

>20% and <50% Treat all school age children (enrolled and not-enrolled) once each year

Also treat: Preschool children Woman of

childbearing age including pregnant women in second and third trimester, lactating women

Adults at high risk in certain occupations (e.g. tea pickers and miners.)

From: Preventive chemotherapy in human helminthiasis, Coordinating use of anthelminthic drugs in control interventions: A manual for health professionals and programme managers (World Health Organization, Geneva) 2006

Timmy   Protocol for Use of Anti-Parasitic Medication Based on WHO recommendations, we have adopted the following protocol for treatment:

i. All children who have not received antiparasitics in past 6 months should be treated.  Note—it is important to ask several different ways if patient has been recently treated including last visit to MD, if received anti-parasitic at school, explanation of fear of resistance and then ask again, etc

ii. Treatment must be clearly documented on intake form; be sure to explain to

parents that they should take note of when the patient received treatment to avoid retreatment in next few months

iii. A patient who recently received treatment and has symptoms suspicious of parasitic infection should be sent for stool sample

iv. While the WHO recommends treatment of pregnant women in the 2nd and 3rd trimesters, Albendazole and Mebendazole are not recommended for use during pregnancy and breastfeeding. Therefore asymptomatic pregnant and lactating women are not treated; any such woman who is symptomatic should be referred to an OB for further evaluation

v. Adults with symptoms suggestive of helminthic infection should be considered for stool testing vs anti-parasitic medication, decided on a case-by-case basis.

    Treatment   regimen

Albendazole 200mg PO x 1 dose for children aged 12-23 months; 400mg PO x 1 dose for children >2 year of age and adults

Or

Mebendazole 500mg PO single dose for children >1 year of age and adults(alternative treatment regimen is 100mg PO BID x 3 days)

Protozoal Intestinal Infections:Protozoal intestinal infections, especially Entamoeba and Giardia Lamblia are also very common infections in the Dominican Republic.

Entamoeba histolytica can cause intestinal amebiasis, although the large majority of patients are asymptomatic. Acute symptoms of amebiasis include diarrhea, abdominal pain, and bloody stools. Patients suspected of having symptomatic intestinal amebiasis should be sent for stool samples or empirically treated as follows:

ChildrenMetronidazole 35-50mg/kg/day divided TID 7-10 daysAdults:Metronidazole 500mg PO TID x 7-10 days

Giardia Lamblia is another protozoal infection that can cause intestinal symptoms. Approximately 55-65% of patients are asymptomatic. Acute giardiasis presents with symptoms including watery diarrhea, abdominal cramping and bloating, flatulence, and nausea. Chronic giardiasis can present with loose stools, weight loss, lactose intolerance, and growth retardationiiii. Infection with Giardia Lamblia should be considered in any

iiiihttp://www.uptodate.com/online/content/topic.do?topicKey=parasite/17013&selectedTitle=1%7E15&source=search_result

patient with these symptoms. Patients can be sent for stool samples or given empiric treatment as follows:

ChildrenMetronidazole 15mg/kg/day divided TID x 5-7 days (max 250mg/dose)Adults:Metronidazole 250mg PO TID x 5-7 days

Treatment of any patient should be accompanied with education regarding water source, hand-washing, etc to avoid re-contamination.

Malnutrition, Stunting, and Use of Growth Charts

IntroductionMalnutrition is a serious problem for children in the bateys of Monte Cristi. In fact, this area has one of the highest levels of malnutrition in the country. Overall, the Dominican Republic is considered to be part of a group of countries that registered a low prevalence of malnutrition in Latin America and the Caribbean. A study by ENDESA in 2007 set the rate of chronic malnutrition in children under five using the WHO criteria, at 9.8%.

In addition to its most acute physical effects, malnutrition has a significant impact on a child’s health and cognitive development. It is estimated that malnutrition is responsible for 44 to 60 percent of deaths from measles, malaria, pneumonia and diarrhea.3 Furthermore, malnutrition significantly affects brain development, school performance and economic potential.

Growth Charts:Given the profound effects of malnutrition on a child’s physical, mental, and cognitive health, it is vital that child’s nutritional status should be clearly documented at all medical visits. The best form for documenting this nutritional status is a growth chart. When determining the height and weight percentiles in developing countries, questions often arise as to which growth charts are most suitable. Many think country specific growth charts are the best measurement, however, in under-resourced nations the use of country specific data masks the degree of malnutrition and does not account for a child’s full growth potential. In other words, a growth chart should provide more generalized and objective standards for how a child should grow if given the necessary nutrition. As such, the WHO’s updated growth standards, released in 2006, used growth data from 6 countries and “reiterate[d] the fact that child populations grow similarly across the world’s major regions when their needs for health and care are met.”4 Similarly, growth charts from the Centers for Disease Control (CDC) in the United States provide objective standards for growth given with proper nutrition.

The use of growth charts based on established grown norms are the most appropriate for children in the Dominican Republic. The World Health Organization (WHO) and CDC growth charts are the two most commonly used. There is a notable difference between the two organizations’ charts from the ages of 0 to 2: at this age the WHO charts reflect a focus breastfeeding, while CDC charts reflect a higher reliance on bottle-feeding. When plotting an identical height or weight on both charts after infancy, the percentile differences are clinically insignificant, especially for the purposes of nutrition assessment and growth monitoring done during and between the brigades5. Given that breastfeeding is very rarely practiced regularly in the Dominican Republic (4% of mothers breastfeed exclusively for 6 months), Timmy Global Health’s policy is to use CDC growth charts for children ages 0-2 and CDC growth charts for children ages 2-18 (WHO growth charts are limited after the age of 5 and utilizing CDC growth charts for all children allows us to reduce the number of different charts used for each patient6).

Protocol: All children ages 0-18 seen on the brigade will receive a growth chart for their chart as follows:

3 http://www.dcp2.org/pubs/DCP/28/Section/39914 http://www.who.int/childgrowth/faqs/how_different/en/index.html5 http://www.cdc.gov/mmwr/pdf/rr/rr5909.pdf6 The CDC growth chart measures height and weight from age 2 until age 20, whereas the WHO has a separate chart for ages 2 to 5 and then additional charts for older children (with weight for age charts only until age 10.)

- Children age 0-2: CDC growth chart - Children ages 2-18: CDC growth chart- There are male and female versions for each age group

Weight for age and Height for age must be plotted for all children. When appropriate, weight for height and/or BMI should also be plotted. The growth chart should then be used as a pictorial tool to discuss the child’s nutritional status with the parent(s).

- Note: It is important to accurately document a child’s age, including not just number of years old, but months as well. (e.g. a child that turned 7 last month needs to be differentiated from a child that is 7 years and 8 months old.)

Any child that is below the third percentile for weight and/or height is considered chronic and should receive regular follow up. Dietary interventions should also be discussed at length with the family (see separate “Dietary Intervention” sheet).

Note: Diets mostly consist of rice, tubers, and plantains in the rural areas of the country. This is partly cultural but largely due to financial strain and the large difference in cost between starches and proteins/vegetables/fruits. A child reporting low appetite may not have much food being offered in the home. It is important to address the issues of food availability in the home delicately with the parent before encouraging the child to generally eat more.

Evaluating and Treating Chronic Diseases on Timmy Brigades

Introduction: Chronic diseases, including cardiovascular diseases and diabetes, are becoming an increasing cause of morbidity and mortality in the Dominican Republic. This is due largely to changes in diet (increased saturated fat, refined foods, and sugar) but also due to genetic factors as well. This protocol will focus on two of the diseases most commonly encountered—hypertension and diabetes.

Diagnosing and/or managing a patient with a chronic disease on a medical brigade is challenging for several reasons, including:

o The patient is unknown to the medical providero The medical history is often uncertain and/or unreliableo Follow up will often not be done by the same medical provider who sees the patient during the brigade

Timmy Global Health has several strategies in place to help deal with these challenges, including:o Partnering with a local organization that has a regular presence in the communitieso Providing a stipend to a local Dominican doctor who consults with patients monthly in the rural

communities and provides follow-up for chronic patients between brigades. o Sending medical brigades every 2-3 months to the same communities to the patients can be followed

closely.

These strategies allow the brigades to adhere closely to established standards in terms of evaluating and managing chronic diseases. These specific protocols for hypertension and diabetes are discussed below.

Hypertension

Review of Classification of Hypertension:Classification of Blood Pressure (BP)

Category SBP mmHg DBP mmHgNormal <120 and <80Prehypertension 120-139 or 80-89Hypertension, Stage 1 140-159 or 90-99Hypertension, Stage 2 >160 or >100

http://www.nhlbi.nih.gov/guidelines/hypertension/phycard.pdf Protocol for Evaluation and Treatment of Hypertension

1. A patient suspected of having Hypertension (HTN) should be treated according to the WHO guidelines below (with modifications described subsequently.)

2. Any patient with pre-HTN, HTN, or risk factors should be clearly flagged and the need for follow up at the next brigade clearly indicated.

3. Any patient with severe and/or symptomatic HTN, after being started on treatment, must be followed up by a medical provider within one week. This must be explained clearly to both the patient and community leader and a plan put in place during the patient encounter.

http://www.who.int/bulletin/volumes/88/6/08-062364/en/

Modifications to above Protocol: Patients with age < 40 and SBP>140 should be screened for causes of secondary hypertension.

Depending on individual case (and degree of suspicion for secondary HTN causes,) the decision should be made to either refer for further workup or perform trial of lifestyle modifications and follow up at next mobile clinic/brigade. This decision process should be clearly documented.

For patients with SBP>180 or SBP 140-179 and co-existing disease should be started on treatment according to the above protocol and followed up within 1-2 weeks. These patients should be discussed with Dr. Miguel to ensure a proper follow up plan has been established.

In a patient with severe/symptomatic HTN, consider administering fast-acting treatment to lower the BP to an acceptable level (while closely monitoring the patient), initiating treatment, and arranging for close follow up following discussion with the in-country medical professionals.

The timing of follow up visits (i.e. Visit 1, Visit 2, Visit 3 referred to in the protocol) will be determined by the mobile clinic and brigade schedule (e.g. Visit 2 may occur at 2-3 months, rather than 4 months.)

Management of Existing HTN:Whenever possible, patients who are well controlled on a treatment regimen should be

continued on this regimen (i.e. medications should not be switched due to provider preference.) If a medication change is felt necessary, this must be clearly explained on the patient chart. The need for patient follow up should also be clearly indicated.

While HCTZ is the drug of choice for initiation of treatment for HTN, drug regimens should be modified according to co-existing conditions (e.g. ACE Inhibitor for diabetic patient, Beta Blocker and/or ACE I if history of MI.)

Diabetes: Preliminary Draft

Review of Diagnosis of Diabetes:American Diabetes Association Criteria for the Diagnosis of Diabetes1. A1C ≥6.5%. The test should be performed in a laboratory using a method that is NGSP certified

and standardized to the DCCT assay.*OR

2. FPG ≥126 mg/dl (7.0 mmol/l). Fasting is defined as no caloric intake for at least 8 h.*OR

3. Two-hour plasma glucose ≥200 mg/dl (11.1 mmol/l) during an OGTT. The test should be performed as described by the World Health Organization, using a glucose load containing the equivalent of 75 g anhydrous glucose dissolved in water.*

OR4. In a patient with classic symptoms of hyperglycemia or hyperglycemic crisis, a random plasma

glucose ≥200 mg/dl (11.1 mmol/l).*In the absence of unequivocal hyperglycemia, criteria 1–3 should be confirmed by repeat testing.

http://care.diabetesjournals.org/content/33/Supplement_1/S62.full.pdf#page=1&view=FitH

Notes on above criteria: Hemoglobin A1C and 2-hour OGTT are not readily available on the brigades and therefore,

except in specific instances, a fasting glucose is the preferred method.

On brigades, finger stick glucose (a.k.a. whole blood glucose) is used in place of plasma glucose.

Screening for Diabetes:

ADA Criteria for testing for diabetes in asymptomatic adult individuals1.

Testing should be considered in all adults who are overweight (BMI ≥25 kg/m2*) and have additional risk factors:

o physical inactivityo first-degree relative with diabeteso members of a high-risk ethnic population (e.g., African American, Latino, Native

American, Asian American, Pacific Islander)o women who delivered a baby weighing >9 lb or were diagnosed with GDMo hypertension (≥140/90 mmHg or on therapy for hypertension)o HDL cholesterol level <35 mg/dl (0.90 mmol/l) and/or a triglyceride level >250 mg/dl

(2.82 mmol/l)o women with polycystic ovary syndromeo A1C ≥5.7%, IGT, or IFG on previous testingo other clinical conditions associated with insulin resistance (e.g., severe obesity,

acanthosis nigricans)o history of CVD

2.

In the absence of the above criteria, testing diabetes should begin at age 45 years

3.

If results are normal, testing should be repeated at least at 3-year intervals, with consideration of more frequent testing depending on initial results and risk status.

*At-risk BMI may be lower in some ethnic groups.http://care.diabetesjournals.org/content/33/Supplement_1/S11/T4.expansion.html

Modifications of above criteria for brigades: Using the criteria above, the patient population served by the brigades is considered a high risk ethnicity (based on the definition of Latino.) However, these screening criteria apply largely to patients living in the United States and does not necessarily mean that all patients of the noted ethnicities are at high risk. Therefore the decision to screen patients should be based on the presence of other risk factors as well. Measurements of cholesterol, triglycerides, and HgB A1c are not readily available for patients and should be considered only in very specific cases. For the purposes of this brigade, the following patients should be screened with a fasting finger stick glucose (or random finger stick glucose when fasting is not possible):

o Known history of diabeteso Symptoms suggestive of diabeteso A BMI>25 and one of the following:

A strong family history of diabetes HTN History of CVD Severe obesity and/or acanthosis nigracans History of GDM and/or an infant with birthweight > 9lbs

Treatment of Diabetes:New Diagnosis:o Most patients with suspected or newly diagnosed diabetes may be initially counseled on lifestyle

modifications and followed up at the next brigade. This includes patients who have a first-time fasting blood glucose level of >126 (remember two readings are needed to confirm diagnosis).

o The exception to the above is patients that are severely hyperglycemic and/or symptomatic. These patients should be started on oral hypoglycemic agents that day and close follow up should be arranged.

o A patient who is being seen for a repeat finger stick glucose level that has persistent hyperglycemia (therefore meeting the criteria for diagnosis outlined above) should also be started on oral hypoglycemic agents as well (again with close follow up arranged).

o Metformin is the initial treatment of choice. Should a patient require a sulfonylurea, symptoms of hypoglycemia should be clearly discussed with the patient and very close follow up for blood glucose monitoring arranged.

Chronic treatment:A patient with a known history of diabetes should be followed closely at every brigade and maintained on a treatment regimen to maximize glycemic control. Diet and exercise modification should also be discussed at every brigade. If changes are made to the patient’s previous regimen, this must be clearly documented in the patient’s chart.

5. Parasite Therapy Quick Reference Guide

De-worming Protocol Albendazole Dosing

200mg PO x 1 dose for children aged 12-23 months; 400mg PO x 1 dose for children >2 year of age and adults

Mebendazole Dosing500mg PO single dose for children >1 year of age and adults

(alternative treatment regimen is 100mg PO BID x 3 days)Please Note:

1. Children over the age of 1 should be empirically treated every six months. (Prior to giving medicine, it is important to ensure the patient has not received treatment in the past six months, either during a previous Timmy brigade or from another source (school, another medical professional, etc.))

2. Symptomatic adults should be considered for treatment (vs stool testing)3. Patients who are pregnant or breastfeeding do not receive de-worming treatment.4. Patients under the age of 1 do not receive de-worming treatment.5. For very young children, the tablet should be crushed prior to administration

Protozoal Intestinal Infections*Due to the fairly indistinguishable symptoms of Entamoeba and Giardia Lamblia and the difficulty of stool testing, we will defer to the higher dose of Metronidazole when either is suspected in the absence of test results.Entamoeba

ChildrenMetronidazole 35-50mg/kg/day divided TID 7-10 days (max 500mg/dose)Adults:Metronidazole 500mg PO TID x 7-10 days

Giardia LambliaChildrenMetronidazole 15mg/kg/day divided TID x 5-7 days (max 250mg/dose)Adults:Metronidazole 250mg PO TID x 5-7 days