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Guideline Summary
Guideline Title
Ulcerative colitis practice guidelines in adults: American College of Gastroenterology, Practice Parameters Committee.
Bibliographic Source(s)
Kornbluth A, Sachar DB, Practice Parameters Committee of the American College of Gastroenterology. Ulcerative colitis practice guidelines in adults: American College of Gastroenterology, Practice Parameters Committee. [Erratum in: Am J Gastroenterol. 2010 Mar;105(3):500]. Am J Gastroenterol. 2010 Mar;105(3):501-23. [426 references] PubMed External Web Site Policy
Guideline Status

This is the current release of the guideline.

Scope

Disease/Condition(s)

Ulcerative colitis

Guideline Category
Diagnosis
Evaluation
Management
Treatment
Clinical Specialty
Colon and Rectal Surgery
Family Practice
Gastroenterology
Internal Medicine
Intended Users
Physicians
Guideline Objective(s)

To indicate preferred approaches to the treatment of ulcerative colitis as established by scientifically valid research

Target Population

Adults with known or suspected ulcerative colitis

Interventions and Practices Considered

Diagnosis and Assessment

  1. Stool examinations
  2. Sigmoidoscopy or colonoscopy
  3. Biopsy

Treatment/Management

  1. Pharmacology
    • Mesalamine agents
    • Aminosalicylates
    • Corticosteroids (e.g., prednisone)
    • Infliximab
    • Thiopurines or azathioprine
    • Sulfasalazine
    • Olsalazine
    • Balsalazide
    • Intravenous cyclosporine
    • Antibiotics (e.g., metronidazole, ciprofloxacin)
  2. Surgery
    • Absolute indications for surgery are exsanguinating hemorrhage, perforation, and documented or strongly suspected carcinoma
    • Total proctocolectomy with a continent ileostomy (Koch pouch) or subtotal colectomy with an ileorectal anastomosis (neither recommended)
    • Ileal pouch-anal anastomosis (IPAA)
    • Management of IPAA post-operative pouchitis
  3. Cancer surveillance
Major Outcomes Considered
  • Sensitivity and specificity of diagnostic tests
  • Symptoms of ulcerative colitis
  • Complications of ulcerative colitis
  • Efficacy of treatments
  • Response and remission rates
  • Relapse rate
  • Complications of treatments
  • Predictive value of risk assessment tests
  • Morbidity and mortality
  • Quality of life

Methodology

Methods Used to Collect/Select the 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

An English language literature search was performed using the PubMed database and the Cochrane database of systematic reviews. Both were searched from inception to 2009. Bibliographies of all relevant references were reviewed for additional references. Only papers published in full manuscript form in peer reviewed journals were included.

The search terms included "ulcerative colitis", as both medical subject headings (MeSH) and free terms. These were combined using the following terms individually, or with the set operator AND (ulcerative colitis):

  • Epidemiology
  • Demographics
  • Medical costs
  • Diagnosis
  • Colonoscopy
  • Sigmoidoscopy
  • Histology
  • Etiology
  • Differential diagnosis
  • Clostridium difficile
  • Crohn's disease
  • Diverticular colitis
  • Serologies
  • Perinuclear antineutrophil cytoplasmic antibodies
  • Treatment
  • Remission
  • Maintenance of remission
  • Mucosal healing
  • Extraintestinal manifestations
  • Vaccination
  • Noncompliance
  • Nonadherence
  • Mesalamine
  • Aminosalicylate
  • Topical mesalamine
  • Topical corticosteroids
  • Sulfasalazine
  • Mesalamine
  • Balsalazide
  • Olsalazine
  • Multimatrix release mesalamine
  • Nicotine
  • Adverse events
  • Prednisone
  • Corticosteroids
  • Toxicity
  • Osteoporosis
  • Dexa scan
  • Osteonecrosis
  • Guidelines
  • Azathioprine
  • 6-mercaptopurine
  • Thiopurine methyltransferase
  • 6-thioguanine
  • 6-methylmercaptopurine
  • Methotrexate
  • Infliximab
  • Opportunistic infection
  • Lymphoma
  • Hepatosplenic T-cell lymphoma
  • Severe colitis
  • Steroid refractory
  • Fulminant
  • Antibiotics
  • Colectomy
  • Cyclosporine
  • Cytomegalovirus
  • Total parental nutrition
  • Megacolon
  • Thromboembolism
  • Hypercoaguable
  • Tacrolimus
  • Surgery
  • Ileoanal pouch anastomosis
  • Pouchitis
  • Fertility
  • Surveillance
  • Dysplasia
  • Carcinoma
  • Adenoma
  • Colon cancer
  • Chromoendoscopy
    • Number of Source Documents

      Not stated

      Methods Used to Assess the Quality and Strength of the Evidence
      Weighting According to a Rating Scheme (Scheme Given)
      Rating Scheme for the Strength of the Evidence

      See the "Rating Scheme for the Strength of the Recommendations" field.

      Methods Used to Analyze the Evidence
      Review of Published Meta-Analyses
      Systematic Review
      Description of the Methods Used to Analyze the Evidence

      Not stated

      Methods Used to Formulate the Recommendations
      Expert Consensus (Nominal Group Technique)
      Description of Methods Used to Formulate the Recommendations

      Each recommendation is generated by a process known as the "nominal group technique." In this process, the authorship group first discusses the goal of the recommendation. Then each member of the group writes one or more statements that they feel best expresses the goal of the recommendation. These statements are disseminated, without attribution of author, among the authors, who then rank the statements, first, second, third, and so on. The statement with the lowest point total is deemed to best express the consensus of the group, and is endorsed.

      Rating Scheme for the Strength of the Recommendations

      The recommendations made are based on the level of evidence found. Grade A recommendations imply that there is consistent level 1 evidence (randomized controlled trials), grade B indicates that the evidence would be level 2 or 3, which are cohort studies or case-control studies. Grade C recommendations are based on level 4 studies, meaning case series or poor-quality cohort studies, and grade D recommendations are based on level 5 evidence, meaning expert opinion.

      Cost Analysis

      Cancer Surveillance

      There appears to be indirect evidence that cancer surveillance is likely to be effective in reducing the risk of death from inflammatory bowel disease (IBD)-associated colorectal cancer and that it may be acceptably cost-effective. Examination every second year as opposed to annually would reduce costs, particularly in patients with longer disease duration, but at the expense of reducing likelihood of early cancer detection, as in some, but not all series annual hazard rates increased with longer disease duration. Whatever schedule might be theoretically most advisable, being both frankly informative and programmatically flexible with patients is important in gaining adherence. The cost of such a surveillance program for each successful detection of precancer or cancer compares favorably with the cost of population-wide screening by flexible sigmoidoscopy for all subjects at average risk for colorectal cancer as well as with the cost of other widely accepted screening programs such as mammography and Pap smears.

      Method of Guideline Validation
      External Peer Review
      Internal Peer Review
      Description of Method of Guideline Validation

      In an effort to make new guidelines as "fresh" as possible when published, the American College of Gastroenterology (ACG) created a special guideline review process, involving members of the Board of Trustees, Practice Parameters Committee and the American Journal of Gastroenterology. It is the goal to review the guideline, allow guideline authors to revise the guideline, and re-review the guideline within 6 months of first submission. Therefore the entire process should take 1 year from commission to finished, accepted guideline.

      Recommendations

      Major Recommendations

      Definitions for level of evidence (1-3) and strength of recommendation (A-D) are given at the end of the "Major Recommendations" field.

      Recommendations for Diagnosis and Assessment

      In a patient presenting with persistent bloody diarrhea, rectal urgency, or tenesmus, stool examinations and sigmoidoscopy or colonoscopy and biopsy should be performed to confirm the presence of colitis and to exclude the presence of infectious and noninfectious etiologies. Characteristic endoscopic and histologic findings with negative evaluation for infectious causes will suggest the diagnosis of ulcerative colitis (UC).

      Approach to Management

      Goals of treatment are induction and maintenance of remission of symptoms to provide an improved quality of life, reduction in need for long-term corticosteroids, and minimization of cancer risk.

      Recommendations for Management of Mild-Moderate Distal Colitis

      Patients with mild to moderate distal colitis may be treated with oral aminosalicylates, topical mesalamine, or topical steroids (Evidence A). Topical mesalamine agents are superior to topical steroids or oral aminosalicylates (Evidence A). The combination of oral and topical aminosalicylates is more effective than either alone (Evidence A). In patients refractory to oral aminosalicylates or topical corticosteroids, mesalamine enemas or suppositories may still be effective (Evidence A). The unusual patient who is refractory to all of the above agents in maximal doses, or who is systemically ill, may require treatment with oral prednisone in doses up to 40–60 mg per day, or infliximab with an induction regimen of 5 mg/kg at weeks 0, 2, and 6, although the latter two agents have not been studied specifically in patients with distal disease (Evidence C).

      Recommendations for Maintenance of Remission in Distal Disease

      Mesalamine suppositories are effective in the maintenance of remission in patients with proctitis, whereas mesalamine enemas are effective in patients with distal colitis when dosed even as infrequently as every third night (Evidence A). Sulfasalazine, mesalamine compounds, and balsalazide are also effective in maintaining remission; the combination of oral and topical mesalamine is more effective than either one alone (Evidence A). Topical corticosteroids including budesonide, however, have not proven effective for maintaining remission in distal colitis (Evidence A). When all of these measures fail to maintain remission in distal disease, thiopurines (6-mercaptopurine [6-MP] or azathioprine) and infliximab (Evidence A), but not corticosteroids, may prove effective (Evidence B).

      Recommendations for Mild-Moderate Extensive Colitis: Active Disease

      Patients with mild to moderate extensive colitis should begin therapy with oral sulfasalazine in daily doses titrated up to 4–6 g per day, or an alternate aminosalicylate in doses up to 4.8 g per day of the active 5-aminosalicylate acid (5-ASA) moiety (Evidence A). Oral steroids are generally reserved for patients who are refractory to oral aminosalicylates in combination with topical therapy, or for patients whose symptoms are so troubling as to demand rapid improvement (Evidence B). 6-MP and azathioprine are effective for patients who do not respond to oral steroids, and continue to have moderate disease, and are not so acutely ill as to require intravenous therapy (Evidence A). Infliximab is an effective treatment for patients who are steroid refractory or steroid dependent despite adequate doses of a thiopurine, or who are intolerant of these medications. The infliximab induction dose is 5 mg/kg intravenously at weeks 0, 2, and 6 weeks (Evidence A). Infliximab is contraindicated in patients with active infection, untreated latent tuberculosis (TB), preexisting demyelinating disorder or optic neuritis, moderate to severe congestive heart failure, or current or recent malignancies.

      Recommendations for Mild-Moderate Extensive Colitis: Maintenance of Remission

      Once the acute attack is controlled, a maintenance regimen is usually required, especially in patients with extensive or relapsing disease. Sulfasalazine, olsalazine, mesalamine, and balsalazide are all effective in reducing relapses (Evidence A). Patients should not be treated chronically with steroids. Azathioprine or 6-MP may be useful as steroid-sparing agents for steroid-dependent patients and for maintenance of remission not adequately sustained by aminosalicylates, and occasionally for patients who are steroid dependent but not acutely ill (Evidence A). Infliximab is effective in maintaining improvement and remission in the patients responding to the infliximab induction regimen (Evidence A).

      Recommendations for Management of Severe Colitis

      The patient with severe colitis refractory to maximal oral treatment with prednisone, oral aminosalicylate drugs, and topical medications may be treated with infliximab 5 mg/kg if urgent hospitalization is not necessary (Evidence A). The patient who presents with toxicity should be admitted to hospital for a course of intravenous steroids (Evidence C). Failure to show significant improvement within 3–5 days is an indication for either colectomy (Evidence B) or treatment with intravenous cyclosporine (CSA; Evidence A) in the patient with severe colitis. Long-term remission in these patients is significantly enhanced with the addition of maintenance 6-MP (Evidence B). Infliximab may also be effective in avoiding colectomy in patients failing intravenous steroids but its long-term efficacy is unknown in this setting (Evidence A).

      Recommendations for Surgery

      Absolute indications for surgery are exsanguinating hemorrhage, perforation, and documented or strongly suspected carcinoma (Evidence C). Other indications for surgery are severe colitis with or without toxic megacolon unresponsive to conventional maximal medical therapy, and less severe but medically intractable symptoms or intolerable medication side effects (Evidence C).

      Recommendations for Management of Pouchitis

      Patients who develop typical symptoms and signs of pouchitis after the ileal pouch-anal anastomosis (IPAA) should be treated with a short course of antibiotics (Evidence A). Controlled trial studies show efficacy for metronidazole in a dose of 400 mg three times daily, or 20 mg/kg daily, or ciprofloxacin 500 mg twice daily (Evidence A). Other etiologies mimicking pouchitis include irritable pouch syndrome, cuffitis, Crohn's disease of the pouch, and postoperative complications such as anastomotic leak or stricture. Inadequate evidence exists to recommend routine surveillance of the pouch for dysplasia or adenocarcinoma (Evidence C).

      Recommendations for Cancer Surveillance

      After 8–10 years of colitis, annual or biannual surveillance colonoscopy with multiple biopsies at regular intervals should be performed (Evidence B). The finding of high-grade dysplasia (HGD) in flat mucosa, confirmed by expert pathologists' review, is an indication for colectomy, whereas the finding of low-grade dysplasia (LGD) in flat mucosa may also be an indication for colectomy to prevent progression to a higher grade of neoplasia (Evidence B).

      Definitions:

      Grade A recommendations imply that there is consistent level 1 evidence (randomized controlled trials), Grade B indicates that the evidence would be level 2 or 3, which are cohort studies or case-control studies. Grade C recommendations are based on level 4 studies, meaning case series or poor-quality cohort studies, and Grade D recommendations are based on level 5 evidence, meaning expert opinion.

      Clinical Algorithm(s)

      None provided

      Evidence Supporting the Recommendations

      Type of Evidence Supporting the Recommendations

      The type of supporting evidence is identified and graded for most recommendations (see the "Major Recommendations" field).

      Benefits/Harms of Implementing the Guideline Recommendations

      Potential Benefits

      Appropriate diagnosis, assessment, and management of ulcerative colitis

      Potential Harms

      Management of Mild-Moderate Distal Colitis

      • Efficacy of olsalazine in active ulcerative colitis (UC) is not conclusively established, perhaps in part because of a confounding dose-related diarrhea.
      • Intolerance to the sulfapyridine moiety of sulfasalazine is fairly common and may result in nausea, vomiting, dyspepsia, anorexia, and headache. More severe but less common adverse effects include allergic reactions, pancreatitis, hepatotoxicity, drug-induced connective tissue disease, bone marrow suppression, interstitial nephritis, and hemolytic anemia or megaloblastic anemia. Abnormal sperm counts, motility, and morphology are also related to the sulfapyridine moiety of sulfasalazine and are not seen with the mesalamine preparations. Approximately 80% of patients intolerant to sulfasalazine are able to tolerate olsalazine, mesalamine, and balsalazide. However, several of the allergic reactions previously thought to be due to the sulfa moiety have occasionally been seen with newer aminosalicylates as well.
      • The occurrence of nephrotoxicity with either sulfasalazine or any of the mesalamine compounds is rare. Nephrotoxicity usually presents as interstitial nephritis; it occurs most frequently during the first year of treatment, but can occur unpredictably with a delayed presentation. See the original guideline document for additional detail.

      Management of Mild-Moderate Extensive Colitis: Active Disease

      • Oral prednisone shows a dose–response effect between 20 and 60 mg per day for management of mild-moderate extensive colitis (active disease), with 60 mg per day modestly more effective than 40 mg per day but at the expense of greater side effects.
      • The frequency and severity of steroid toxicity are substantial and may involve many metabolic activities in virtually every organ system. These adverse effects include cushingoid features, emotional and psychiatric disturbances, infections, glaucoma, and cataracts. Annual ophthalmologic examinations for patients on chronic steroids are recommended. Additional steroid-induced complications include gastroduodenal mucosal injury, skin striae, impaired wound healing, and metabolic bone disease. The latter can present insidiously with osteopenia and osteoporosis, or with the more dramatic bone fracture or unpredictable osteonecrosis. See the original guideline document for additional detail.
      • Infliximab infusion is administered over a 2h period in a monitored setting, with personnel trained to treat severe infusion reactions. Besides infusion reactions, the most common or troubling adverse effects of infliximab include autoimmunity and increased risks of infection, lymphoma, and possibly other malignancies. Other rare but serious adverse effects of infliximab include hepatotoxicity, development or exacerbation of multiple sclerosis or optic neuritis, and worsening of congestive heart failure in patients with preexisting cardiac disease. See the original guideline document for additional detail.
      • Azathioprine and 6-mercaptopurin (6-MP) toxicities include bone marrow suppression, particularly leukopenia, which is usually dose dependent. Leukopenia most often occurs within the first weeks to months of use, so complete blood counts should be measured more frequently during this period, though late bone marrow suppression may occur. The risk of opportunistic infections is increased approximately threefold, and there is a further synergistic risk when thiopurines are used concomitantly with either steroids or infliximab. There is a greater tendency for serious infections in patients with lower absolute lymphocyte counts or leukopenia. The frequency of liver abnormalities varies between 2% and 17% of patients and depends largely on the definitions of liver abnormalities reported. The liver test abnormalities are usually reversible and generally occur soon after the initiation of thiopurine treatment. Although the thiopurine metabolite 6-methylmercaptopurine (6-MMP) has been associated with elevated transaminases, the sensitivity and specificity of 6-MMP for hepatotoxicity are poor. Allergic reactions occur in approximately 2-5% of patients and usually present as some combination of fever, rash, myalgias, or arthralgias. Pancreatitis occurs as a hypersensitivity reaction in approximately 2% of patients, and will invariably reoccur if treatment with the alternative thiopurine is attempted. Conversely, patients with gastrointestinal intolerance to azathioprine not related to pancreatitis may tolerate 6-MP. Long-term use of thiopurines has not been associated with increased risk of solid tumors.

      Mild-Moderate Extensive Colitis: Maintenance of Remission

      • The risk-benefit ratio of indefinite azathioprine or 6-MP use for the maintenance of remission, especially when compared with colectomy, is not known. However, experience with the thiopurines over the last four decades indicates that there is not an increased risk of the development of solid tumors or overall mortality. Conversely, a recent meta-analysis of six cohort studies calculated a fourfold increased risk of lymphoma among inflammatory bowel disease (IBD) patients treated with thiopurines, but it remains unclear whether this risk was due to the medications themselves or due to the underlying disease.

      Management of Severe Colitis

      • Significant toxicity may occur with cyclosporine-A (CSA) use in UC. Severe adverse events include nephrotoxicity, infection, and seizures (particularly in patients with associated hypocholesterolemia or hypomagnesemia). More common but less severe side effects include paresthesias, hypertension, hypertrichosis, headache, abnormal liver function tests, hyperkalemia, and gingival hyperplasia. During intervals of triple immunosuppression with steroids, CSA, and a thiopurine, many experts treat patients with prophylaxis against Pneumocystis jiroveci (carinii), such as trimethoprim/sulfamethoxazole or dapsone. Most authors have found that CSA does not increase the rate of postoperative complications in patients undergoing proctocolectomy, in contrast to the preoperative use of corticosteroids in patients with IBD that substantially increases the risk of postoperative infections.
      • There are no controlled or uncontrolled trials directly comparing CSA to infliximab in patients with severe steroid-refractory UC. However, in a series of 19 patients who failed one therapy, and were then treated with the alternative drug within 30 days, two patients developed septicemia, and one died during the 30-day interval of receiving both the drugs. There is conflicting evidence as to whether infliximab increases the risk of postoperative complications. See the original guideline document for additional detail.

      Surgery

      • The option of a total proctocolectomy with a continent ileostomy (Koch pouch) is rarely used because of the frequency of pouch outlet obstruction over time.
      • A subtotal colectomy with an ileorectal anastomosis is rarely advisable as it leaves the potential for disease recurrence and/or cancer risk in the retained rectal segment.
      • There is increasing recognition of the potential complications following ileal pouchanal anastomosis (IPAA). Besides pouchitis, which may occur in up to 50% of patients during long-term follow-up, a variety of surgical complications may ensue. (See the original guideline document for additional detail.) Patients should be counseled regarding the effects of the IPAA on fertility and sexual function.

      Contraindications

      Contraindications
      • In patients on immunosuppressants, live vaccines are contraindicated, so if these are required they should be administered at the time of ulcerative colitis (UC) diagnosis.
      • Infliximab is contraindicated in patients with active infection, untreated latent tuberculosis (TB), preexisting demyelinating disorder or optic neuritis, moderate to severe congestive heart failure, or current or recent malignancies.
      • Patients with decompensated heart failure should not be treated with infliximab because of the risk of further decline in cardiac function.
      • Rare reports of the development of optic neuritis and multiple sclerosis have led to the recommendation that infliximab is relatively contraindicated in patients with a history of these disorders.
      • Patients may present with a megacolon with or without toxicity. In patients with either toxic signs (fever, leukocytosis, or worsening symptoms) or megacolon, medications with anticholinergic or narcotic properties should be avoided for possibility of worsening colonic atony or dilatation, as increased colonic and small intestinal gas is a predictor of a poor outcome to medical therapy.

      Qualifying Statements

      Qualifying Statements

      Guidelines for clinical practice are aimed to indicate preferred approaches to medical problems as established by scientifically valid research. Double-blind placebo controlled studies are preferable, but compassionate-use reports and expert review articles are used in a thorough review of the literature conducted through Medline with the National Library of Medicine. When only data that will not withstand objective scrutiny are available, a recommendation is identified as a consensus of experts. Guidelines are applicable to all physicians who address the subject regardless of specialty training or interests and are aimed to indicate the preferable but not necessarily the only acceptable approach to a specific problem. Guidelines are intended to be flexible and must be distinguished from standards of care, which are inflexible and rarely violated. Given the wide range of specifics in any healthcare problem, the physician must always choose the course best suited to the individual patient and the variables in existence at the moment of decision. Guidelines are developed under the auspices of the American College of Gastroenterology and its Practice Parameters Committee and approved by the board of trustees. Each has been intensely reviewed and revised by the Committee, other experts in the field, physicians who will use them, and specialists in the science of decision analysis. The recommendations of each guideline are therefore considered valid at the time of composition based on the data available. New developments in medical research and practice pertinent to each guideline will be reviewed at a time established and indicated at publication to assure continued validity.

      Implementation of the Guideline

      Description of Implementation Strategy

      An implementation strategy was not provided.

      Implementation Tools
      Patient Resources
      For information about availability, see the Availability of Companion Documents and Patient Resources fields below.

      Institute of Medicine (IOM) National Healthcare Quality Report Categories

      IOM Care Need
      Getting Better
      Living with Illness
      Staying Healthy
      IOM Domain
      Effectiveness
      Patient-centeredness
      Safety

      Identifying Information and Availability

      Bibliographic Source(s)
      Kornbluth A, Sachar DB, Practice Parameters Committee of the American College of Gastroenterology. Ulcerative colitis practice guidelines in adults: American College of Gastroenterology, Practice Parameters Committee. [Erratum in: Am J Gastroenterol. 2010 Mar;105(3):500]. Am J Gastroenterol. 2010 Mar;105(3):501-23. [426 references] PubMed External Web Site Policy
      Adaptation

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

      Date Released
      2010 Mar
      Guideline Developer(s)
      American College of Gastroenterology - Medical Specialty Society
      Source(s) of Funding

      American College of Gastroenterology

      Guideline Committee

      Practice Parameters Committee of the American College of Gastroenterology

      Composition of Group That Authored the Guideline

      Authors: Asher Kornbluth, MD; David B. Sachar, MD, MACG

      Financial Disclosures/Conflicts of Interest

      Potential Competing Interests

      Asher Kornbluth is a consultant for Salix Pharmaceutical, Shire Pharmaceutical, Proctor and Gamble Pharmaceutical, Centocor, and Prometheus Laboratory and has received research support from Salix Pharmaceutical, Procter and Gamble Pharmaceuticals, and Centocor Inc. He is also on the Speaker's Bureau of Salix Pharmaceutical, Shire Pharmaceutical, Proctor and Gamble Pharmaceutical, Centocor, Prometheus, and Axcan Pharmaceutical.

      David Sachar serves as expert witness for the plaintiffs in litigation claiming that isotretinoin was a cause of their inflammatory bowel disease. He has no other conflicts of interest to report.

      Guideline Status

      This is the current release of the guideline.

      Guideline Availability

      Electronic copies: Available from the American College of Gastroenterology (ACG) Web site External Web Site Policy.

      Availability of Companion Documents

      The following is available:

      Patient Resources

      The following is available:

      Please note: This patient information is intended to provide health professionals with information to share with their patients to help them better understand their health and their diagnosed disorders. By providing access to this patient information, it is not the intention of NGC to provide specific medical advice for particular patients. Rather we urge patients and their representatives to review this material and then to consult with a licensed health professional for evaluation of treatment options suitable for them as well as for diagnosis and answers to their personal medical questions. This patient information has been derived and prepared from a guideline for health care professionals included on NGC by the authors or publishers of that original guideline. The patient information is not reviewed by NGC to establish whether or not it accurately reflects the original guideline's content.

      NGC Status

      This NGC summary was completed by ECRI Institute on October 5, 2012.

      Copyright Statement

      This NGC summary is based on the original guideline, which is subject to the guideline developer's copyright restrictions.

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