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©
THE WASHINGTON
<
Z
5
MANUAL® OF MEDICALTHERAPEUTICS
E D I T I O N
Department
Washington
School St
Louis,Missouri
.
of
3 7
Medicine
of
University
Medicine
Washington
University
B
Wo
Iters
Kluwer
SCHOOL
in
OF
MEDICINE
St
Louis
THEWASHINGTONMANUAL®OFMEDICAL
THERAPEUTICS
37thEdition
Editors
SiriAncha,MD
ChristineAuberle,MD
DevinCash,MD,PhD
MohitHarsh,MD
JohnHickman,MD
CaroleKounga,MD,PharmD
AcquisitionsEditor:JoeCho DevelopmentEditor:ThomasCelona/ArielS.Winter EditorialCoordinator:AnthonyGonzales ProductionProjectManager:KirstinJohnson MarketingManager:KirstenWatrud Manager,GraphicArts&Design:StephenDruding ManufacturingCoordinator:BethWelsh PrepressVendor:TNQTechnologies
Copyright©2023DepartmentofMedicine,WashingtonUniversitySchoolofMedicine.
Copyright©2020,2016,2014,2010,2007,2004DepartmentofMedicine,WashingtonUniversitySchoolofMedicine.Allrightsreserved.This bookisprotectedbycopyright.Nopartofthisbookmaybereproducedortransmittedinanyformorbyanymeans,includingasphotocopies orscanned-inorotherelectroniccopies,orutilizedbyanyinformationstorageandretrievalsystemwithoutwrittenpermissionfromthe copyrightowner,exceptforbriefquotationsembodiedincriticalarticlesandreviews.Materialsappearinginthisbookpreparedbyindividuals aspartoftheirofficialdutiesasU.S.governmentemployeesarenotcoveredbytheabove-mentionedcopyright.Torequestpermission,please contactWoltersKluweratTwoCommerceSquare,2001MarketStreet,Philadelphia,PA19103,viaemailatpermissions@lww.com,orvia ourwebsiteatshop.lww.com(productsandservices).
9 8 7 6 5 4 3 2 1
PrintedinMexico.
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ISBN-13:978-1-975190-62-0
CataloginginPublicationdataavailableonreques tfrompublisher.
Thisworkisprovided“asis,”andthepublisherdisclaimsanyandallwarranties,expressorimplied,includinganywarrantiesastoaccuracy, comprehensiveness,orcurrencyofthecontentofthiswork.
Thisworkisnosubstituteforindividualpatientassessmentbaseduponhealthcareprofessionals’examinationofeachpatientandconsideration of,amongotherthings,age,weight,gender,currentorpriormedicalconditions,medicationhistory,laboratorydataandotherfactorsuniqueto thepatient.Thepublisherdoesnotprovidemedicaladviceorguidanceandthisworkismerelyareferencetool.Healthcareprofessionals,and notthepublisher,aresolelyresponsiblefortheuseofthisworkincludingallmedicaljudgmentsandforanyresultingdiagnosisandtreatments.
Givencontinuous,rapidadvancesinmedicalscienceandhealthinformation,independentprofessionalverificationofmedicaldiagnoses, indications,appropriatepharmaceuticalselectionsanddosages,andtreatmentoptionsshouldbemadeandhealthcareprofessionalsshould consultavarietyofsources.Whenprescribingmedication,healthcareprofessionalsareadvisedtoconsulttheproductinformationsheet(the manufacturer’spackageinsert)accompanyingeachdrugtoverify,amongotherthings,conditionsofuse,warningsandsideeffectsand identifyanychangesindosagescheduleorcontraindications,particularlyifthemedicationtobeadministeredisnew,infrequentlyusedorhasa narrowtherapeuticrange.Tothemaximumextentpermittedunderapplicablelaw,noresponsibilityisassumedbythepublisherforanyinjury and/ordamagetopersonsorproperty,asamatterofproductsliability,negligencelaworotherwise,orfromanyreferencetoorusebyany personofthiswork.
shop.lww.com
Wethankourfamiliesfortheirloveandsupportandourmentorsfortheirguidanceanddedication.
Siri:TomyfamilyDr.SudhakarAncha,Rani,Suma,andJack;tomymentorsDr.OsamaAltayarand
Dr.JeffCrippin.
Christine:TomyfamilyDr.JacobBeck,MelissaandJakeStuder,MaryanneTsivitse,andDr.Jim
Auberle;tomymentorDr.AmandaCashen.
Devin:TomyfamilySherrie,Tim,Derek,Therese,Josephine,andDaphneCash;tomymentorsDr.
CynthiaCornelissen,Dr.StephanieCall,Dr.PatrickAguilar,andDr.NickoleForget.
Mohit:Tomyparentsandbrother.Toallofmymentors:Dr.GeromeEscota,Dr.RezaManesh,Dr.Bob
Centor,andDr.JamesJensen.TomyacademicpartnersDr.LucasBracero,Dr.KeeganMullins,and
Dr.EamonnMaher.TomyMUSOMfamilyandmycollegesquad.Toallofmypatientswhoteachand
humbleme.
John:ToAlex,Joanna,andElliot;ZachariahandFrank;Dr.JanetandDr.RobertHickman;Allison;
Dr.SteveBus;andDr.PeggieFindlay.
Carole:TotheTaboutafamily,Dr.Kounga,Drs.Djoko,PapaMaurice,MamanRebecca,Anne, Melaine,Maggie,Laure,Valery,andmyteammateArmand.Tomyfriends,especiallyDr.Briana McLaughlin.TomymentorsDr.Battle,Dr.Maynard,Dr.D.Brown,Dr.A.Brown,Dr.Bauch,Dr.
Faddis,andDr.Lenihan.
TotheDepartmentofGeneralMedicineStaff:Dr.AnnAhrens,JenBogovich,JulieByington,Jenae
Davis,MeganDietrich,AmyFoyil,KirstenJones,BethanyMillar,RachelNoon,andKatieSidler.
Preface
Wehavetheprivilegeandhonortointroducethe37theditionofTheWashingtonManual®ofMedical Therapeutics.TheManualbeganasasimpleassortmentof“TherapeuticNotes”collectedbyasenior
resident,WaylandMacFarlane,in1943attheWashingtonUniversitySchoolofMedicineinSt.Louis. Thatcollectionofnoteshasbecomeoneofthemostsuccessfulmedicalreferencemanualsinthehistory ofmedicine.Duringthemid-1960s,TheManualgrewinpopularitywiththepublishingof4000copiesof the16theditionbyRobertPackman,MD,makingitavailabletonumerousmedicalschoolsacrossthe UnitedStatesforthefirsttime.Thesubsequenteditiongrewto25,000copiessold.TheManualhassince expandedtoincorporatethebroaddepthofmedicalknowledgeinitsincreasingcomplexity.TheManual hassoldmorethan1millionelectronicandprintcopiesworldwideandhasbeentranslatedintomore than20languages.DespitethegrowthofTheManual,theinitialmissionremainssteadfast:toprovide relevant,evidence-basedclinicalsupporttophysiciansatthebedsideandtopositivelyimpactpatient care.
WiththeadventoftheCOVID-19pandemic,theeditorsappreciatethespeedatwhichmedical knowledgecanadvancethroughinterprofessionalandglobalcollaboration.ThiseditionofTheManual wascompiledthroughtheeffortsofgenerationsofphysiciansandlearnerswhosoughttocontributetothat growingknowledge.
ThiseditionisforemostatributetotheWashingtonUniversityinSt.LouisInternalMedicine housestaff,fellows,medicalstudents,andattendingswithwhomweworkdaily.Theirrolemodeling, mentoring,compassion,teaching,brilliance,andhardworkareanunlimitedsourceofenthusiasm, inspiration,anddedication.Weconsiderourselvesveryluckyandgratefultohavetrainedalongsidethem, inservicetoourpatients.
WehavegreatappreciationforthesubstantialsupportanddirectionthatDr.ThomasCiesielski,the executiveeditor,providedinthecreationofthisedition.WealsosincerelythankKatieSharpandthe editorialstaffatWoltersKluwerfortheirassistanceandguidanceinthiseffort.
WehavehadthedistinctionofservingaschiefresidentsintheDepartmentofMedicineatthe WashingtonUniversitySchoolofMedicineinSt.Louis,andouraccomplishmentswouldnothavebeen possiblewithoutourlargerdepartmentalteam.Wewouldliketoacknowledgethesupportand collaborationwehaveexperiencedfromourAssociateProgramDirectors,Drs.ThomasCiesielski, GeoffreyCislo,AnthonyDao,AmberDeptola,MichaelDeVita,PatriciaKao,MaryClareMcGregor, JenniferSchmidt,andMeganWren.OurProgramDirector,Dr.DominiqueCosco,hasprovideduswith guidanceandimmensesupportduringthecourseofthisyear.TheChairoftheDepartmentofMedicine, Dr.VictoriaFraser,hasservedasanexcellentrolemodelandmentorandholdsoursincereadmiration.
https://t.me/med1917
DepartmentChair’sNote
Medicineandhealthcaredeliverycontinuetoevolvebasedonthesignificantadvancesinbiomedical science,improvementsinpatientsafetyandquality,anddiversityofhealthcaresettings.Ithasbecome moreimportantthaneverforphysicianstohaverapidaccesstonewevidencetoguideclinicalpractice. Tremendousadvancesinsciencehaveledtonewmoleculardiagnostics,moresensitivebiomarkers,and noveltherapiesthatimprovepatientoutcomes.TheWashingtonManual®ofMedicalTherapeutics providesanexcellentsourceofinformationfocusedonpracticalclinicalapproachestothediagnosis, investigation,andtreatmentofcommonmedicalconditionsregularlyencounteredbyinternists.Theonline andin-printversionsofTheWashingtonManual®ensurethatitwillcontinuetobeofenormous assistancetointerns,residents,medicalstudents,andotherpractitioners.TheWashingtonManual
®
providesanimportantresourceofmedicalinformationandefficientapproachestotransfernew knowledgeintoevidenced-basedpatientcare.
Iamverygratefultotheauthors,whoincludeoutstandinghouseofficers,fellows,andattendingsat WashingtonUniversity/Barnes-JewishHospital.Theireffortsandexceptionalskillsareevidentinthe qualityofthefinalproduct.Inparticular,Iamproudofoureditors:Drs.SiriAncha,ChristineAuberle, DevinCash,MohitHarsh,JohnHickman,andCaroleKounga,andExecutiveEditorThomasM. Ciesielski,whohaveproducedanotheroutstandingeditionofTheWashingtonManual®ofMedical Therapeutics.IalsothankDr.DominiqueCoscoforherleadershipofourresidencytrainingprogram.I amconfidentthatthiseditionwillmeetitsdesiredgoalofprovidingpracticalknowledgethatwillbe directlyappliedtoimprovingpatientcare.
VictoriaJ.Fraser,MD
AdolphusBuschProfessorofMedicine
Chair,DepartmentofMedicine
WashingtonUniversitySchoolofMedicine
St.Louis,Missouri
https://t.me/med1917
Contents
Preface
DepartmentChair’sNote 
Contributors
1 InpatientCareinInternalMedicine
MichaelLin,EricJohnson,andCrystalAtwood
2 NutritionSupport
KaiJones,DominicReeds,andKatrinaHan
3 PreventiveCardiology
LaurenEast,DominiqueS.Williams,andAnneC.Goldberg
4 IschemicHeartDisease
NoahN.WillifordandMarcA.Sintek
5 HeartFailureandCardiomyopathy
BinQ.Yang,JustinC.Hartupee,andJustinM.Vader
6 PericardialandValvularHeartDisease
PhillipM.KingandNishathQuader
7 CardiacArrhythmias
SandeepS.Sodhi,DanielH.Cooper,andMitchellN.Faddis
8 CriticalCare
DavidB.RoseandMarinH.Kollef
9 ObstructiveLungDisease
JamesG.Krings,LauraHalverson,RodrigoVazquezGuillamet,andKaharuSumino
10 PulmonaryDiseases
AdrianShifren,MuraliChakinala,AlexanderChen,GabrielSchroeder,KatherineDittman,PaulKannarkat,NathanielMoulton, PraveenChenna,JamesG.Krings,andTonyaD.Russell
11 AllergyandImmunology
JenniferM.MonroyandDayneVoelker
12 FluidandElectrolyteManagement
MaryamSaleemandStevenCheng
13 RenalDiseases
BlessingOsonduandSethGoldberg
14 TreatmentofInfectiousDiseases
MiguelA.Chavez,NigarKirmani,andStephenY.Liang
15 Antimicrobials
DavidJ.Ritchie,NigarKirmani,andDanielT.Ilges
https://t.me/med1917
16 SexuallyTransmittedInfections,HumanImmunodeficiencyVirus,and
AcquiredImmunodeficiencySyndrome
JosephN.Cherabie,RachelM.Presti,andHilaryE.L.Reno
17 SolidOrganTransplantMedicine
RowenaDelosSantosandWutYiHninn
18 GastrointestinalDiseases
MartinH.GregoryandC.PrakashGyawali
19 LiverDiseases
LolwaAl-Obaid,RebeccaRoediger,ParthShah,andJeffreyCrippen
20 DisordersofHemostasisandThrombosis
KristenM.Sanfilippo,BrianF.Gage,Tzu-FeiWang,andRogerD.Yusen
21 HematologicDisordersandTransfusionTherapy
BindiyaG.Patel,AmyZhou,SanaSaifUrRehman,andRayZhang
22 Cancer
ZacharyD.Crees,SiddharthaDevarakonda,AmandaCashen,RamaswamyGovindan,andDanielMorgensztern
23 DiabetesMellitusandRelatedDisorders
CynthiaJ.HerrickandJanetB.McGill
24 Endocrine
SamanthaE.Adamson,CynthiaJ.Herrick,AmyE.Riek,andWilliamE.Clutter
25 ArthritisandRheumatologicDiseases
AndreaRamirezGomezandDeepaliSen
26 MedicalEmergencies
SueLinHilbert,MarkD.Levine,andEvanS.Schwarz
27 NeurologicDisorders
MaryE.PetrulisandJamesA.Giles
28 Toxicology
JasonDevgun,KevinBaumgartner,andMichaelE.Mullins
AppendixA:ImmunizationsandPostexposureTherapies
CarlosMejia-ChewandStephenY.Liang
AppendixB:InfectionControlandIsolationRecommendations
CalineMattar,StephenY.Liang
AppendixC:AdvancedCardiacLifeSupportAlgorithms
SiriAncha
Index
https://t.me/med1917
Contributors
SamanthaE.Adamson,MD,PhD
Fellow DivisionofEndocrinology
SiriAncha,MD
InstructorinMedicine DivisionofGeneralMedicine
LolwaAl-Obaid,MD
Fellow DivisionofGastroenterology
CrystalAtwood,MD
AssistantProfessorofMedicine DivisionofHospitalMedicine
KevinBaumgartner,MD
AssistantProfessorofMedicine DepartmentofEmergencyMedicine
AmandaCashen,MD
ProfessorofMedicine DivisionsofHematologyandOncology
MuraliChakinala,MD
ProfessorofMedicine DivisionofPulmonaryandCriticalCareMedicine
MiguelA.Chavez,MD,MSc
InstructorinMedicine DivisionofHospitalMedicine
AlexanderChen,MD
AssociateProfessorofMedicineandSurgery DivisionofPulmonaryandCriticalCareMedicine
StevenCheng,MD
ProfessorofMedicine DivisionofNephrology
PraveenChenna,MD
https://t.me/med1917
AssociateProfessor DivisionofPulmonaryandCriticalCareMedicine
JosephN.Cherabie,MD,MSc
InstructorinMedicine DivisionofInfectiousDiseases
WilliamE.Clutter,MD
AssociateProfessorofMedicine DivisionofEndocrinology,Metabolism,andLipidResearch
DanielH.Cooper,MD
AssociateProfessor CardiovascularDivision
ZacharyD.Crees,MD
Fellow DivisionsofHematologyandOncology
JeffreyCrippen,MD
ProfessorofMedicine DivisionofGastroenterology
SiddharthaDevarakonda,MD
AssistantProfessorofMedicine DivisionofMedicalOncology
JasonDevgun,MD
AssistantProfessorofEmergencyMedicine DepartmentofEmergencyMedicine
KatherineDittman,DO
Fellow DivisionofPulmonaryandCriticalCareMedicine
LaurenEast,MD
Resident DepartmentofInternalMedicine
MitchellN.Faddis,MD,PhD
ProfessorofMedicine CardiovascularDivision
BrianF.Gage,MD
ProfessorofMedicine
https://t.me/med1917
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