# Evidence-Based Intervention Guidelines

## Overview

This reference provides comprehensive guidance on selecting, implementing, and documenting evidence-based interventions across pharmacological, non-pharmacological, and procedural treatment modalities. These guidelines support treatment plan development with current best practices and clinical recommendations.

## Evidence Hierarchy

### Levels of Evidence

**Level I: Highest Quality**
- Systematic reviews and meta-analyses of randomized controlled trials (RCTs)
- Large multi-center RCTs

**Level II: High Quality**
- Individual RCTs
- Systematic reviews of observational studies

**Level III: Moderate Quality**
- Cohort studies
- Case-control studies
- Well-designed observational studies

**Level IV: Lower Quality**
- Case series
- Case reports
- Expert opinion

**Recommendation Strength**:
- **Grade A**: Strong recommendation, high-quality evidence
- **Grade B**: Moderate recommendation, moderate-quality evidence  
- **Grade C**: Weak recommendation, low-quality evidence
- **Grade D**: Recommendation against (evidence of harm or no benefit)

## Pharmacological Interventions

### Medication Selection Principles

#### 1. Evidence-Based Prescribing
- Use medications with proven efficacy for indication
- Follow clinical practice guidelines
- Consider comparative effectiveness data
- Prefer medications with better safety profiles when equivalent efficacy

#### 2. Patient-Specific Factors
- Comorbidities and contraindications
- Organ function (renal, hepatic)
- Drug allergies and intolerances
- Concurrent medications (drug interactions)
- Age, pregnancy status
- Genetic factors (pharmacogenomics when available)
- Cost and insurance coverage

#### 3. Medication Safety
- Start low, go slow (especially in elderly, multiple comorbidities)
- Titrate to target dose based on response and tolerance
- Monitor for adverse effects
- Avoid potentially inappropriate medications (Beers Criteria for elderly)
- Polypharmacy reduction when possible

### Common Medication Classes by Indication

#### Hypertension

**First-Line Agents** (per JNC-8, ACC/AHA guidelines):
- **ACE Inhibitors** (lisinopril, enalapril): Preferred if diabetes, CKD, or heart failure
- **ARBs** (losartan, valsartan): Alternative to ACE if intolerant
- **Calcium Channel Blockers** (amlodipine): Particularly effective in elderly, Black patients
- **Thiazide Diuretics** (chlorthalidone, HCTZ): Cost-effective, good CV outcomes

**Dosing Strategy**:
- Start single agent at low dose
- Titrate to maximum tolerated dose before adding second agent
- Combination therapy often needed (2-3 agents)
- Monitor BP response, adjust every 2-4 weeks

#### Type 2 Diabetes Mellitus

**First-Line** (ADA Standards of Care):
- **Metformin**: First-line for all patients unless contraindicated (eGFR <30)
  - Start 500-850mg daily or BID, titrate to 2000mg total daily

**Second-Line** (individualize based on comorbidities):
- **SGLT2 Inhibitors** (empagliflozin, dapagliflozin): If heart failure or CKD (strong cardio-renal benefits)
- **GLP-1 Receptor Agonists** (semaglutide, dulaglutide): If ASCVD or high risk, weight loss needed
- **DPP-4 Inhibitors** (sitagliptin): If low hypoglycemia risk desired
- **Sulfonylureas** (glipizide): Cost-effective but hypoglycemia risk
- **Insulin**: If HbA1c very elevated ($>$10%) or symptoms of hyperglycemia

#### Depression

**First-Line SSRIs** (APA guidelines):
- Sertraline, escitalopram, fluoxetine, citalopram, paroxetine
- Start low (e.g., sertraline 50mg, escitalopram 10mg)
- Titrate after 2-4 weeks if partial response
- Full trial: 6-8 weeks at therapeutic dose
- Continue 6-12 months after remission (longer if recurrent)

**Second-Line**:
- **SNRIs** (venlafaxine, duloxetine): Especially if chronic pain comorbidity
- **Bupropion**: If sexual dysfunction concern, smoking cessation
- **Mirtazapine**: If insomnia/appetite stimulation needed

**Augmentation** (if partial response):
- Second antidepressant from different class
- Atypical antipsychotic (aripiprazole, quetiapine) - FDA-approved augmentation
- Lithium, thyroid hormone (triiodothyronine)

#### Chronic Pain

**Multimodal Analgesia** (WHO Pain Ladder, CDC Opioid Guidelines):

**Non-Opioid Analgesics**:
- **Acetaminophen**: 3-4g/day divided, safe if liver function normal
- **NSAIDs**: Ibuprofen, naproxen, meloxicam - short-term or chronic with GI protection
  - Monitor: Renal function, BP, GI bleeding risk

**Adjuvant Analgesics for Neuropathic Pain**:
- **Gabapentin**: 300mg titrated to 1800-3600mg/day divided TID
- **Pregabalin**: 75mg BID titrated to 150-300mg BID (better bioavailability than gabapentin)
- **SNRIs** (duloxetine): 60mg daily for diabetic neuropathy, chronic MSK pain
- **TCAs** (amitriptyline, nortriptyline): Low-dose (10-75mg QHS) - second-line due to side effects

**Topical Agents**:
- Lidocaine patches 5%, diclofenac gel, capsaicin cream
- Local effect, minimal systemic absorption

**Opioids** (CDC guidelines - use cautiously):
- Only after non-opioid multimodal therapies inadequate
- Lowest effective dose, short-acting preferred initially
- Avoid $>$90 MME/day if possible
- UDS, PDMP monitoring, naloxone co-prescription
- Reassess frequently, taper if not meeting functional goals

#### Heart Failure with Reduced Ejection Fraction (HFrEF)

**Guideline-Directed Medical Therapy (GDMT)** - "Foundational Four":

1. **ACE Inhibitor or ARB or ARNI**
   - ACE: Lisinopril 20-40mg daily, enalapril 10-20mg BID
   - ARNI (Sacubitril/Valsartan): 24/26mg BID → 97/103mg BID (superior to ACE/ARB)
   - Monitor: BP, renal function, potassium

2. **Beta-Blocker**
   - Carvedilol 3.125-6.25mg BID → 25mg BID (target)
   - Metoprolol succinate 12.5-25mg daily → 200mg daily
   - Bisoprolol 1.25mg → 10mg daily
   - Titrate slowly, monitor HR, BP

3. **Mineralocorticoid Receptor Antagonist (MRA)**
   - Spironolactone 12.5-25mg daily (up to 50mg)
   - Eplerenone 25mg daily → 50mg daily
   - Monitor: Potassium, renal function (risk hyperkalemia)

4. **SGLT2 Inhibitor**
   - Dapagliflozin 10mg daily or empagliflozin 10mg daily
   - Reduces HF hospitalizations and mortality
   - Also beneficial for diabetes and CKD

**Additional Therapies**:
- Loop diuretic (furosemide) for volume management (not mortality benefit)
- Hydralazine-isosorbide dinitrate (if African American or intolerant to ACE/ARB)
- Ivabradine (if EF $\leq$35%, HR $>$70 on max beta-blocker)
- Digoxin (symptomatic benefit, reduce hospitalizations)

### Medication Documentation Best Practices

**Include in Treatment Plan**:
- Generic name (brand name optional)
- Dose, route, frequency
- Indication/rationale
- Titration plan if applicable
- Expected timeline for benefit
- Key side effects to monitor
- Drug interactions
- When to adjust or discontinue

**Example**: "Lisinopril 10mg PO daily - ACE inhibitor for hypertension and renal protection in diabetes. Titrate to 20mg in 2-4 weeks if BP not at goal and tolerating (monitor for cough, hyperkalemia). Target BP <130/80."

## Non-Pharmacological Interventions

### Lifestyle Modifications

#### Diet and Nutrition

**Mediterranean Diet** (Evidence: multiple RCTs, PREDIMED trial):
- **Indications**: Cardiovascular disease prevention, diabetes management
- **Components**:
  - High intake: Fruits, vegetables, whole grains, legumes, nuts, olive oil
  - Moderate: Fish, poultry
  - Low: Red meat, sweets
- **Evidence**: Reduces cardiovascular events by 30%, improves glucose control
- **Implementation**: Dietitian referral for medical nutrition therapy

**DASH Diet** (Dietary Approaches to Stop Hypertension):
- **Indication**: Hypertension
- **Components**: High fruits/vegetables, low-fat dairy, reduced sodium (<2300mg, ideally <1500mg)
- **Evidence**: Reduces SBP by 8-14 mmHg
- **Implementation**: DASH eating plan education, sodium tracking

**Carbohydrate Counting** (for Diabetes):
- Consistent carbohydrate intake: 45-60g per meal
- Enables insulin dosing adjustment
- Prevents glycemic variability
- Dietitian teaches carb counting skills

**Weight Management**:
- Caloric deficit: 500-750 kcal/day for 1-2 lb/week weight loss
- Behavior change strategies: Self-monitoring, stimulus control, goal-setting
- Structured programs (Weight Watchers, MOVE!, etc.) more effective than self-directed
- Pharmacotherapy (GLP-1 agonists, orlistat) or bariatric surgery for BMI $\geq$30-35 with comorbidities

#### Physical Activity and Exercise

**Aerobic Exercise**:
- **Recommendation**: 150 min/week moderate intensity OR 75 min/week vigorous
- **Moderate**: Brisk walking, cycling, swimming - can talk but not sing
- **Vigorous**: Running, fast cycling - can say few words before pause
- **Benefits**: Cardiovascular health, glucose control, weight management, mood
- **Implementation**: Start with 10 min sessions, gradually increase

**Resistance Training**:
- **Recommendation**: 2-3 sessions/week, all major muscle groups
- **Benefits**: Muscle strength, bone density, metabolic rate, glucose control
- **Implementation**: Bodyweight exercises, resistance bands, free weights, machines

**Balance and Flexibility**:
- Important for fall prevention in elderly
- Yoga, tai chi
- Stretching routines

**Exercise Prescription**:
- FITT principle: **F**requency, **I**ntensity, **T**ime, **T**ype
- Individualize based on fitness level, comorbidities, goals
- Cardiac clearance if indicated (using ACSM or ACC/AHA guidelines)

**Example**: "Aerobic exercise: Walk 30 minutes, 5 days/week at moderate intensity (target HR 50-70% max). Resistance training: Upper and lower body exercises 2x/week, 2 sets of 10-12 reps."

#### Smoking Cessation

**Evidence**: Strongest intervention for COPD, cardiovascular disease, cancer prevention

**5 A's Approach**:
1. **Ask**: Screen all patients for tobacco use
2. **Advise**: Urge all tobacco users to quit
3. **Assess**: Willingness to make quit attempt
4. **Assist**: Aid in quitting (counseling + medication)
5. **Arrange**: Follow-up contact

**Pharmacotherapy** (doubles quit rates):
- **Nicotine Replacement**: Patch, gum, lozenge - OTC, safe
- **Varenicline**: Most effective (Chantix), start 1 week before quit date
- **Bupropion**: Alternative, also treats depression
- **Combination**: NRT + varenicline/bupropion more effective

**Counseling**:
- Quitline: 1-800-QUIT-NOW
- Individual or group counseling
- Cognitive-behavioral techniques

**Implementation**: Set quit date within 30 days, prescribe pharmacotherapy + counseling referral, follow up within 1 week of quit date.

#### Sleep Hygiene

**Indications**: Insomnia, poor sleep quality

**Components**:
- Consistent sleep-wake schedule (same bedtime/wake time)
- Bedroom: Dark, quiet, cool (60-67°F)
- Avoid: Caffeine after 2 PM, alcohol, large meals before bed
- Screen time: Stop 1 hour before bed
- Wind-down routine: Reading, bath, relaxation
- Use bed only for sleep (not TV, work)
- If can't sleep after 20 min, get up and do quiet activity

**Evidence**: Effective for chronic insomnia, often combined with CBT for insomnia (CBT-I)

#### Stress Management

**Techniques**:
- **Mindfulness meditation**: 10-20 min daily, reduces anxiety, depression
- **Progressive muscle relaxation**: Systematic tensing and relaxing muscle groups
- **Deep breathing**: Diaphragmatic breathing, 4-7-8 technique
- **Yoga, tai chi**: Mind-body practices
- **Cognitive restructuring**: Challenge stress-inducing thoughts

**Evidence**: Reduces stress hormones, improves mood, pain perception

### Behavioral Interventions

#### Cognitive Behavioral Therapy (CBT)

**Indications**: Depression, anxiety, insomnia, chronic pain, substance use

**Core Components**:
- Psychoeducation
- Cognitive restructuring (identify and challenge distorted thoughts)
- Behavioral activation (increase rewarding activities)
- Problem-solving skills
- Relapse prevention

**Evidence**: Equivalent to antidepressants for mild-moderate depression, first-line for anxiety, insomnia

**Implementation**: 12-16 weekly 50-min sessions with trained therapist, homework between sessions

**Variants**:
- **CBT-I** (insomnia): Sleep restriction, stimulus control, cognitive therapy for sleep
- **CBT-CP** (chronic pain): Pain education, activity pacing, cognitive restructuring of pain catastrophizing

#### Motivational Interviewing (MI)

**Indication**: Ambivalence about behavior change (diet, exercise, substance use, medication adherence)

**Principles**:
- Express empathy
- Develop discrepancy (between current behavior and goals/values)
- Roll with resistance (don't argue)
- Support self-efficacy

**Techniques**:
- Open-ended questions
- Affirmations
- Reflective listening
- Summarizing
- Elicit "change talk"

**Evidence**: Effective for initiating behavior change in multiple domains

### Patient Education and Self-Management

**Components**:
- Disease education (pathophysiology, natural history, treatment)
- Self-monitoring skills (blood glucose, BP, weight, symptoms)
- Medication management (purpose, dosing, side effects)
- Symptom recognition and action plans
- Lifestyle modification skills
- Problem-solving
- When to seek care

**Evidence**: Self-management education improves outcomes in diabetes, asthma, heart failure, chronic pain

**Delivery**:
- Individual education by clinician or educator
- Structured programs (DSMES for diabetes, cardiac rehab for heart disease)
- Group classes
- Written materials, videos, apps

## Procedural and Interventional Therapies

### Rehabilitation Therapies

#### Physical Therapy

**Indications**: Musculoskeletal injuries, post-surgical rehabilitation, balance/gait disorders, chronic pain

**Interventions**:
- Therapeutic exercise: Strengthening, stretching, endurance
- Manual therapy: Soft tissue mobilization, joint mobilization
- Gait and balance training
- Modalities: Heat, ice, ultrasound, electrical stimulation, TENS
- Functional training: ADL retraining, body mechanics

**Evidence**: Strong evidence for specific conditions (e.g., PT for knee OA reduces pain and improves function equivalent to NSAIDs)

**Prescription**: Frequency (e.g., 2-3x/week), duration (e.g., 4-8 weeks), specific interventions/goals

#### Occupational Therapy

**Indications**: ADL limitations, upper extremity dysfunction, cognitive-perceptual deficits, work-related injuries

**Interventions**:
- ADL/IADL training
- Adaptive equipment and environmental modifications
- Upper extremity strengthening and coordination
- Energy conservation techniques
- Cognitive rehabilitation
- Work hardening/conditioning

**Evidence**: Improves independence post-stroke, post-injury, with chronic conditions

#### Speech-Language Pathology

**Indications**: Dysphagia, aphasia, dysarthria, cognitive-communication disorders

**Interventions**:
- Swallow therapy and diet modifications
- Language therapy (aphasia)
- Articulation therapy
- Cognitive-linguistic therapy
- Augmentative and alternative communication (AAC)

### Interventional Pain Procedures

#### Epidural Steroid Injections (ESI)

**Indication**: Radicular pain from disc herniation or spinal stenosis

**Evidence**: Moderate-quality evidence for short-term pain relief (3-6 weeks to 3 months), variable long-term benefit

**Approach**: Fluoroscopy-guided, transforaminal, interlaminar, or caudal

**Frequency**: Up to 3-4 injections per year

**Risks**: Infection, bleeding, nerve injury (rare), dural puncture

#### Radiofrequency Ablation (RFA)

**Indication**: Facet joint-mediated pain (after positive diagnostic medial branch blocks)

**Evidence**: Good evidence for lumbar facet pain relief for 6-12 months

**Procedure**: Thermal lesioning of medial branch nerves supplying facet joints

**Repeatable**: Can repeat when pain returns

#### Spinal Cord Stimulation (SCS)

**Indication**: Refractory chronic neuropathic pain (failed back surgery syndrome, CRPS, diabetic neuropathy)

**Evidence**: 50-60% achieve $\geq$50% pain relief, improves function

**Procedure**: Trial lead placement (5-7 days), if successful → permanent implant

**Technologies**: Traditional, high-frequency, burst stimulation, dorsal root ganglion (DRG)

### Surgical Interventions

**When to Refer for Surgery**:
- Failed conservative management (adequate trial - typically 6-12 weeks minimum)
- Progressive neurologic deficit
- Cauda equina syndrome (emergency)
- Severe functional limitation affecting quality of life
- Structural pathology amenable to surgical correction
- Patient preference after risks/benefits discussion

**Shared Decision-Making**: Discuss operative vs. non-operative management, risks, benefits, expected outcomes, recovery

## Integrative and Complementary Therapies

### Acupuncture

**Evidence**:
- **Moderate evidence** for chronic low back pain, osteoarthritis knee pain, tension headaches, migraine
- **Mechanism**: Unclear (endorphin release, gate control theory, placebo)

**Implementation**: 8-12 sessions by licensed acupuncturist

### Massage Therapy

**Evidence**: Modest benefit for chronic low back pain, anxiety, cancer-related symptoms

**Types**: Swedish, deep tissue, myofascial release

**Implementation**: 1-2x/week, 30-60 min sessions

### Yoga

**Evidence**: Improves back pain, balance, flexibility, reduces stress and anxiety

**Types**: Hatha (gentle), Vinyasa (flowing), Iyengar (alignment-focused)

**Implementation**: Group classes or home practice, 2-3x/week

### Mindfulness-Based Stress Reduction (MBSR)

**Evidence**: Reduces stress, anxiety, depression, chronic pain

**Program**: 8-week structured program, weekly 2.5-hour sessions, daily home practice

**Components**: Meditation, body scan, mindful movement (yoga)

### Chiropractic Care

**Evidence**: Effective for acute and chronic low back pain, neck pain

**Techniques**: Spinal manipulation, mobilization, soft tissue therapy

**Safety**: Generally safe, avoid high-velocity manipulation if osteoporosis, spinal instability

## Intervention Selection and Documentation

### Treatment Algorithm Approach

1. **Diagnosis-Specific**: Follow evidence-based guidelines for condition
2. **Severity-Appropriate**: Mild → conservative; severe → aggressive
3. **Stepwise Intensification**: Start with first-line, add or switch if inadequate response
4. **Multimodal**: Combine complementary interventions (pharmacologic + non-pharmacologic)
5. **Individualized**: Adjust for patient factors (comorbidities, preferences, resources)

### Documentation Template

For each intervention, document:
- **Intervention**: Specific name/type
- **Indication**: Why this intervention for this patient
- **Evidence**: Guideline-based, RCT data supporting use
- **Dose/Frequency/Duration**: Specific parameters
- **Expected Benefit**: What should improve, by how much, when
- **Monitoring**: How will response be assessed
- **Risks/Side Effects**: Key concerns to monitor
- **Alternatives Considered**: What else was considered, why not chosen

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**Document Version**: 1.0  
**Last Updated**: January 2025  
**Next Review**: January 2026