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ACP PrincipalStaff Beth Goldner Medicql Editor Davoren Chick, MD, FACP Senior Vice President, Medical Education Suzanne Meyers Medical Editor Tabassum Salam, MD, MBA, EACP Vice President, Medical Education Elise Paxson Medical Editor Margaret Wells, EdM Vice President, Learning Assessment, Accreditation, Chuck Graver andResearch Finance and Operations Administrotor Patrick C. Alguire, MD, F:ACP Kimberly Kerns MKSAP 19 Senior Deputy Editor and Boord Bcsics Administratiu e Co o rdinator Editor-in-Chief The following committee members, peer reviewers, or staff BeckyKrumm have disclosed relationship(s) wittr an entity producing, Director, Assessment o nd Education Programs marketing, reselling, or distributing health care goods or services consumed by, or used on, patients. Individuals not Jackie Twomey listed below have nothing to disclose. ManagingEditor Mark Dominic Corriere, MD, EACP Julia Nawrocki Other/Speakers Bureau Digital Contenf Asso ciate / Editor AbbVie, AstraZeneca, Eli Lilly and Company, Novo Nordisk, LinneaDonnarumma Sanofi US Services Inc. Senior Medical Editor Tabassum Salam, MD, MBA, EACP Amanda Cowley Consultantship Medical Editor Johnson & lohnson

Patrick C. Alguire, MD, F:ACP Kimberly Kerns MKSAP 19 Senior Deputy Editor and Boord Bcsics Administratiu e Co o rdinator Editor-in-Chief The following committee members, peer reviewers, or staff BeckyKrumm have disclosed relationship(s) wittr an entity producing, Director, Assessment o nd Education Programs marketing, reselling, or distributing health care goods or services consumed by, or used on, patients. Individuals not Jackie Twomey listed below have nothing to disclose. ManagingEditor Mark Dominic Corriere, MD, EACP Julia Nawrocki Other/Speakers Bureau Digital Contenf Asso ciate / Editor AbbVie, AstraZeneca, Eli Lilly and Company, Novo Nordisk, LinneaDonnarumma Sanofi US Services Inc. Senior Medical Editor Tabassum Salam, MD, MBA, EACP Amanda Cowley Consultantship Medical Editor Johnson & lohnson SandyCrump Benjamin T. Suratt, MD Research Grants / Contracts MedicslEditor National Institutes of Health Georgette Forgione Employment MedicalEditor Sanofi Pasteur Biologics, LLC lv

Acknowledgments are required to disclose all relevant financial relationships The American College of Physicians (ACP) gratefully with any entity producing, marketing, re selling, or distrib- acknowledges the special contributions to the develop- uting health care goods or services consumed by, or used ment and production of the 19th edition of the Medical on, patients. Contributors are required to use generic names in the discussion of therapeutic options and are required Knowledge Self Assessment Program- (MKSAP' 19) made to identily any unapproved, off-label, or investigative use by the following people: of commercial products or devices. Where a trade name is Graphic Design: Barry Moshinski (Director, Graphic Services), used, all available trade names for the same product tlpe Raymond DeJohn (Designer, Graphic Services), Tom Malone are also included. If trade name products manufactured by (Print/Mail Production Manager, Graphic Services), Mike companies with whom contributors have relationships are Ripca (Technical Administrator, Graphic Services). discussed, contributors are asked to provide evidence based citations in support of the discussion. The information is Production / Systems; Dan Hoffmann (Vice President, reviewed by the committee responsible for producing this Information Technologz), Scott Hurd (Manager. Content content. [f necessary adjustments to topics or contributors' Systems), Neil Kohl (Senior Architect), and Chris Patterson roles in content development are made to balance the (Senior Architect). discussion. All relevant relationships are mitigated. MKSAP 19 Digital: Under the leadership of Steven Spadt Readers of this content are asked to evaluate it for evidence (Senior Vice President, Information Technolog, and Chief of commercial bias and send any relevant comments to Technologr Officer), the development of the digital version of mksap_editors6racponline.org so that future decisions MKSAP 19 was implemented by ACP's Digital Products and about content and contributors can be made in light of SeMces Department, directed and led by Brian Sweigard (Vice this information. President, Digital Products and Services). Other members of the team included Dan Barron (Senior Web Application Developer/Architect), Callie Cramer (Data Visualization/ Mitigation of Conflicts Web Developer), Chris Forrest (Senior Web Application To mitigate all conJlicts of interest and influences of vested Developer), Kathleen Hoover (Manager, User Intetface Design interests, ACP's content planners used best evidence and and Development), Kara Regis (Director, Product Design and updated clinical care guidelines in developing content, when Development), Brad Lord (Senior Web Application Developer/ such evidence and guidelines were available. Contributors' Architect), and John McKnight (Senior Web Developer). disclosure information can be found with the list of contrib The College also wishes to acknowledge that many other utors' names and those of ACP principal staff listed in the persons, too numerous to mention, have contributed to the beginning of this book. production of this program. Without their dedicated efTorts, this program would not have been possible. Educational Disclaimer The editors and publisher of MKSAP 19 recognize that MKSAP Resource Site the development of new material off'ers many opportu- The MKSA P Resource Page (wT,lr,v. acponline. org / nities for error. Despite our best efforts, some errors may mksaplg-resources) provides access to MKSAP 19 online persist in print. Drug dosage schedules are, we believe, answer sheets for transcribing answers from the print edi accurate and in accordance with current standards. tion; access to MKSAP 19 Digital; Board Basics-; infbrma- Readers are advised, however, to ensure that the recom tion on Continuing Medical Education (CME), Maintenance mended dosages in MKSAP 19 concur with the infor of Certification (MOC), and international Continuing mation provided in the product information material. Professional Development (CPD) and MOC fbr MKSAP 19; This is especially important in cases of new inliequently errata; and other new information. used, or highly toxic drugs. Application ol'the informa tion in MKSAP 19 remains the professional responsibility of the practitioner. Disclosure Policy The primary purpose of MKSAP 19 is educational. It is the policy of the American College of Physicians (ACP) Infbrmation presented, as well as publications, technol- to ensure balance, independence, objectivity, and scientific ogies, products, and/or seryices discussed, is intended to rigor in all of its educational activities. To this end, and con- intbrm subscribers about the knowledge, techniques, and sistent with the policies of the ACP and the Accreditation experiences of the contributors. A diversity of prof'essional Council for Continuing Medical Education (ACCME), con opinion exists, and the views of the contributors are their tributors to all ACP continuing medical education activities own and not those of the ACP. lnclusion of any material

The American College of Physicians (ACP) gratefully with any entity producing, marketing, re selling, or distrib- acknowledges the special contributions to the develop- uting health care goods or services consumed by, or used ment and production of the 19th edition of the Medical on, patients. Contributors are required to use generic names in the discussion of therapeutic options and are required Knowledge Self Assessment Program- (MKSAP' 19) made to identily any unapproved, off-label, or investigative use by the following people: of commercial products or devices. Where a trade name is Graphic Design: Barry Moshinski (Director, Graphic Services), used, all available trade names for the same product tlpe Raymond DeJohn (Designer, Graphic Services), Tom Malone are also included. If trade name products manufactured by (Print/Mail Production Manager, Graphic Services), Mike companies with whom contributors have relationships are Ripca (Technical Administrator, Graphic Services). discussed, contributors are asked to provide evidence based citations in support of the discussion. The information is Production / Systems; Dan Hoffmann (Vice President, reviewed by the committee responsible for producing this Information Technologz), Scott Hurd (Manager. Content content. [f necessary adjustments to topics or contributors' Systems), Neil Kohl (Senior Architect), and Chris Patterson roles in content development are made to balance the (Senior Architect). discussion. All relevant relationships are mitigated. MKSAP 19 Digital: Under the leadership of Steven Spadt Readers of this content are asked to evaluate it for evidence (Senior Vice President, Information Technolog, and Chief of commercial bias and send any relevant comments to Technologr Officer), the development of the digital version of mksap_editors6racponline.org so that future decisions MKSAP 19 was implemented by ACP's Digital Products and about content and contributors can be made in light of SeMces Department, directed and led by Brian Sweigard (Vice this information. President, Digital Products and Services). Other members of the team included Dan Barron (Senior Web Application Developer/Architect), Callie Cramer (Data Visualization/ Mitigation of Conflicts Web Developer), Chris Forrest (Senior Web Application To mitigate all conJlicts of interest and influences of vested Developer), Kathleen Hoover (Manager, User Intetface Design interests, ACP's content planners used best evidence and and Development), Kara Regis (Director, Product Design and updated clinical care guidelines in developing content, when Development), Brad Lord (Senior Web Application Developer/ such evidence and guidelines were available. Contributors' Architect), and John McKnight (Senior Web Developer). disclosure information can be found with the list of contrib The College also wishes to acknowledge that many other utors' names and those of ACP principal staff listed in the persons, too numerous to mention, have contributed to the beginning of this book. production of this program. Without their dedicated efTorts, this program would not have been possible. Educational Disclaimer The editors and publisher of MKSAP 19 recognize that MKSAP Resource Site the development of new material off'ers many opportu- The MKSA P Resource Page (wT,lr,v. acponline. org / nities for error. Despite our best efforts, some errors may mksaplg-resources) provides access to MKSAP 19 online persist in print. Drug dosage schedules are, we believe, answer sheets for transcribing answers from the print edi accurate and in accordance with current standards. tion; access to MKSAP 19 Digital; Board Basics-; infbrma- Readers are advised, however, to ensure that the recom tion on Continuing Medical Education (CME), Maintenance mended dosages in MKSAP 19 concur with the infor of Certification (MOC), and international Continuing mation provided in the product information material. Professional Development (CPD) and MOC fbr MKSAP 19; This is especially important in cases of new inliequently errata; and other new information. used, or highly toxic drugs. Application ol'the informa tion in MKSAP 19 remains the professional responsibility of the practitioner. Disclosure Policy The primary purpose of MKSAP 19 is educational. It is the policy of the American College of Physicians (ACP) Infbrmation presented, as well as publications, technol- to ensure balance, independence, objectivity, and scientific ogies, products, and/or seryices discussed, is intended to rigor in all of its educational activities. To this end, and con- intbrm subscribers about the knowledge, techniques, and sistent with the policies of the ACP and the Accreditation experiences of the contributors. A diversity of prof'essional Council for Continuing Medical Education (ACCME), con opinion exists, and the views of the contributors are their tributors to all ACP continuing medical education activities own and not those of the ACP. lnclusion of any material v

in the program does not constitute endorsement or rec- of its parts in any form either for individual use or for ommendation by the ACP The ACP does not warrant the distribution. safety, reliability, accuracy, completeness, or usefulness of ACP will consider granting an individual permission to and disclaims any and all liability for damages and claims reproduce only limited portions of this publication for that may result from the use of information, publications, his or her own exclusive use. Send requests in writing to technologies, products, and/or services discussed in this MKSAP' Permissions, American College of Physicians, 190 N. program. Independence Mall West, Philadelphia, PA 19106-1572, or email your request to mksap-editors6acponline.org. Publishert I nformation MKSAP 19 ISBN: 978-r-938245-75-6 Copynght o 2022 American College of Physicians. All rights Board Basics ISBN: 978-1-953654-04-5 reserved. Frinted in the United States of America. This publication is protected by copyright. No part ofthis publication may be reproduced, stored in a retrieval system, For order information in the U.S. or Canada, call 800-ACP- or transmitted in any form or by any means, electronic or 1915. In all other countries, call 215-351-2600 (Monday mechanical, including photocopy, without the express to Friday, 9 eu-5 pr,r ET). Fax inquiries to 215-351-2799 or consent ofthe ACP. email to custserv@acponline.org.

in the program does not constitute endorsement or rec- of its parts in any form either for individual use or for ommendation by the ACP The ACP does not warrant the distribution. safety, reliability, accuracy, completeness, or usefulness of ACP will consider granting an individual permission to and disclaims any and all liability for damages and claims reproduce only limited portions of this publication for that may result from the use of information, publications, his or her own exclusive use. Send requests in writing to technologies, products, and/or services discussed in this MKSAP' Permissions, American College of Physicians, 190 N. program. Independence Mall West, Philadelphia, PA 19106-1572, or email your request to mksap-editors6acponline.org. Publishert I nformation MKSAP 19 ISBN: 978-r-938245-75-6 Copynght o 2022 American College of Physicians. All rights Board Basics ISBN: 978-1-953654-04-5 reserved. Frinted in the United States of America. This publication is protected by copyright. No part ofthis publication may be reproduced, stored in a retrieval system, For order information in the U.S. or Canada, call 800-ACP- or transmitted in any form or by any means, electronic or 1915. In all other countries, call 215-351-2600 (Monday mechanical, including photocopy, without the express to Friday, 9 eu-5 pr,r ET). Fax inquiries to 215-351-2799 or consent ofthe ACP. email to custserv@acponline.org. Unauthorized Use of This Book Errata and Revisions ls Against the Law Errata and revisions for MKSAP 19 will be available through Unauthorized reproduction of this publication is unlaw- MKSAP 19 Digital at mksapl9.acponline.org as new informa- ful. ACP prohibits reproduction of this publication or any tion becomes known to the editors.

Unauthorized Use of This Book Errata and Revisions ls Against the Law Errata and revisions for MKSAP 19 will be available through Unauthorized reproduction of this publication is unlaw- MKSAP 19 Digital at mksapl9.acponline.org as new informa- ful. ACP prohibits reproduction of this publication or any tion becomes known to the editors. vt