What are the recommended treatment guidelines for hypertension in the Philippines?

Treatment Guidelines for Hypertension in the Philippines

The 2020 Philippine Society of Hypertension recommends a combination of lifestyle modifications and pharmacological therapy, with drug treatment initiated immediately for high-risk patients with BP ≥140/90 mmHg and a target BP of <130/80 mmHg for most patients. 1

Diagnosis of Hypertension

• Hypertension is defined as office BP ≥140/90 mmHg following proper standard BP measurement techniques 2
• Diagnosis should be confirmed with repeated measurements over 2-3 office visits 1
• Home BP ≥135/85 mmHg or 24-hour ambulatory BP ≥130/80 mmHg can confirm the diagnosis 1
• Use validated automated devices with appropriate cuff size for accurate measurement 1

Lifestyle Modifications

• DASH (Dietary Approaches to Stop Hypertension) meal plan that is low in sodium and high in dietary potassium is recommended for all hypertensive patients without renal insufficiency 1
• Sodium restriction to as low as 1500 mg/day (approximately half a teaspoon of table salt) 1
• Regular physical activity 1
• Weight reduction for overweight/obese patients 1
• Limited alcohol consumption 3
• Smoking cessation 1

Pharmacological Treatment

Initial Treatment Strategy

• For Grade 1 Hypertension (140-159/90-99 mmHg):

  • Start lifestyle interventions for all patients 1
  • Initiate drug treatment immediately in high-risk patients (with CVD, CKD, diabetes, organ damage, or aged 50-80 years) 1
  • For low-moderate risk patients, start drug treatment after 3-6 months of lifestyle intervention if BP remains elevated 1

• For Grade 2 Hypertension (≥160/100 mmHg):

  • Start both lifestyle interventions and drug treatment immediately 1

Drug Therapy Algorithm

For Non-Black Filipino Patients:

1. Start with low dose ACE inhibitor (ACEI) or Angiotensin Receptor Blocker (ARB) 1
2. Add Dihydropyridine Calcium Channel Blocker (DHP-CCB) 1
3. Increase to full dose 1
4. Add thiazide-like diuretic 1
5. Add spironolactone or, if not tolerated or contraindicated, consider amiloride, doxazosin, eplerenone, clonidine or beta-blocker 1

For Black Filipino Patients:

1. Start with low dose ARB + DHP-CCB or DHP-CCB + thiazide-like diuretic 1
2. Increase to full dose 1
3. Add diuretic or ACE inhibitor/ARB (whichever was not used initially) 1
4. Add spironolactone or, if not tolerated or contraindicated, consider amiloride, doxazosin, eplerenone, clonidine or beta-blocker 1

Treatment Targets

• Target BP <130/80 mmHg for most patients 1
• For elderly patients (>65 years), target may be individualized based on frailty, with a typical goal of <140/80 mmHg 1
• Aim to reduce BP by at least 20/10 mmHg from baseline 1
• BP control should be achieved within 3 months 1

Special Populations

Patients with Comorbidities

• Coronary Artery Disease: Use RAS blockers, beta-blockers with or without CCBs as first-line drugs 1
• Previous Stroke: Use RAS blockers, CCBs, and diuretics as first-line drugs 1
• Heart Failure: Use RAS blockers, beta-blockers, and mineralocorticoid receptor antagonists 1
• Chronic Kidney Disease: Use RAS inhibitors as first-line drugs; add CCBs and diuretics (loop diuretics if eGFR <30 ml/min/1.73m²) 1
• Diabetes: Use RAS inhibitor with a CCB and/or thiazide-like diuretic 1
• COPD: Consider ARB and CCB and/or diuretic; beta-blockers (β1-receptor selective) may be used in selected patients 1

Resistant Hypertension

• Defined as BP >140/90 mm Hg despite treatment with three or more antihypertensive medications at optimal doses including a diuretic 1
• Exclude pseudoresistance (poor BP measurement technique, white coat effect, nonadherence) 1
• Screen for secondary causes of hypertension 1
• Optimize current treatment regimen including lifestyle changes and diuretic-based treatment 1
• Add low-dose spironolactone as fourth-line agent if serum potassium <4.5 mmol/L and eGFR >45 ml/min/1.73m² 1
• If spironolactone is contraindicated or not tolerated, consider amiloride, doxazosin, eplerenone, clonidine, or beta-blockers 1
• Refer resistant hypertension to specialist centers 1

Monitoring and Follow-up

• Monitor BP control regularly, aiming to achieve target within 3 months 1
• Check medication adherence at each visit 1
• Monitor for adverse effects of medications 1
• Assess for target organ damage periodically 1
• Consider referral to a specialist if BP remains uncontrolled despite optimal therapy 1

Common Pitfalls to Avoid

• Monotherapy has been the mode of treatment in more than 80% of Filipino patients, which may explain low BP control rates (only 27% of hypertensive Filipinos have controlled BP) 2
• Use single-pill combinations when possible to improve adherence 1
• Nearly half of hypertensive Filipinos are unaware of their condition, highlighting the need for better screening programs 2
• Inadequate assessment for secondary causes of hypertension, which account for 5-10% of cases 1
• Failure to address lifestyle modifications alongside pharmacological treatment 1
• Inappropriate drug combinations or inadequate dosing 2

Economic Considerations

• Hospitalization from hypertensive complications can be financially catastrophic, especially for lower-income Filipinos 2
• Common complications include stroke (11.6%), ischemic heart disease (7.7%), chronic kidney disease (6.3%), and hypertensive retinopathy (2.3%) 2
• Consider cost-effective medication choices to improve long-term adherence 2