What are the recommended initial approaches for managing hypertension in the Philippines, according to the Clinical Practice Guidelines (CPG)?

Philippine Clinical Practice Guidelines for Hypertension Management

Diagnostic Criteria

The 2020 Philippine Society of Hypertension defines hypertension as office blood pressure ≥140/90 mm Hg, following proper standardized measurement technique. 1, 2

• Confirm elevated readings with at least 2-3 measurements using a validated automated device with appropriate cuff size 3
• Consider out-of-office monitoring (home BP ≥135/85 mm Hg or 24-hour ambulatory BP ≥130/80 mm Hg) to confirm diagnosis and exclude white coat hypertension 3

Lifestyle Modifications (First-Line for All Patients)

The Philippine guidelines emphasize lifestyle changes as foundational therapy, with specific focus on dietary patterns relevant to Filipino populations 1:

Dietary Interventions

• Sodium restriction to 1500 mg/day (approximately half a teaspoon of table salt daily) 1
• Adopt DASH meal plan that is low in sodium and high in dietary potassium for all patients without renal insufficiency 1
• Increase dietary potassium intake to 3500-5000 mg/day through fresh fruits and vegetables (avoid in patients with chronic renal failure or those taking potassium-sparing diuretics) 1
• Emphasize fresh vegetables, fruits, fish, bean products, coarse grains, and skim milk 1
• Avoid added salt, processed foods, and traditional high-sodium Filipino preparations like pickles and chips 1

Additional Lifestyle Measures

• Weight loss: Aim for ideal body weight; expect approximately 1 mm Hg SBP reduction per 1 kg weight loss 1
• Physical activity: Aerobic exercise 5-7 times weekly (30-60 minutes per session), targeting at least 150 minutes weekly 1
• Alcohol moderation: Men ≤2 standard drinks/day; Women ≤1 standard drink/day 1
• Smoking cessation for all patients 3

Pharmacological Treatment

Initial Therapy Selection

A critical issue in the Philippines is that monotherapy has been used in over 80% of patients, contributing to poor BP control rates of only 27%. 2 The guidelines now recommend:

For most Filipino patients with confirmed hypertension (BP ≥140/90 mm Hg), initiate combination therapy as first-line treatment, preferably as a single-pill combination. 1, 3

Preferred First-Line Combinations

• RAS blocker (ACE inhibitor or ARB) + dihydropyridine calcium channel blocker (e.g., amlodipine), OR 3
• RAS blocker + thiazide-like diuretic 3

Ethnicity Considerations for Southeast Asian Populations

Filipino patients share characteristics with other Southeast Asian populations, including greater salt-sensitivity and higher prevalence of stroke (particularly hemorrhagic) compared to Western populations 1

• Standard treatment approaches as outlined above are recommended until more population-specific evidence becomes available 1
• Morning and nighttime hypertension are more common in Asian populations, warranting consideration of home BP monitoring 1

Blood Pressure Targets

Target BP <140/90 mm Hg for all patients, with consideration of <130/80 mm Hg in those at high cardiovascular risk based on individual tolerability. 1, 3

• Aim to achieve target BP within 3 months of initiating therapy 4
• For patients with diabetes, renal impairment, or established cardiovascular disease, target ≤130/80 mm Hg 3

Monitoring and Follow-Up

Schedule follow-up monthly for dose titration until BP is controlled, then every 3-6 months once controlled. 3

• Home BP monitoring is strongly recommended to assess control and improve adherence 3
• Monitor for medication adherence and side effects at each visit 4
• If BP remains uncontrolled despite multiple medications, refer to a hypertension specialist 4

Management of Resistant Hypertension

For patients with BP ≥140/90 mm Hg despite three medications (including a long-acting CCB, RAS blocker, and diuretic) 5:

• Add spironolactone (25-50 mg/day) as fourth-line agent 1, 5
• Alternative fourth-line options include amiloride, doxazosin, or eplerenone 5
• Reassess adherence, exclude secondary causes, and optimize lifestyle modifications 1, 5
• Monitor serum potassium and creatinine closely when adding mineralocorticoid receptor antagonists 1

Common Pitfalls in the Philippine Context

• Avoid monotherapy: The historical reliance on single-agent treatment has resulted in poor control rates; combination therapy is essential 2
• Address economic barriers: Hospitalization from hypertensive complications is catastrophic for lower-income Filipinos; emphasize prevention and control 2
• Screen for complications: Most prevalent complications in the Philippines are stroke (11.6%), ischemic heart disease (7.7%), chronic kidney disease (6.3%), and hypertensive retinopathy (2.3%) 2
• Cultural considerations: Filipino dietary practices may include high-sodium traditional foods; provide specific culturally-relevant dietary counseling 6