What are the Philippine clinical guidelines for managing hypertension?

Management of Hypertension Based on Philippine Clinical Guidelines

The Philippine Society of Hypertension recommends restricting sodium intake to as low as 1500 mg/day and implementing a DASH meal plan that is low in sodium and high in dietary potassium for all patients with hypertension without renal insufficiency. 1

Blood Pressure Targets

• Target blood pressure should be <130/80 mm Hg for most hypertensive patients, with more lenient targets (<140/80 mm Hg) considered for elderly patients (≥85 years), those with symptomatic orthostatic hypotension, or moderate-to-severe frailty 1, 2
• Diastolic blood pressure should be targeted to <80 mm Hg but not <70 mm Hg to avoid organ hypoperfusion 3
• For patients with diabetes, systolic BP should be consistently <130 mm Hg and diastolic <80 mm Hg 2
• For patients with previous stroke or chronic kidney disease, BP should be consistently <140/90 mm Hg 1, 2

Lifestyle Modifications (First-Line Therapy)

Dietary Interventions

• Restrict sodium intake to 1500 mg/day (approximately half a teaspoon of table salt), with the American Heart Association recommending a limit of 2300 mg/day for most healthy individuals 1
• Implement the DASH (Dietary Approaches to Stop Hypertension) meal plan, which is low in sodium and high in dietary potassium 1, 2
• Increase dietary potassium intake through consumption of fresh fruits and vegetables (potatoes, spinach, tomatoes, bananas, oranges) unless contraindicated 1, 2
• Adopt Mediterranean dietary patterns as an alternative evidence-based approach 2
• Limit free sugar consumption, particularly sugar-sweetened beverages, to maximum 10% of energy intake 2

Weight Management

• Maintain healthy body mass index (20-25 kg/m²) 2
• Target waist circumference <94 cm in men and <80 cm in women 2

Physical Activity

• Engage in moderate-intensity aerobic exercise ≥150 minutes/week (30+ minutes, 5-7 days/week) 2, 4
• Complement aerobic exercise with resistance training 2-3 times/week 2

Alcohol and Tobacco

• Limit alcohol consumption to <100 g/week of pure alcohol (approximately 14 drinks/week for men, 9/week for women) 2
• Complete smoking cessation with appropriate supportive care 2

Pharmacological Treatment Strategy

Initial Therapy

• For most patients with confirmed hypertension (BP ≥140/90 mm Hg), initiate combination BP-lowering treatment as first-line therapy 2
• Preferred initial combinations include a RAS blocker (ACE inhibitor or ARB) with either a dihydropyridine calcium channel blocker OR a thiazide/thiazide-like diuretic 1, 2, 4
• Fixed-dose single-pill combinations are strongly recommended to improve adherence 2

Escalation Strategy

• If BP remains uncontrolled on dual therapy, add a third agent to create a three-drug combination: RAS blocker + dihydropyridine CCB + thiazide/thiazide-like diuretic 2
• For resistant hypertension requiring fourth-line therapy, consider spironolactone, or alternatively amiloride, doxazosin, eplerenone, clonidine, or beta-blocker 3
• Never combine ACE inhibitor with ARB, as this increases adverse events without additional benefit 3, 2

Special Considerations

• Beta-blockers should be reserved for specific indications (coronary artery disease, post-myocardial infarction, heart failure, or heart rate control) and combined with other major BP-lowering drug classes 1, 2
• For patients ≥85 years, those with symptomatic orthostatic hypotension, or moderate-to-severe frailty, monotherapy may be considered instead of combination therapy 2

Implementation and Monitoring

Treatment Timeline

• Achieve target BP within 3 months of treatment initiation 3
• For patients with high-normal BP or grade 1 hypertension without high risk factors, attempt lifestyle modifications first for 3-6 months before initiating medications 5
• Regular follow-up (monthly) is recommended until target BP is achieved 2

Long-Term Management

• Maintain BP-lowering drug treatment lifelong, even beyond age 85, if well tolerated 2
• Medications should be taken at the most convenient time of day to establish habitual patterns and improve adherence 2
• Lifestyle modifications should continue even after initiating pharmacological therapy, as they enhance medication efficacy 5, 6

Critical Caveats and Common Pitfalls

Dietary Sodium Misconceptions

• Many patients mistakenly believe not adding salt to food equals a low-salt diet 2
• Education must emphasize checking food labels for hidden sodium sources in processed foods 2
• Patients should avoid added salt, processed foods, and salt-containing foods such as pickles, chips, and preparations containing baking powder 1
• Failure to adhere to low-sodium diets is a significant cause of resistant hypertension 2

Potassium Supplementation Contraindications

• A potassium-rich diet should be avoided in patients with chronic renal failure or those taking potassium-sparing diuretics 1, 2
• Potassium should come from food sources (fruits, vegetables, dairy, fish), not supplements 1

Adherence Strategies

• Inform patients about hypertension risks and treatment benefits 2
• Provide clear written and oral instructions 2
• Tailor treatment regimens to patient's lifestyle 2
• Simplify treatment by reducing the number of daily medications through fixed-dose combinations 2
• Involve family members in treatment plans 2
• Encourage home BP monitoring 2
• Address side effects promptly 2
• Utilize a team approach involving physicians, nurses, dietitians, and other healthcare providers 2

Assessment Requirements

• Confirm hypertension diagnosis using out-of-office BP measurements when office BP is 140-159/90-99 mm Hg 3
• Evaluate cardiovascular risk using serum creatinine, eGFR, urine albumin-to-creatinine ratio, and 12-lead ECG in all hypertensive patients 3
• Patients with refractory hypertension should undergo comprehensive investigations for secondary causes 2