CLINICAL UPDATE

Clinical Pathways for the Management of

Dyspepsia in Family and Community Practice
Noel L. Espallardo MD, MSc, FPAFP; Ma. Teresa Tricia Guison-Bautista, MD, FPAFP;
Ma Elinore Alba-Concha, MD, FPAFP and Louie R. Ocampo, MD, FPAFP

Background: Dyspepsia is any chronic or recurrent discomfort in the epigastric area described as bloatedness, fullness,
gnawing or burning continuously or intermittently for at least 2 weeks. About 40% of the adult population may suffer
from dyspeptic symptoms but most of them are un-investigated because only about 2% consult their physician.
Method: The general objective of this clinical pathway is to improve outcomes of patients with dyspepsia in family and
community practice.
Method: The PAFP Clinical Pathways Group reviewed the previous Clinical Practice Guideline for the Treatment of Dyspepsia
in Family Practice, a local guideline developed by the Family Medicine Research Group and adopted as policy statement by the
Philippine Health Insurance Corporation. The reviewers then developed a time-related representation of recommendations on
patient care processes, in terms of history and physical examination, laboratory tests, pharmacologic and non-pharmacologic
interventions as well as social and community strategies to treat hypertension and prevent complications.
Recommendation: All patients with upper gastrointestinal pain or discomfort should have a detailed history focusing
on weight loss, hematemesis, hematochezia, melena, dysphagia, odynophagia, vomiting, NSAID intake, alcohol intake,
smoking, frequent medical complaints, depression, anxiety, personal or family history of gastrointestinal disease using
family genogram. Physical examination findings provide minimal information but should be done to rule out an organic
pathology and to look for alarm clinical features like anemia, abdominal tenderness or mass, jaundice, melena etc. If the
patient is with history of previous dyspepsia treatment, more than 45 years old or long-term use of NSAID, the physician
may request for non-invasive H. pylori test. Upper abdominal ultrasound, liver function test, pancreatic amylase may be
done if organic problem is considered. Start therapeutic trial of prokinetic treatment for 1-2 weeks or proton-pump inhibitor
depending on the symptoms. Fixed drug combination may be used if symptoms are undifferentiated. The patient should
be educated about upper gastrointestinal disorders and dyspepsia, risk factors and complications. If medications were
prescribed, explain the dose, frequency, intended effect, possible side effects and importance of medication adherence.
Lifestyle modifications focusing on low fat meals, weight reduction, avoidance of alcohol intake and smoking cessation,
eating way before bedtime, elevated head while sleeping, etc. may also be done. Recommendations were also made on
subsequent visits.
Implementation:
Quality improvement strategy is recommended for implementation of this pathway. This will involve pre- and post-intervention
data collection using records review. Intervention strategies may be feedback, group consensus or incentive mechanisms.

130 THE FILIPINO FAMILY PHYSICIAN

 Introduction
Our previous guideline in family medicine, defined
dyspepsia as any chronic or recurrent discomfort in the
epigastric area described as bloatedness, fullness, gnawing
or burning continuously or intermittently for at least 2
weeks. Concomitant symptoms like anorexia, early satiety,
belching, nausea, regurgitation or vomiting may also be
present.1 This is a very common symptom complaint in
family and community medicine practice.
About 40% of the adult population may suffer from
dyspeptic symptoms but most of them are un-investigated
because only about 2% consult their physician. Based
on systematic reviews, the pooled prevalence of un-
investigated dyspepsia was 21% (95% confidence interval,
18% to 24%). The risk is higher among females and those
with Helicobacter pylori (H pylori) infection, smokers,
and non-steroidal anti-inflammatory drug users.2 Even
after endoscopy, more than 75% with dyspepsia don’t
have obvious structural abnormality. Among those with
abnormality, the most common findings are esophagitis
(13%) and peptic ulcer (8%).3 There is high direct and
indirect costs due to dyspepsia because of its prevalent,
recurrent and chronic condition. Fortunately there is no
mortality associated with dyspepsia symptoms.4
Several treatment guidelines have been developed for
the management of dyspepsia. The American and European
multidisciplinary working group as well as a local Family
Medicine Research Group, Inc. have also developed clinical
practice guideline for the management of dyspepsia in
Philippine family and community medicine practice.1,5,6
The main recommendations were basically similar in terms
of indication for prompt endoscopy, the application of
diagnostic tests and treatment of recurrent symptoms. In
summary the recommendations were: 1) patients with alarm
symptoms should undergo prompt endoscopy, 2) those
without alarm symptoms non-invasive testing for H pylori
is recommended, 3) empiric trial of acid suppression with a
proton pump inhibitor is recommended if H pylori testing is
not feasible, 5) prokinetics are not currently recommended
as first-line therapy for un-investigated dyspepsia, 6) test-
VOL. 55 NO. 3 JULY - SEPTEMBER, 2017 131
and-treat is preferable in patients with moderate to high
prevalence of H. pylori infection (specialist practice) and
empiric proton pump inhibitor low prevalence situations
(family and community practice), 7) if empiric treatment
with proton pump inhibitor fails, consider changing or
adding another drug class or increase dose, 8) If the patient
still fails to respond testing for H pylori and endoscopy may
be considered, and 9) If there is improvement in symptoms
patients may be treated on either on demand or intermittent
basis.5,6
The general objective of this clinical pathway is to
improve outcomes of patients with dyspepsia in family and
community practice. It hopes to achieve this by:
o Promoting a standardized management of patients
with dyspepsia
o Promoting quality improvement initiatives at the
clinic and organizational level
Methods of Development and Implementation
The PAFP Clinical Pathways Group reviewed the
previous Clinical Practice Guideline for the Treatment of
Dyspepsia in Family Practice, a local guideline developed by
the Family Medicine Research Group and adopted as policy
statement by the Philippine Health Insurance Corporation.
The group also reviewed published medical literature to
identify, summarize, and operationalize the clinical content
of diagnostics, interventions and clinical indicators or
outcomes to develop an evidence-based clinical pathway in
family medicine practice. The reviewers then developed a
time-related representation of recommendations on patient
care processes, in terms of history and physical examination,
laboratory tests, pharmacologic and non-pharmacologic
interventions as well as social and community strategies to
treat hypertension and prevent complications.
The group adopted several strategies in developing
the recommendations. The first strategy is emphasizing
on evidence-based recommendations as recommended
assessments and interventions. The second strategy is
recognition of potential variations between-patient and
between specific practice settings. The third strategy is
the recognition of “stakeholder groups” outside of family
and community practice with careful attention to getting
their opinion and support but without sacrificing the
objectives of the project. The fourth strategy is emphasis
on the commitment to establishment of the ultimate goal
of improving the effectiveness, efficiency and quality of
patient care in family and community practice.
The evidences for the patient care processes were
reviewed and summarized as notes on the recommendations.
The clinical pathway was then disseminated to selected
PAFP chapters and members and other stakeholders for
consensus development. Dissemination was publication
in the Filipino Family Physician journal, conference
presentations and focused group discussions.
The implementation of clinical pathways to be adopted
by the PAFP will be quality improvement activities in
a form of patient record reviews, audit and feedback.
Audit standards will be the assessment and intervention
recommendations in the clinical pathway. Implementation
of clinical pathways will be at the practice level and the
organizational level. Practice level can be a simple count
of family and community medicine practitioners using and
applying the clinical pathways. Organizational outcomes
can be activities of the PAFP devoted to the promotion,
development, dissemination and implementation of clinical
pathways.
Grading of the Recommendations
The PAFP QA Committee met as a panel and graded
the recommendations as shown in Table 1. The grading
system was a mix of the strength of the reviewed published
evidence and the consensus of a panel of experts. In some
cases the published evidence may not be applicable if
Philippine family practice setting, so a panel grade based on
the consensus of clinical experts was also used. Thus if the
recommendation was based on a published evidence that
is a well done randomized controlled trial and the panel
of expert voted unanimously for the recommendation, it
was given a grade of A-I. If the level of evidence is based
132 THE FILIPINO FAMILY PHYSICIAN
on an observational study but the panel still unanimously
considered the recommendation, the grade given was A-II
and if the level of evidence is just an opinion but the panel
still unanimously recommended it, the grade was A-III.
Table 1. Grading of the recommendations.
Panel Grade Level Evidence Grade Level
1 2 3
A A-I A-II A-III
B B-I B-II B-III
C C-I C-II C-III
Panel Grade Levels
A - All the panel members agree that the recommendation
should be adopted because it is relevant, applicable
and will benefit many patients.
B - Majority of the panel members agree that the
recommendation should be adopted because it is
relevant, applicable in many areas and will benefit
many patients.
C - Panel members were divided that the recommendation
should be adopted and is not sure if it will be applicable
in many areas or will benefit many patients.
Evidence Grade Levels
I - The best evidence cited to support the recommendation
is a well-conducted randomized controlled trial. The
CONSORT standard may be used to evaluate a well-
conducted randomized controlled trial.
II - The best evidence cited to support the recommendation
is a well-conducted observational study i.e. match
control or before and after clinical trial, cohort studies,
case control studies and cross-sectional studies. The
 STROBE statement may be used to evaluate a well-
conducted observational study.
III - The best evidence cited to support the recommendation
is based on expert opinion or observational study that
did not meet the criteria for level 2.
Pathway Recommendations
Visit History and Physical Examination
In the implementation of the clinical pathways, the
PAFP QA committee strongly recommends compliance to
guideline recommendations that are graded as either A-I,
A-II or B-I. However, the committee also recommends using
sound clinical judgment and patient involvement in the
decision making before applying the recommendations.
Pathway Tasks
Laboratory Pharmacologic Non-pharmacologic Interventions Patient Outcomes
Intervention

First Visit __All patients with upper __Request for non- Probably motility Patient interventions __Aware of initial
gastrointestinal pain or discomfort invasive H. pylori test if problem __Educate the patient about diagnosis (A-III)
should have a detailed history with history of previous __Start therapeutic upper gastrointestinal disorders __Aware of risk factors
focusing on weight loss, dyspepsia treatment, trial of prokinetic and dyspepsia, risk factors and and complications
hematemesis, hematochezia, more than 45 years old treatment for 1-2 complications (A-II) (A-III)
melena, dysphagia, odynophagia, or long-term use of weeks (A-I) __If medications were prescribed, __Aware of
vomiting, NSAID intake, alcohol NSAID (A-II) explain the dose, frequency, importance of
intake, smoking, frequent medical Probably acid- intended effect, possible side effects adherence to
complaints, depression, anxiety, __ Upper abdominal related problem and importance of medication diagnostics and
personal or family history of ultrasound, liver __Start therapeutic adherence (A-II) interventions (A-III)
gastrointestinal disease using family function test, trial with proton-pump __Lifestyle modifications focusing
genogram. (A-II) pancreatic amylase inhibitor or H2 blocker on low fat meals, weight reduction,
__ Physical examination findings if organic problem is for 1-2 weeks (A-I) avoidance of alcohol intake and
provide minimal information but considered (A-II) smoking cessation, eating way
should be done to rule out an Undifferentiated before bedtime, elevated head
organic pathology and to look for upper while sleeping, etc. (A-II)
alarm clinical features like anemia, gastrointestinal
abdominal tenderness or mass, problem Family interventions
jaundice, melena etc. (A-II) __Start therapeutic __Inquire and recommend family
trial with combination members’ lifestyle activities (A-III)
Pathway decisions of prokinetic and
__If there is organic/structural proton-pump inhibitor Community interventions
problem based on significant or H2 blocker for 1-2 __Inquire for community lifestyle
physical examination finding, refer weeks (A-I) activities (A-III)
to specific clinical pathway (A-III)
__Probably motility problem if Continuing Care
prominent history of bloatedness, __Follow-up after 1-2 weeks
dysphagia and vomiting (A-III) __Offer family wellness package
__Probable acid-related problem if (A-III)
prominent history of epigastric pain,
NSAID and alcohol intake and reflux
symptoms (A-III)
__Undifferentiated upper
gastrointestinal problem (A-III)

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VOL. 55 NO. 3 JULY - SEPTEMBER, 2017 133

 Pathway Tasks
Visit History and Physical Examination Laboratory Pharmacologic Non-pharmacologic Interventions Patient Outcomes
Intervention

Second __Review and note any change __Request for Improved symptoms Patient interventions __Improved symptom
Visit in history focusing on weight loss, endoscopy if symptoms __Continue __Enhance education about control (A-I)
hematemesis, melena, dysphagia, did not improve with medications until 4 upper gastrointestinal disorders __Modification of
odynophagia, vomiting, NSAID therapeutic trial for 2-4 weeks (A-I) and dyspepsia, risk factors and risk factors i.e. diet,
intake, alcohol intake, smoking weeks (A-II) complications (A-II) lifestyle, smoking and
frequent medical complaints, With upper __If medications were prescribed, alcohol intake (A-I)
depression, anxiety, personal or __Complete request gastrointestinal enhance explanation on the dose, __Absence of new
family history of gastrointestinal for upper abdominal organic problem frequency, intended effect, possible complications (A-III)
disease using family genogram. ultrasound, liver __Refer to side effects and importance of __Adherence to
(A-II) function test and gastroenterologist or medication adherence (A-II) diagnostics and
__Repeat and note any change pancreatic amylase manage according __Enhance lifestyle modifications interventions (A-II)
in physical examination focusing if organic problem is to available clinical focusing on low fat meals, weight __Agreed plan for
on the upper gastrointestinal tract considered (A-II) pathway (A-III) reduction, avoidance of alcohol family intervention
(A-II) intake and smoking cessation, (A-III)
__Review the results of laboratory eating way before bedtime,
tests and response to empiric elevated head while sleeping, etc.
treatment (A-II) (A-II)

Family interventions
Pathway decisions __Enhance recommendation
__If there is symptom for family members’ appropriate
improvement with the therapeutic lifestyle activities (A-III)
trial, continue until 4 weeks (A-III)
__If no symptom improvement, Community interventions
refer for gastrointestinal endoscopy __Recommend participation in
(A-III) appropriate community lifestyle
__If the H pylori test is positive, activities like alcohol anonymous
start eradication treatment (A-III) (A-III)
__If ultrasound and other
laboratory tests are positive manage Continuing care
accordingly (A-III) __Follow-up after 1 month until
upper gastrointestinal symptom is
resolved and every 3-6 months if BP
target is already achieved (A-III)

Variations

134 THE FILIPINO FAMILY PHYSICIAN

 Pathway Tasks
Visit History and Physical Examination Laboratory Pharmacologic Non-pharmacologic Interventions Patient Outcomes
Intervention

Continuing __Review and note any change __Repeat request H Improved symptoms Patient interventions __Improved symptom
Visit in history focusing on weight loss, pylori test, endoscopy __Self-management __Enhance education about control (A-I)
hematemesis, melena, dysphagia, or upper abdominal with the same upper gastrointestinal disorders __Modification of
odynophagia, vomiting, NSAID ultrasound, liver medications for and dyspepsia, risk factors and risk factors i.e. diet,
intake, alcohol intake, smoking function test and symptom recurrence complications (A-II) lifestyle, smoking and
frequent medical complaints, pancreatic amylase if (A-I) __Educate the patient on alcohol intake (A-I)
depression, anxiety, personal or organic problem was self-management for symptom __Absence of new
family history of gastrointestinal considered after 3-6 With upper recurrence (A-II) complications (A-III)
disease using family genogram. months to monitor gastrointestinal __Enhance lifestyle modifications __Adherence to
(A-II) response to treatment organic problem focusing on low fat meals, weight diagnostics and
__Repeat and note any change (A-II) __Refer to reduction, avoidance of alcohol interventions (A-II)
in physical examination focusing gastroenterologist or intake and smoking cessation, __Implemented
on the upper gastrointestinal tract manage according eating way before bedtime, plan for family
(A-II) to available clinical elevated head while sleeping, etc. and community
__Review the results of endoscopy pathway (A-III) (A-II) intervention (A-III)
and other laboratory tests (A-II)
Family interventions
__Enhance recommendation
Pathway decisions for family members’ appropriate
__If endoscopy was positive for lifestyle activities (A-III)
bleeding peptic ulcer and other
serious organic problem consider Community interventions
transfer of care to gastroenterologist __Recommend participation in
(A-III) appropriate community lifestyle
__If there is continued positive activities like alcohol anonymous
response to therapeutic trial and (A-III)
H. pylori eradication continue with
current care (A-III) Continuing care
__Follow-up after 1 month until
upper gastrointestinal symptom
is resolved and every 6-12 months
(A-III)

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VOL. 55 NO. 3 JULY - SEPTEMBER, 2017 135

Notes on the Recommendations
Guidelines and clinical pathways are important tools
in family and community practice. These are usually based
on published evidence. But when evidence is limited,
guidelines have to rely on the opinions and experience of
physicians and arrive at a consensus.7 This pathway contains
specific recommendations for decisions to be made during
the first, second and continuing visits that are based on
published clinical evidence as well as consensus.
First Visit
History and Physical Examination
Patients with dyspepsia will be consulting a physician’s
clinic for the following symptoms; recurrent epigastric pain,
heartburn or acid regurgitation, with or without bloating,
nausea or vomiting. These symptoms fit in the definition of
dyspepsia adopted by the National Institute of Health Care
and Clinical Excellence (NICE) in the United Kingdom.8
The clinical history and physical examination must focus
on investigating for the presence of age at onset greater
than 45 years old, weight loss, anemia, hematemesis,
melena, hematochezia, dysphagia, odynophagia, persistent
vomiting, abdominal mass, jaundice, chronic NSAID
intake, chronic alcohol intake and previous history of
ulcer. These were considered alarm features in previous
guidelines and may signify that the patient may be at
high risk. Other features like frequent medical complaints,
depression, anxiety, family history of dyspepsia or peptic
ulcer disease and smoking should also be obtained.1 It
is also recommended to review medications for possible
causes of dyspepsia for example, calcium antagonists,
nitrates, theophylline, bisphosphonates, corticosteroids
and nonsteroidal anti-inflammatory drugs (NSAIDs).8
Gastrointestinal complaints are common among patients
with somatization and anxiety disorders. A cohort study
showed that certain personality characteristics like trait
anger reactivity and stress proneness, frequent use of
coping strategies and social stress predispose individuals
136 THE FILIPINO FAMILY PHYSICIAN
to develop functional gastrointestinal disease including
dyspepsia. It was noted that patients with functional
gastrointestinal disease had more stressors (98% vs 36%
compared to normal healthy controls) and that the greater
the number of stressors is also associated with greater
severity of the disease.9
Physical examination rarely helps in establishing
the etiology of dyspepsia. The usual PE for patients with
dyspepsia will usually show no masses, no organomegaly
and variable epigastric tenderness.10,11
After conducting a history and physical examination,
the patient’s dyspepsia may be classified into the following
symptom syndrome that may guide initial choice of
diagnostic and therapeutic management.
• Dysmotility like dyspepsia - Agreus and Talley both
described this subgroup by naming the following most
bothersome symptoms: Upper abdominal discomfort
(not pain); early satiety, bloating in upper abdomen,
post-prandial fullness, and nausea, retching or
vomiting.12
• Ulcer-like dyspepsia – Barbara’s article succinctly
described the symptoms as suggestive of peptic ulcer
diseases. Talley and Agreus agreed on the following
symptomatology: relapsing epigastric pain, aggravated
by hunger and relieved by antacids.12
• Reflux-like dyspepsia – Talley and Agreus described
the most bothersome symptom as heartburn and acid
regurgitation which may awaken patient at night.12
• Functional dyspepsia – Barbara briefly described this
subgroup as patients who report dyspeptic symptoms
in whom no disease can be identified by any clinical,
biochemical, endoscopic, ultrasonographic pathology.
The diagnosis is usually made after an extensive
gastrointestinal diagnostic work-up.13
Aside from the four symptom syndromes mentioned,
family and community medicine practitioners may also
limit the diagnosis to just two types i.e. post-prandial
dysmotility syndrome (motility-related dyspepsia) or
epigastric pain syndrome (acid-related dyspepsia). This has
around 70% pre-test probability as a provisional diagnosis
after a thorough history and physical examination.
Although overlapping symptoms may be present, these
two syndromes separate out more clearly and can guide
the initial diagnostic and therapeutic decisions.14 The
possibility of cardiac or biliary disease should also be part
of the differential diagnosis.8 Some authors make mention
of those chronically abusing alcohol being at a higher risk
for developing conditions such as chronic pancreatitis which
may present as dyspepsia.
After making a provisional diagnosis, the family and
community physician has two main options. The first
option is empiric medical therapy based the dominant
symptom or symptom complex i.e. motility-related
dyspepsia and acid-related dyspepsia with further
investigation reserved for ‘empiric treatment failures’
for low risk patients (no alarm features). The previous
guideline on dyspepsia recommended that the presence
of alarm symptoms physician should warrant prompt
referral. However, there is little evidence in the literature
of the exact predictive value of these alarm features
in the diagnosis of cancer or other serious diseases
causing dyspepsia. 15 Acid-related and gastroesophageal
reflux disease (GERD) can be diagnosed clinically if the
patient’s dominant symptoms are heartburn or acid
regurgitation, or both. Individuals who reflux gastric
contents into the esophagus may cause symptoms
sufficient to reduce quality of life. They may be treated
empirically with proton pump inhibitors or H2 blockers
without further investigation provided there are no
alarm features. 16 Dysmotility-related dyspepsia may be
treated with prokinetic drugs. There are available fixed
dose combination of acid suppression and dysmotility
drugs or acid suppression and anti-H pylori drugs that
family physicians can also use for empiric treatment.
The second option is immediate referral for diagnostic
evaluation like endoscopy for high risk patients. 17
Alarm features like melena, hematochezia, anemia and
VOL. 55 NO. 3 JULY - SEPTEMBER, 2017 137
significant weight loss are listed because intuitively they
are indicators of the presence of either a malignancy or a
peptic ulcer disease that may warrant prompt endoscopy
and referral. 8 The decision of prompt referral may depend
on the clinical judgment of the family physician, the
availability of the specialist facility and a shared decision
with the patient.
Laboratory Tests
Most patients with dyspepsia may undergo empiric
treatment for 2-4 weeks. However, a “test and treat”
strategy for Helicobacter pylori (H pylori) may be done
among uninvestigated dyspepsia in people over 45 years
of age or long-term non-steroidal anti-inflammatory drug
treatment.8,18,19 There may be a need for a 1-week washout
period after proton pump inhibitor (PPI) use before
testing for H pylori. The urea breath and fecal antigen
tests are acceptable for diagnosis of H. pylori but is not yet
readily available in family and community practice in the
Philippines.
Ultrasonography is a non-invasive and readily
available diagnostic procedure in most parts of the country.
Ultrasonography shows 100% sensitivity and 87.5%
specificity compared to ambulatory gastro-oesophageal
reflux disease diagnosis. It can estimate whole gastric
volume, antral area or diameters, and transpyloric flow
in fasting state and in response to test meal. Gallbladder,
liver and pancreas ultrasonography is reliable to determine
structural problems in these organs. All these make
ultrasound an appealing diagnostic test to assess upper
gastrointestinal disease.20
A special group of patients may also need psychiatric
testing especially if the physician suspects that the dyspeptic
patient has some underlying psychological disturbance.
Drossman recommended psychiatric testing if there are:
1) complains of chronic pain, 2) longer pain history,
3) abnormal illness behavior - relentless search to validate
the disease, 4) family dysfunction, 5) disorder affects QOL
and daily function, 6) history of psychiatric diagnosis, and
7) poor coping strategies.21
Pharmacologic Interventions
Before starting empiric treatment, the family and
community physician must first ensure the following: 1) the
symptoms originate in the upper gastrointestinal tract and
cardiac, biliary or pancreatic problem was clinically ruled
out, 2) alarm features associated with bleeding peptic ulcer
or cancer are absent, 3) discontinued use of non-steroidal
anti-inflammatory drugs, and 5) H. pylori infection is not
highly considered. The family physician must discuss with
patients over 45 years of age who present with dyspepsia
and alarm features associated with bleeding peptic ulcer or
cancer to get prompt investigation, preferably endoscopy.
Patients who use NSAIDs regularly are recommended
to stop NSAID. If NSAID therapy cannot be stopped,
prophylactic therapy or enteric coated NSAID may be tried.
Non-steroidal anti-inflammatory drugs, acetylsalicylic acid
and cyclooxygenase-2-selective inhibitors can all cause
dyspepsia. Combination therapy with either a proton pump
inhibitor or high-dose H2RA is recommended.22 If practically
feasible, patients who had history of chronic dyspepsia,
NSAID use but without alarm symptoms warranting
endoscopy should be tested for H. pylori infection, and
those with a positive result should be treated with H. pylori-
eradication therapy. Those with a negative result should
have their symptoms treated with optimal anti-secretory
therapy or a prokinetic agent or a combination of both.21
Most patients with dyspepsia may be offered acceptable
symptomatic management. As there is no single ideal first
choice drug, selection is often empiric after considering the
following: level of contact and care, dominant dyspepsia
symptom, availability and cost of medicines, individual
preferences. Most guidelines recommend empirical full-
dose PPI therapy for 2-4 weeks to people with dyspepsia.8
H2-receptor antagonists and prokinetic agents may
be considered as second-line or alternative empiric
medication.24,25,26 Drug treatment should continue for a
finite period (2-4 weeks) and response should be monitored.
All patients should be given advice on lifestyle changes.17
For frequent or severe GERD symptoms, proton pump
inhibitors for 2-4 weeks are recommended for GERD. Over-
138 THE FILIPINO FAMILY PHYSICIAN
the-counter antacids or H2 blockers may be effective for
some patients with mild or infrequent symptoms. Routine
testing for Helicobacter pylori infection is unnecessary
before starting treatment. Endoscopic screening for Barrett’s
epithelium may be considered in adults with GERD for more
than 10 years.27
Non-pharmacologic Interventions
Once a patient is diagnosed with dyspepsia, the family
and community physician should carefully explain the
pathophysiology and benign nature of this condition. To
avoid anxiety and further cost of diagnosis and treatment,
the patient must be re-assured about the disease. Recurrence
is common and self-management is essential for adequate
control of symptoms. The physician must establish a good
doctor-patient relationship.28
The following points must be emphasized. Offer simple
lifestyle advice, including advice on healthy eating, weight
reduction and smoking cessation. Advise people to avoid
known precipitants they associate with their dyspepsia
where possible. These include smoking, alcohol, coffee,
chocolate, fatty foods and being overweight. Raising the
head of the bed and having a main meal well before going
to bed may help some people. Provide people with access
to educational materials to support the care they receive.
Recognize that psychological therapies, such as cognitive
behavioural therapy and psychotherapy, may reduce
dyspeptic symptoms in the short term in individual people.8
Patient Outcomes
At the end of the consultation, the patient must be
aware of the diagnosis of dyspepsia and its recurrent
nature. The patient must also be aware of the potential
complications and differential diagnosis. The patient must
agree to follow the recommended lifestyle changes. If the
patient was given empiric treatment, the patient must also
be aware of its dose, frequency of intake, expected effect
and potential side effects. A baseline symptom score or
quality of life score should also be obtained as baseline.
Second Visit
History and Physical Examination
Evaluate the patient’s response to empiric treatment.
If laboratory evaluation was requested, evaluate the
results. Review the history and physical examination
and correlate with results of laboratory and response to
empiric treatment. Consider referral to a specialist service
for patients of any age with gastro-oesophageal symptoms
that are non-responsive to treatment.8
Laboratory Tests
If empiric treatment or after a trial of a second drug
fails, then further investigation should be considered. Upper
gastrointestinal endoscopy and H pylori testing are valuable
diagnostic tools that can guide future clinical decisions. The
need for endoscopy is a difficult decision in patients with
dyspepsia. It is costly and not readily available in family and
community practice. However early endoscopy will often
prove more cost effective than delaying until the indications
are clearer.29
H. pylori testing is another test to be considered. There
is now direct clinical evidence supporting a test-and-treat
approach in patients with dyspepsia symptoms.22 Empiric
H. pylori eradication therapy is not recommended.
The role of H. pylori is an important development in
gastroduodenal disease. It has changed our understanding
of the pathophysiology of diseases in the in the upper
gastrointestinal tract. It may also have a role in un-
investigated and functional dyspepsia and ulcer risk in
patients taking low-dose aspirin or starting therapy with a
non-steroidal anti-inflammatory medication.30 Eradication
of the bacterium resulted to faster cure of peptic ulcer disease
and decreased the symptoms of non-ulcer dyspepsia.31
H. pylori infection can be accurately diagnosed with urea
breath test or a stool antigen test. It can also be diagnosed
invasively by histology or culture.32 Proton pump inhibitor
therapy should be stopped at least 1 week prior to H pylori
testing.33
VOL. 55 NO. 3 JULY - SEPTEMBER, 2017 139
Pharmacologic Interventions
If the initial empiric treatment fails a trial of an
additional second drug may be done. H2 blocker therapy
if there is an inadequate response to a PPI may be added.8
Cure of H. pylori infection decreases recurrence rates and
facilitates healing. Thus antibiotic therapy is indicated for
all H. pylori-infected patients. No optimal, simple antibiotic
regimen has yet emerged.
While choosing a treatment regimen for H. pylori,
patients should be asked about previous antibiotic
exposure and this information should be incorporated
into the decision-making process. For first-line treatment,
clarithromycin triple therapy should be confined to patients
with no previous history of macrolide exposure who reside
in areas where clarithromycin resistance amongst H. pylori
isolates is known to be low. Most patients will be better
served by first-line treatment with bismuth quadruple
therapy or concomitant therapy consisting of a PPI,
clarithromycin, amoxicillin, and metronidazole.30
The Asia-Pacific Consensus Conference recommended
H. pylori eradication among infected patients with
functional dyspepsia and those receiving long-term
maintenance proton pump inhibitor for gastroesophageal
reflux disease. In Asia, the currently recommended first-
line therapy for H. pylori infection is PPI-based triple
therapy with amoxicillin/metronidazole and clarithromycin
for 7 days, while bismuth-based quadruple therapy is an
effective alternative. There appears to be an increasing
rate of resistance to clarithromycin and metronidazole in
parts of Asia, leading to reduced efficacy of PPI-based triple
therapy.34 The recommended doses are a twice daily, seven-
day regimen of a proton pump inhibitor (omeprazole 20
mg, lansoprazole 30 mg, pantoprazole 40 mg) or ranitidine
bismuth citrate 400 mg, plus clarithromycin 500 mg and
amoxicillin 1000 mg, or plus clarithromycin 500 or 250
mg and metronidazole 500 mg.35,36 This usually result to
eradication of H. pylori infection in 80-90% of cases. In case
of lack of efficacy, the 7-14 day treatment may be repeated
using triple therapies (PPI + 2 antibiotics) substituting
the antibiotic with the metronidazole or tetracycline, or
quadruple therapies (PPI + bismuth citrate + 2 antibiotics).
Side effects during eradicative treatments occur in about 15
to 30% of patients.37
Non-pharmacologic Interventions
Reinforce advice on diet and lifestyle modification.
Patient Outcomes
On second visit, the patient must have improvement in
symptoms and must be able to do usual activities of daily
living or work. An improved quality of life may also be
achieved based on simple instrument.
Continuing Visit
History and Physical Examination
Evaluate the full 4 week treatment. If there is
improvement but not total resolution of symptoms, the
family physician may extend treatment until 8 weeks.
Consider referral to a specialist service for patients of any
age with gastro-oesophageal symptoms that are non-
responsive to treatment or with H pylori that has not
responded to second-line eradication therapy.8
Laboratory Tests
If there is response to treatment, the laboratory tests
that showed positive results may be repeated after 3-6
months to monitor cure or further response to treatment.
For patients on long-term NSAID therapy fecal occult blood
testing may be done. Renal function may also be monitored
in high-risk patients.38
Pharmacologic Interventions
Dyspepsia is a recurrent illness. Some people may need
long-term and intermittent management of dyspepsia
symptoms. Patients may need to be taught on self-
140 THE FILIPINO FAMILY PHYSICIAN
management when appropriate. PPI or H2 blocker therapy
to the lowest dose needed to control symptoms should be
adviced on an ‘as needed’ basis with people to manage
their own symptoms. Patients on long-term management
self-management should have an annual review of their
condition.8
Recommendations for Implementation
Clinic Level
Quality improvement strategy is recommended for
implementation of this pathway. This will involve pre- and
post-intervention data collection using records review.
Intervention strategies may be feedback, group consensus
or incentive mechanisms. This strategy has been shown to
be effective in improving the quality of care for patients
with dyspepsia. Adherence to guideline criteria increased
significantly among family physicians after the intervention
(from 55% to 75%).39
References
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3. Ford AC, Marwaha A, Lim A, Moayyedi P. What is the prevalence of
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4. Chang JY, Locke GR 3rd, McNally MA, et al. Impact of functional
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335-53.
16. Armstrong D, Marshall JK, Chiba N, Enns R, Fallone CA, Fass R,
Hollingworth R, Hunt RH, Kahrilas PJ, Mayrand S, Moayyedi P,
Paterson WG, Sadowski D, van Zanten SJ. Canadian Association
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adults - update 2004. Can J Gastroenterol 2005; 19(1): 15-35.
17. [No authors listed] Diagnosis and management of dyspepsia--clinical
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Helicobacter pylori infection. J Physiol Pharmacol 2006; 57 Suppl 3:
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19. Goh KL, Mahendra Raj S, Parasakthi N, Kew ST, Kandasami P, Mazlam
Z. Management of Helicobacter pylori infection--a Working Party
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G, Roda E, Festi D. Standards for diagnosis of gastrointestinal motility
disorders. Section: ultrasonography. A position statement from the
Gruppo Italiano di Studio Motilità Apparato Digerente. Dig Liver Dis
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21. Drossman, D. Diagnosis and treatment of patients with refractory
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22. Veldhuyzen van Zanten SJ, Bradette M, Chiba N, Armstrong D, Barkun
A, Flook N, Thomson A, Bursey F. Canadian Dyspepsia Working
Group. Evidence-based recommendations for short- and long-
term management of uninvestigated dyspepsia in primary care: an
update of the Canadian Dyspepsia Working Group (CanDys) clinical
management tool. Can J Gastroenterol 2005; 19(5): 285-303.
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23. Veldhuyzen van Zanten SJ, Flook N, Chiba N, Armstrong D, Barkun
A, Bradette M, Thomson A, Bursey F, Blackshaw P, Frail D, Sinclair P.
An evidence-based approach to the management of uninvestigated
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Working Group. CMAJ. 2000; 162(12 Suppl): S3-23.
24. Paikka N. [Update on current care guidelines. A current care guideline:
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Tominaga K, Nakada K, Nagahara A, Futagami S, Manabe N, Inui A,
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Epub 2015 Jan 14.
26. Jee SR, Jung HK, Min BH, Choi KD, Rhee PL, Kang YW, Lee SI. Korean
Society of Neurogastroenterology and Motility. [Guidelines for the
treatment of functional dyspepsia]. [Article in Korean] Korean J
Gastroenterol 2011; 57(2): 67-81.
27. Armstrong D, Marshall JK, Chiba N, Enns R, Fallone CA, Fass R,
Hollingworth R, Hunt RH, Kahrilas PJ, Mayrand S, Moayyedi P,
Paterson WG, Sadowski D, van Zanten SJ. Canadian Association
of Gastroenterology GERD Consensus Group. Canadian Consensus
Conference on the management of gastroesophageal reflux disease in
adults - update 2004. Can J Gastroenterol 2005; 19(1): 15-35.
28. Miwa H, Kusano M, Arisawa T, Oshima T, Kato M, Joh T, Suzuki H,
Tominaga K, Nakada K, Nagahara A, Futagami S, Manabe N, Inui A,
Haruma K, Higuchi K, Yakabi K, Hongo M, Uemura N, Kinoshita Y,
Sugano K, Shimosegawa T. Japanese Society of Gastroenterology.
Evidence-based clinical practice guidelines for functional dyspepsia. J
Gastroenterol 2015; 50(2): 125-39. doi: 10.1007/s00535-014-1022-3.
Epub 2015 Jan 14.
29. Axon AT, Bell GD, Jones RH, Quine MA, McCloy RF. Guidelines on
appropriate indications for upper gastrointestinal endoscopy.
Working Party of the Joint Committee of the Royal College of
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College of Anaesthetists, Association of Surgeons, the British Society
of Gastroenterology, and the Thoracic Society of Great Britain. BMJ
1995; 310(6983): 853-6.
30. Chey WD, Leontiadis GI, Howden CW, Moss SF. ACG Clinical Guideline:
Treatment of Helicobacter pylori Infection. Am J Gastroenterol 2017;
112(2): 212-39. doi: 10.1038/ajg.2016.563. Epub 2017 Jan 10.
31. Buckley M, Culhane A, Drumm B, Keane C, Moran AP, O’Connor HJ,
Collins J, Kelleher D, McAvinchey D, Sloan J, O’Morain C. Guidelines for
the management of Helicobacter pylori-related upper gastrointestinal
diseases. Irish Helicobacter Pylori Study Group. Ir J Med Sci 1996; 165
Suppl 5: 1-11.
32. Fischbach W, Malfertheiner P, Hoffmann JC, Bolten W, Kist M, Koletzko
S. Association of Scientific Medical Societies. Helicobacter pylori and
gastroduodenal ulcer disease. Dtsch Arztebl Int 2009; 106(49): 801-8.
doi: 10.3238/arztebl.2009.0801. Epub 2009 Dec 4.
33. Bytzer P, Dahlerup JF, Eriksen JR, Jarbøl DE, Rosenstock S, Wildt S.
Danish Society for Gastroenterology. Diagnosis and treatment of
Helicobacter pylori infection. Dan Med Bull 2011; 58(4): C4271.
34. Fock KM, Katelaris P, Sugano K, Ang TL, Hunt R, Talley NJ, Lam SK,
Xiao SD, Tan HJ, Wu CY, Jung HC, Hoang BH, Kachintorn U, Goh KL,
Chiba T, Rani AA; Second Asia-Pacific Conference. Second Asia-
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Gastroenterol Hepatol 2009; 24(10): 1587-600. doi: 10.1111/j.1440-
1746.2009.05982.x.
35. Hunt RH, Fallone CA, Thomson AB. Canadian Helicobacter pylori
Consensus Conference update: infections in adults. Canadian
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36. Goh KL, Mahendra Raj S, Parasakthi N, Kew ST, Kandasami P, Mazlam
Z. Management of Helicobacter pylori infection--a Working Party
Report of the Malaysian Society of Gastroenterology and Hepatology.
Med J Malaysia. 1998; 53(3): 302-10.
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Helicobacter pylori infection. J Physiol Pharmacol 2006; 57 Suppl
3:143-54.
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Health Care 2007; 16(1): 67-70.
 CLINICAL UPDATE

Clinical Pathways for the Management of

Hypertension in Family and Community Practice

Noel L. Espallardo, MD, MSc, FPAFP; Limuel Anthony B. Abrogena, MD, FPAFP; Marishiel Mejia-Samonte, MD, DFM
Anna Guia O. Limpoco, MD, FPAFP and Ryan Jeanne V. Ceralvo, MD, FPAFP

Background: Hypertension is a major risk factor for cardiovascular disease. The prevalence of hypertension in the Western
Pacific Region is 37% of adults older than 24, while in the Philippines it is 25% of adults 21 years old and above. Several
guidelines have been developed for the management of hypertension. All these guidelines have recommendations for
assessment and treatment.
Objectives: The overall objective of the development and implementation of this clinical pathway is to improve outcomes
of patients with hypertension seen in family and community practice.
Methods: The PAFP Clinical Pathways Group reviewed published medical literature to identify, summarize, and operationalize
the clinical content of diagnostics, interventions and clinical indicators or outcomes to develop an evidence-based clinical
pathway in family medicine practice. The group developed a time-related representation of recommendations on patient
care processes, in terms of history and physical examination, laboratory tests, pharmacologic and non-pharmacologic
interventions as well as social and community strategies to treat hypertension and prevent complications.
Recommendations: Recommendations were made based on the number of visits. During the first visit, all adult patients
consulting at the clinic should be screened for hypertension with appropriate BP measurement. A thorough history
focusing on symptoms, family history using genogram, smoking and other lifestyle and co-existing chronic disease and
a thorough physical examination focusing on the weight/BMI, waist/hip ratio, funduscopy, neurological, cardiac, renal
and peripheral arteries should be done. For the laboratory, request for 12-lead ECG, urinalysis, FBS, creatinine, serum K
and lipid profile to determine co-morbidities and baseline values. If the patient is already diagnosed hypertensive, start/
continue medications with either or a combination of thiazide-type diuretic, calcium channel blockers, angiotensin-
converting enzyme inhibitors and angiotensin receptor blocker depending on co-morbidities or side effects. But if there
is a need for further confirmation, no medication is warranted. Educate the patient about hypertension, risk factors and
complications. If medications were prescribed, explain the dose, frequency, intended effect, possible side effects and
importance of medication adherence. Lifestyle modifications focusing on weight control, exercise and smoking cessation
should be adviced. During the first visit it is expected that the patient is aware of the diagnosis of hypertension, its risks
factors and complications to encourage compliance.
Implementation: Education, training and audit are recommended strategies to implement the clinical pathway.

VOL. 55 NO. 3 JULY - SEPTEMBER, 2017 143

 Introduction
Hypertension is a condition of persistently high
systemic arterial blood pressure. It is currently defined as
a systolic pressure consistently greater than 140 mm Hg
or diastolic pressure is consistently 90 mm Hg or more in
multiple readings.1 Blood pressure measurement should be
taken on two separate occasion at least one week apart.
Hypertension is a major risk factor for cardiovascular
disease. Worldwide, it is estimated that almost half of deaths
due to stroke and heart disease are cause by hypertension.
Adequate management of hypertension may lead to a
significant decrease in stroke and myocardial infarction. The
prevalence of hypertension in the Western Pacific Region is
37% of adults older than 24, while in the Philippines it is 25%
of adults 21 years old and above.2 This is approximately 10
million adults in 2008 and the incidence is increasing.3
In 2010, hypertension is the leading single risk
factor for global burden of disease.4 The annual mortality
per 100,000 people from hypertensive heart disease in
Philippines has increased by an average of 3.9% a year since
1990. In 2013 there were 696 deaths per 100,000 among
men 690 deaths per 100,000 among women. The mortality
rate is highest at age 80 and above in both sexes.5 The cost
of treatment is usually attributed to antihypertensive drugs
(42.7%), followed by hospital admission (28.4%), clinic
visits (15.1%) and laboratory tests (10.6%).6
Several guidelines have been developed for the
management of hypertension. All these guidelines have
recommendations for assessment and treatment. Aside
from pharmacologic treatment, they also recommended
lifestyle interventions like smoking cessation, reduction
of sodium and fat intake, aerobic exercise, maintenance of
ideal body mass index and moderation of alcohol intake. For
patients with co-morbidity like diabetes and dyslipidemia,
pharmacologic treatment to control blood sugar and
cholesterol is adviced.7 These guideline recommendations
are published in several medical journals from Canada, USA,
Europe and UK. This clinical pathway for hypertension is an
attempt to implement these recommendations in family
and community medicine practice in the Philippines.
144 THE FILIPINO FAMILY PHYSICIAN
The overall objective of the development and
implementation of this clinical pathway is to improve
outcomes of patients with hypertension seen in family
and community practice. This is expected to be achieved
by: 1) Improving the quality of care for patients with
hypertension in individual clinic of family and community
medicine practitioners, 2) Standardizing the quality of
care among the members of the Philippine Academy of
Family Physicians, Inc., 3) Implementing organizational and
health system strategies to promote the use of this clinical
pathway.
Methods of Development and Implementation
The PAFP Clinical Pathways Group reviewed published
medical literature to identify, summarize, and operationalize
the clinical content of diagnostics, interventions and clinical
indicators or outcomes to develop an evidence-based clinical
pathway in family medicine practice. The group developed a
time-related representation of recommendations on patient
care processes, in terms of history and physical examination,
laboratory tests, pharmacologic and non-pharmacologic
interventions as well as social and community strategies to
treat hypertension and prevent complications.
The group adopted several strategies in developing
the recommendations. The first strategy is emphasizing
on evidence-based recommendations as recommended
assessments and interventions. The second strategy is
recognition of potential variations between-patient and
between specific practice settings. The third strategy is
the recognition of “stakeholder groups” outside of family
and community practice with careful attention to getting
their opinion and support but without sacrificing the
objectives of the project. The fourth strategy is emphasis
on the commitment to establishment of the ultimate goal
of improving the effectiveness, efficiency and quality of
patient care in family and community practice.
The evidences for the patient care processes were
reviewed and summarized as notes on the recommendations.
The clinical pathway was then disseminated to the selected
PAFP chapters and members and other stakeholders for
consensus development. Dissemination was publication
in the Filipino Family Physician journal, conference
presentations and focused group discussions.
The implementation of clinical pathways to be
adopted by the PAFP will be quality improvement
activities in a form of patient record reviews, audit and
feedback. Audit standards will be the assessment and
intervention recommendations in the clinical pathway.
Implementation of clinical pathways will be at the
practice and organizational levels. Practice level can
be a simple count of family and community medicine
practitioners using and applying the clinical pathways.
Organizational outcomes can be activities of the PAFP
devoted to the promotion, development, dissemination
and implementation of clinical pathways.
Grading of the Recommendations
The PAFP QA Committee met as a panel and graded
the recommendations as shown in Table 1. The grading
system was a mix of the strength of the reviewed published
evidence and the consensus of a panel of experts. In some
cases, the published evidence may not be applicable if
Philippine family practice setting, so a panel grade based on
the consensus of clinical experts was also used. Thus if the
recommendation was based on a published evidence that
is a well done randomized controlled trial and the panel
of expert voted unanimously for the recommendation, it
was given a grade of A-I. If the level of evidence is based
on an observational study but the panel still unanimously
considered the recommendation, the grade given was A-II
and if the level of evidence is just an opinion but the panel
still unanimously recommended it, the grade was A-III.
Table 1. Grading of the recommendations.
Panel Grade Level Evidence Grade Level
1 2 3
A A-I A-II A-III
B B-I B-II B-III
C C-I C-II C-III
VOL. 55 NO. 3 JULY - SEPTEMBER, 2017 145
Panel Grade Levels
A - All the panel members agree that the recommendation
should be adopted because it is relevant, applicable
and will benefit many patients.
B - Majority of the panel members agree that the
recommendation should be adopted because it is
relevant, applicable in many areas and will benefit
many patients.
C - Panel members were divided that the recommendation
should be adopted and is not sure if it will be applicable
in many areas or will benefit many patients.
Evidence Grade Levels
I - The best evidence cited to support the recommendation
is a well-conducted randomized controlled trial. The
CONSORT standard may be used to evaluate a well-
conducted randomized controlled trial.
II - The best evidence cited to support the recommendation
is a well-conducted observational study i.e. match
control or before and after clinical trial, cohort studies,
case control studies and cross-sectional studies. The
STROBE statement may be used to evaluate a well-
conducted observational study.
III - The best evidence cited to support the recommendation
is based on expert opinion or observational study that
did not meet the criteria for level 2.
In the implementation of the clinical pathways, the
PAFP QA committee strongly recommend compliance
to guideline recommendations that are graded as
either A-I, A-II or B-I. However, the committee also
recommend using sound clinical judgment and patient
involvement in the decision making before applying the
recommendations.
Pathway Recommendations
Pathway Tasks
Visit History and Physical Examination Laboratory Pharmacologic Non-pharmacologic Interventions Patient Outcomes
Intervention

First Visit __All adult patients consulting Diagnosed Diagnosed Patient interventions __Aware of initial
at the clinic should be screened hypertension hypertension __Educate the patient about diagnosis (A-III)
for high blood pressure with __Request for 12- __Start/continue hypertension, risk factors and __Aware of risk factors
appropriate BP measurement (A-III) lead ECG, urinalysis, medications with complications (A-I) and complications
__Make a thorough history FBS, creatinine, either or a combination __If medications were prescribed, (A-III)
focusing on symptoms, family serum K and lipid of thiazide-type explain the dose, frequency, __Aware of
history using genogram, smoking profile to determine diuretic, calcium intended effect, possible side effects importance of
and other lifestyle and co-existing co-morbidities and channel blockers, and importance of medication adherence to
chronic disease (A-II) baseline values (B-II) angiotensin-converting adherence (A-I) diagnostics and
__Make thorough physical enzyme inhibitors and __Lifestyle modifications focusing interventions (A-III)
examination focusing on the Pathway decisions angiotensin receptor on weight control, exercise and
weight/BMI, waist/hip ratio, __ For patients with blocker depending on smoking cessation (A-I)
funduscopy, neurological, cardiac, previously diagnosed co-morbidities or side
renal and peripheral arteries (A-II) co-morbidities, refer effects (A-I) Family interventions
to specific pathway __Inquire and recommend family
Pathway decisions for management of Need to confirm members’ lifestyle activities (A-I)
__If BP is ≥ 140/90 mmHg with co-morbidity (A-III) hypertension
signs and symptoms of acute end- __No medications are Community interventions
organ damage, consider referral to warranted (A-III) __Inquire for community lifestyle
hospital (A-III) activities (A-III)
__If the initial BP is ≥ 180/110 Patients for
mmHg consider hypertension and emergency referral Continuing care
start medication. (A-III) __Consider giving a __Follow-up after 1-2 weeks (A-II)
__IF BP is ≥ 140/90 mmHg single dose of anti- __Offer family wellness package
and with previous history of hypertensive prior to (A-III)
high BP taken by another health transport (A-I)
professional within the month
consider hypertension and start
medication. (A-III)
__If BP is ≥ 140/90 mmHg and first
time high BP confirm with home
BP measurements or second visit
within 4 weeks (A-III)

Variations

146 THE FILIPINO FAMILY PHYSICIAN

 Pathway Tasks
Visit History and Physical Examination Laboratory Pharmacologic Non-pharmacologic Interventions Patient Outcomes
Intervention

Second __Review and note any change Diagnosed Diagnosed Patient interventions __Improved BP control
Visit in history focusing on symptoms, hypertension hypertension __Enhance education about (Age 18 to 59: <140/90
family history using the genogram, __Complete request __Start/continue hypertension, risk factors and mmHg;
smoking and other lifestyle and co- for 12-lead ECG, medications with complications (A-I) Age > 60: <150/90
existing chronic disease (A-II) urinalysis, FBS, either or a combination __If medications were prescribed, mmHg) (A-II)
__Repeat and note any change in creatinine, serum of thiazide-type repeat explanation about the dose, __ Body mass index
physical examination focusing on K and lipid profile diuretic, calcium frequency, intended effect, possible between 18.5-24.9 kg/
the weight/BMI, waist/hip ratio, to determine channel blockers, side effects and importance of m2 (A-II)
funduscopy, neurological, cardiac, co-morbidities and angiotensin-converting medication adherence (A-I) __Modification of
renal and peripheral arteries (A-II) baseline values (B-II) enzyme inhibitors and __Enhance advice on lifestyle risk factors i.e. diet,
__Review BP monitoring if angiotensin receptor modifications focusing on weight lifestyle, smoking and
available (A-II) blocker depending on control, exercise and smoking exercise (A-II)
__Review laboratory results and Pathway decisions co-morbidities or side cessation (A-I) __Absence of new
establish the presence of other risk __ For patients with effects (A-I) complications (A-III)
factors and co-morbidities (A-II) previously diagnosed Family interventions __Adherence to
co-morbidities, refer With co-morbidities __Enhance recommendation diagnostics and
to specific pathway __Refer to clinical for family members’ appropriate interventions (A-II)
Pathway decisions for management of pathway of the co- lifestyle activities (A-I) __Agreed plan for
__If home BP and/or second visit co-morbidity (A-III) morbidity (A-III) family intervention
BP are ≥ 140/90 mmHg diagnose as Community interventions (A-III)
hypertension (A-II) __Recommend participation in __Agreed plan
__If home BP and/or second visit appropriate community lifestyle for community
BP are < 140/90 mmHg rule out activities (A-III) involvement (A-III)
hypertension but monitor after 6-12
months (A-III) Continuing care
__Follow-up after 1 month until
BP target is achieved and every
3-6 months if BP target is already
achieved (A-III)

Variations

VOL. 55 NO. 3 JULY - SEPTEMBER, 2017 147

 Pathway Tasks
Visit History and Physical Examination Laboratory Pharmacologic Non-pharmacologic Interventions Patient Outcomes
Intervention

Continuing __Review and note any change
Visit in history focusing on symptoms,
family history using genogram,
smoking and other lifestyle and co-
existing chronic disease (A-II)
__Repeat and note any change in
physical examination focusing on
the weight/BMI, waist/hip ratio,
funduscopy, neurological, cardiac,
renal and peripheral arteries (A-II)
__Review laboratory results and
establish the presence of other risk
factors and co-morbidities (A-II)
Pathway decisions
__Enhance/revise pharmacologic
and non-pharmacologic
interventions until BP control is
achieved (Age 18 to 59: <140/90
mmHg;
Age > 60: <150/90 mmHg) (A-III)
Diagnosed Diagnosed Patient interventions __Improved BP control
hypertension hypertension __Enhance education about (Age 18 to 59: <140/90
__After 6-12 months __Continue/revise hypertension, risk factors and mmHg;
repeat for 12-lead medications with complications (A-I) Age > 60: <150/90
ECG, urinalysis, FBS, either or a combination __If medications were prescribed, mmHg) (A-II)
creatinine, serum K and of thiazide-type repeat explanation about the dose, __ Body mass index
lipid profile (B-II) diuretic, calcium frequency, intended effect, possible between 18.5-24.9 kg/
channel blockers, side effects and importance of m2 (A-II)
angiotensin-converting medication adherence (A-I) __Modification of
Pathway decisions enzyme inhibitors and __Enhance advice on lifestyle risk factors i.e. diet,
__ For patients with angiotensin receptor modifications focusing on weight lifestyle, smoking and
previously diagnosed blocker depending on control, exercise and smoking exercise (A-II)
co-morbidities, refer co-morbidities or side cessation (A-I) __Absence of new
to specific pathway effects (A-I) complications (A-III)
for management of Family interventions __Adherence to
co-morbidity (A-III) With co-morbidities __Enhance recommendation diagnostics and
__Refer to clinical for family members’ appropriate interventions (A-II)
pathway of the co- lifestyle activities (A-I) __Agreed plan for
morbidity (A-III) family intervention
Community interventions (A-III)
__Recommend participation in __Agreed plan
appropriate community lifestyle for community
activities (A-III) involvement (A-III)

Continuing care
__Follow-up after 1 month until
BP target is achieved then every
3-6 months if BP target is already
achieved (A-III)

Variations

148 THE FILIPINO FAMILY PHYSICIAN

Notes on the Recommendations
The subsequent sections discuss the clinical evidences
to support the recommendations in this clinical pathway.
The recommendations are packages of health care
interventions designed to improve clinical outcomes
of patients with hypertension. This is supposed to be
implemented by family and community doctors in their
outpatient clinics. The recommendations cover history and
physical examination, laboratory, pharmacologic and non-
pharmacologic intervention. Pharmacologic interventions
include prescription of anti-hypertensive drugs. Non-
pharmacologic interventions include health education,
lifestyle modification, and family and community
intervention. The interventions are designed to achieve
patient outcomes that include blood pressure control,
control of risk factors, prevention of complications and
improved quality of life.
The current evidences on hypertension treatment look
at the effectiveness of individual intervention. Currently,
a package of interventions including: 1) healthy lifestyle
counseling (smoking cessation, and salt, oil, and alcohol
reduction); 2) prescription of a combination of drugs
(antihypertensives, aspirin, and statin); and 3) adherence
support for drug compliance and healthy lifestyle change is
now being tested in a cluster randomized controlled trial. The
primary outcome is the incidence of severe cardiovascular
events over 24 months of follow-up. This trial will show the
effectiveness of the comprehensive cardiovascular event
reduction package for hypertensive patients in routine
practice. This will also identify the barriers and facilitators
to implementation and get informed advise on policy and
practice change.8
First Visit
History and Physical Examination
It is recommended that a blood pressure measurement
should be done to all patients consulting in a family or
community clinic. It is however not necessary to measure
VOL. 55 NO. 3 JULY - SEPTEMBER, 2017 149
the blood pressure of every patient at every clinic visit. The
Canadian Hypertension Education Program recommended
measurement only during appropriate visits that include
periodic health examinations, urgent office visits for
neurologic or cardiovascular-related issues, medication
renewal visits, and other visits where the primary care
practitioner deems it an appropriate opportunity to monitor
blood pressure.9
History and physical examination should be done to
all patients suspected or diagnosed with hypertension.
History should include checking for family history using the
genogram. Family history of hypertension, cardiovascular
and cerebrovascular disease and diabetes should be actively
elicited. The physical examination should focus not only on
the blood pressure measurement but also with the body
mass index. Organ system that may be damaged by high
blood pressure should be examined like the central nervous
system, retina, heart, kidneys and peripheral arteries. All
these findings should be clearly written in the patient’s
clinical record.
Checkbox for History
• What is your highest/lowest blood pressure in the past? What is
your usual blood pressure?
• When did it start? When did it happen? When were you
diagnosed as hypertensive?
• Obtain following information: extent of end-organ damage
(eg, heart, brain, kidneys, eyes), assessment of patients’
cardiovascular risk status and exclusion of secondary causes of
hypertension
• What happened during that time? What were the triggering/
contributory factors? What were you doing that time?
• What symptoms did you experience? Headache, dizziness,
blindness/blurring of vision, chest pain/discomfort, difficulty
of breathing/shortness of breath, epigastric pain, difficulty
in urination, hematuria, edema (face, upper and lower
extremities), leg/foot pain?
• Aside from hypertension what other diseases/illnesses does
the patient have?
• Past Medical History: If the patient is a male, ask if he took
any pill/powder form for protein building? If the patient is a
female, did she take any oral contraceptive pill? Intake of other
maintenance drugs/vitamins/herbal medicines/supplements
 • Family History: hypertension, coronary artery disease,
sudden death, cerebrovascular accident, diabetes mellitus,
hyperthyroidism, cancer. Draw genogram.
• Lifestyle: diet: what do you usually eat? What are you fond of?
Do you have food preferences? Do you eat fish, vegetables and
fruits? If yes, how many servings do you get per meal? Do you
use condiments? Give a sample menu for a day. Are you taking
any supplements? Any weight gain/loss? Exercise/any form of
physical activity? Sports? How often?
• Substance use/abuse: smoking/tobacco alcohol illicit drugs
energy drinks caffeine/coffee. If yes, ask for the amount, how
often? What does he feel after?
• Occupation: time of work? What are his preparations before
going to work? Is he pressured? Do you work overtime? How
often? Was there any instance that you were late or absent due
to high blood or any other disease? When was the last time you
were on a vacation?
• Last check-up? Last blood chemistry done? What were the
results? Increased total cholesterol/LDL and decreased HDL
Checkbox for Physical Examination
• Blood pressure measurement: both arms and if feasible in one
leg
• Office reading (clinic):
• Other vital signs: cardiac rate, respiratory rate, temperature,
BMI
• General: conscious, coherent, oriented to time, person and
place
• Skin: color (cyanosis)
• Fundoscopic exam: floaters, arteriovenous nicking, exudates,
hemorrhages, papilledema
• Examine the neck: distended veins, enlarged thyroid gland and
listen for carotid bruits
• Cardiac exam: displacement of apex, sustained and enlarged
apical impulse, presence of heaves, thrills, murmurs
• Abdomen: waist circumference, waist to hip ratio,
organomegaly, mass, listen for renal artery bruit
• Extremity: edema, deformity, palpation of pulses (absent,
weak, delayed), mid-upper arm circumference
• Neurologic exam: cranial nerves, cerebellar function, motor
and sensory
• For adults, Beck’s Depression Scale may be used to assess
possible psychosocial stressors*
• For the elderly please do Mini-Mental Status Examination and
Geriatric Depression Scale*
* These may be done in cases where compliance to medication may
be affected by these findings.
150 THE FILIPINO FAMILY PHYSICIAN
The history and physical examination must be written
legibly in a clinical record. A random sample of 18 general
practice in London showed that 340 (47%) of 716 patients
consulting in a 10 year period had no blood pressure
readings in their records. Of 84 hypertensive patients with
records, 62 (74%) had no physical examination performed
by the physician. Absence of data from the records may
suggest deficiencies in the management of hypertension in
general practice.10 This should be avoided in the Philippine
family and community medicine practice.
Assessment of absolute cardiovascular risk is a rational
method of managing hypertension. Determination of the
presence or absence of these factors must be the focus
of history taking. The CONTROLRISK study was designed
to determine how the cardiovascular risk profile of the
hypertensive patients were being conducted at primary
care and specialist setting in Spain. In this study, target
organ damage and associated clinical conditions were more
frequently obtained in specialist setting. The most common
risk factor was age. The most frequently reported target
organ damage was left ventricular hypertrophy. Ischemic
heart disease was the most common associated clinical
condition. In this study, physicians tend to underestimate
the cardiovascular risk in daily clinical practice.11 A similar
study in UK also showed that risk was correctly estimated
in 21% of patients, underestimated in 63% of patients,
and overestimated in 16% of patients. It is therefore
recommended that family and community medicine
practitioners use cardiovascular risk charts or tables in the
management of hypertensive patients.12
Office BP measurement (OBPM) should be performed
using an electronic oscillometric device. Measurement
by aneroid sphygmomanometers has not been found
to be accurate. Maintenance of the quality of aneroid
sphygmomanometers has also been low. A study to check the
instruments against British Hypertension Society guidelines,
only 38.8% of anaeroid instruments were accurate at all test
pressure levels. The defects noted could have an impact on
diagnosis and monitoring of hypertension.13 If a patient
has elevated blood pressure reading readings in the office
(≥ 140/90), a series of standardized out-of-office blood
pressure measurements should be performed in order to
rule out white-coat hypertension.14
Laboratory Tests
Most studies on hypertension profiling include not
only history and physical examination but also laboratory
evaluation. In one study, medical examination included
weight, height, blood pressure and laboratory analyses
including fasting blood glucose, serum cholesterol, serum
triglycerides, electrocardiogram and simple spirometry. 15
Caution must be raised against over requesting for
laboratory tests. In clinics where office chemistry machine
is available, the test requests increased but the level
of blood pressure control was the same. 16 Since most
outpatient treatment is out-of-pocket, it is better to save
some money for drugs.
Pharmacologic Interventions
There is enough evidence that pharmacologic
treatment of hypertension prevents stroke, congestive
heart failure, and other blood pressure-related
complications. Even among the elderly, the Systolic
Hypertension in the Elderly Program (SHEP) also showed
a reduction in myocardial infarction and other coronary
events in older patients. Similar findings of cardiovascular
mortality reduction was also seen in the Swedish STOP-
Hypertension Trial and the British MRC Trial in Older
Patients. These studies have in common the use of
diuretics and/or beta blockers. 17
In general, the initial antihypertensive treatment
should include one or a combination of thiazide-
type diuretic, calcium channel blocker, angiotensin-
converting enzyme inhibitor, or angiotensin receptor
blocker. But angiotensin-converting enzyme inhibitor
and angiotensin receptor blocker cannot be combined. 18
The choice of drug class will depend on the co-morbid
condition, cost and patient preference after these have
been explained.
After deciding on what drug class to prescribe, the next
is to choose the specific drug. The choice of individual drugs
depend on efficacy, safety, suitability, and cost. There are
number of options within each class. It may be good for
the family and community doctor to narrow their choice
to only 1-2 preferred options for a particular patient based
on the above factors. This may be included into a personal
formulary or essential drug list. This will allow the physician
to have more experience and become more familiar with the
expected drug effect, adverse effects, and interactions. A
new drug also needs to be evaluated before it is added to
the personal formulary.19

Table 1. Antihypertensive Drugs for Maintenance

Drugs Dose Indication Adverse Reaction Remarks

ACE Inhibitors (ACEIs)
Captopril* 25 mg tab Heart failure, left Cough, hyperkalemia Contraindicated in pregnancy
25-50 mg per day ventricular (LV) and lactation
BID dysfunction, diabetic,
myocardial infarction
(MI)

Enalapril* 5, 10 and 20 mg tab Headache, dizziness, fatigue,

5-40 mg per day nausea, diarrhea, decreased
BID hgb/hct, cough, hyperkalemia

VOL. 55 NO. 3 JULY - SEPTEMBER, 2017 151

 Drugs Dose Indication Adverse Reaction Remarks
Angiotensin II Receptor Antagonists (ARBs)
Candesartan* 8 and 16 mg tab Heart failure and Angioedema, hyperkalemia, Contraindicated in pregnancy
8 – 16 mg per day impaired LV systolic hypoglycemia, acute and lactation
OD function renal failure, hepatic
dysfunction, agranulocytosis,
rhabdomyolysis, interstitial
pneumonia

Irbesartan* 150 and 300 mg tab Diabetics and mild Fatigue, edema, nausea, Contraindicated in moderate
150 – 300 mg per day renal disease vomiting, dizziness, headache to severe renal impairment,
OD pregnancy and lactation

Losartan*+ 50 and 100 mg tab LVH and for renal Diarrhea, abdominal Contraindicated in pregnancy
50 – 100 mg per day protection in Type 2 pain, nausea, headache, and co-administration with
OD diabetic patients dizziness, hyperkalemia, aliskiren in diabetic patients
hypotension, URI symptoms,
angioedema, anemia, liver
function abnormalities,
vomiting, myalgia, arthralgia,
photosensitivity

Olmesartan 10, 20 and 40 mg tab Dizziness Contraindicated in pregnancy

10 – 40 mg per day (2nd & 3rd trimester) and
OD lactation

Telmisartan* 40 and 80 mg tab Prevention of Diarrhea, abdominal pain, Contraindicated in cholestasis,

40 – 80 mg per day cardiovascular nausea, headache, dizziness, biliary tract disorder, severe
OD morbidity and fatigue, light-headedness, hepatic impairment, pregnancy
mortality in patients hypotension, URI symptoms, and lactation
> 55 y/o with high hyperkalemia, intermittent Food decrease bioavailability
CV risk claudication and skin ulcer

Valsartan* 80, 160 and 320 mg tab Heart failure, post-MI, Dizziness, postural dizziness, Contraindicated in pregnancy
80 – 320 mg per day delay of diabetes hypotension, renal failure and
OD for maintenance progression in impairment
BID for HF and MI hypertensives at CV risk
°40 mg per day for and children 6 – 18 y/o
children <35 kg
Cardioselective Beta-blockers (BBs)
Atenolol* 25, 50 and 100 mg Angina, MI or heart Bradycardia, decreased libido Contraindicated in sinus
tablet failure bradycardia, cardiogenic shock,
25 – 100 mg per day acute unstable HF
OD

Metoprolol* 50 and 100 mg tablet Angina, MI or heart Fatigue, weakness, orthostatic Contraindicated in sinus
100 – 400 mg per day failure hypotension, impotence, bradycardia, cardiogenic shock,
BID drowsiness, bradycardia, acute unstable HF
pulmonary edema, CHF

152 THE FILIPINO FAMILY PHYSICIAN

 Drugs Dose Indication Adverse Reaction Remarks

Propranolol 10 and 40 mg tab Angina, anxiety, Fatigue, weakness, orthostatic Take before meals
160-320 mg per day migraine, post-MI, hypotension, impotence, Contraindicated in patients with
BID arrhythmia drowsiness, bradycardia, history of bronchial asthma
pulmonary edema, CHF or bronchospasm, cardiogenic
shock, tachycardia, 2nd and 3rd
degree block
Calcium Channel Blockers (CCBs)
Nifedipine 5, 30 mg cap Headache, vomiting 5 mg preparation is short-acting
5-30 mg per day 30 mg preparation is extended-
release

Amlodipine*+ 5 and 10 mg tab Peripheral edema, headache, Contraindicated for unstable

5-10 mg per day sleep, urinary, visual and taste angina, uncompensated heart
OD disturbance, abdominal pain, failure, acute MI, pregnancy
nausea, palpitations, flushing

Felodipine* 2.5, 5 and 10 mg tab Peripheral edema, headache, Contraindicated for unstable
2.5 – 10 mg per day flushing, palpitations angina, uncompensated heart
OD failure, acute MI, pregnancy
Combined Alpha & Beta Blocker
Carvedilol* 6.25 and 25 mg tab Angina and mild to Diarrhea, nausea, dizziness, Contraindicated in unstable
6.25 – 50 mg per day moderate heart failure abnormal or blurred vision heart failure, 2nd or 3rd degree
OD - BID AV block, severe bradycardia or
hypotension, history of COPD or
bronchospasm
Thiazide Diuretics
Hydrochlorothiazide 12.5 and 25 mg tab Edema and Dry mouth, thirst, weakness, Contraindicated in renal
12.5 - 100 mg per day nephrogenic diabetes lethargy, muscle pain, cramps, impairment, can cause
OD insipidus hypotension hyperglycemia

Combination drugs
Hydrochlorothiazide- Hydrochlorothizide Dry mouth, thirst, weakness, Contraindicated in renal
losartan (50-100mg)-losartan lethargy, muscle pain, impairment, can cause
(12.5-25mg) cramps, hypotension diarrhea, hyperglycemia, pregnancy
abdominal pain, nausea,
headache, dizziness, URI
symptoms, cough

* Drugs included in PNDF 2008

+ Available at local health centers under the DOH program for noncommunicable diseases

CSAP – Chronic Stable Angina Pectoris

DM – Diabetes Mellitus
HCTZ – Hydrochlorothiazide
HF – Heart Failure
MI – Myocardial Infarction

VOL. 55 NO. 3 JULY - SEPTEMBER, 2017 153

Non-pharmacologic Interventions
Knowledge about patient-related determinants of
adherence to interventions (pharmacologic and non-
pharmacologic) is needed to improve the management
and outcomes of hypertensive patients. One study
tried to measure the association between patient-
related determinants (medication self-efficacy, beliefs
about medication and hypertension, social support, and
satisfaction with care) and treatment adherence. Medication
self-efficacy and fewer concerns about medication use
were associated with improved pharmacologic and non-
pharmacologic intervention adherence. Family and
community doctors should support medication adherence
by paying attention to patients’ medication self-efficacy, the
concerns they may have about medication use and patients’
perceptions on hypertension.20 This can be achieved by
patiently explaining hypertension as a health problem and
the risks associated with it. The medication dose, effect,
potential side effect and cost should also be explained. This
will eventually lead to adherence to interventions.
A cross sectional study in family practice clinics showed
that two-thirds of patients described hypertension based
on biomedical definition. Half of them believed that stress
was a cause of their high blood pressure; two-thirds were
aware that stroke and heart attack respectively are possible
consequences of hypertension. As a result, three-quarters
were fully adherent to their medications in the preceding
month.21 This study showed that appropriate awareness of
hypertension and its consequences resulted to an improved
adherence to interventions.
Despite the absence of strong evidence, most
family physicians should still offer non-pharmacological
management at the first consultation before prescribing
medication. However, few offered detailed and structured
interventions. Dietary therapy, restriction of alcohol
consumption and exercise were suggested by most.
Restriction of sodium intake and behavioural therapy were
less popular non-pharmacological interventions. These
non-pharmacologic advices were consistent with current
guidelines on the treatment of hypertension.22 In order to
154 THE FILIPINO FAMILY PHYSICIAN
accommodate cultural variations, it is advised that family
and community medicine practitioners should develop a
structured non-pharmacologic intervention program. Use
of flyers, audio visual presentation at the waiting room and
face-to-face health education may be used.
The purpose of patient information leaflets is to
inform patients about the administration, precautions
and potential side effects of their prescribed medication.
However, this must be prepared carefully. One study showed
that current description of potential risk information caused
feelings of fear and anxiety to the patients. Flyers need to
convey potential risk information in a language that is less
frightening while retaining the necessary information.23
Dietary fat plays a major role in the development of
cardiovascular disease. Modification of fat intake could
have a preventive potential. The guideline of the German
Nutrition Society recommended to reduce total and
saturated fat intake. It also recommended increased intake
of polyunsaturated fatty acids. A high fat intake increases
the risk of obesity with probable evidence when total energy
intake is not controlled for. When energy intake is controlled
for, there is probable evidence for no association between
fat intake and risk of obesity.24 There should be a balance
between calorie source from fats and carbohydrates.
There are few randomized controlled trial studies on
the effectiveness of dietary intervention for hypertensive
patients in family practice. But family and community
practice is an ideal setting for the provision of lifestyle
interventions for patients with hypertension. There is
currently an ongoing randomized controlled trial that may
release its results soon. The trial will test a behaviourally-
based, matched prescriptive physical activity and diet
change program. The primary goal is to increase physical
activity and improve dietary intake. The results will provide
scientific rationale for the implementation of this lifestyle
intervention in primary care.25
With regards to advice on exercise, the results of
a systematic review suggested that physical activity of
moderate intensity involving rhythmic movements with
the lower limbs for 50-60 minutes, 3 or 4 times per week,
reduces blood pressure and appears to be more effective
than vigorous exercise. With this type of exercise, harm is
uncommon and is generally restricted to musculoskeletal
strain. Injury occurs more often with jogging than
with walking, cycling or swimming. People with mild
hypertension should engage in 50-60 minutes of brisk
walking or cycling, 3 or 4 times per week to reduce blood
pressure. Exercise should be prescribed as an adjunctive
intervention to pharmacologic therapy for hypertension.
People who do not have hypertension should also participate
in regular exercise as it reduce the risk of coronary artery
disease.26
A systematic review of randomized clinical trials was
conducted to evaluate the acceptability and usefulness
of computerized patient education interventions. Most
interventions used instructional programs for educational
intervention. Others used information support networks
and computer systems for health assessment and history-
taking. Most studies reported positive results for interactive
educational intervention. Computerized educational
interventions can lead to improved health status in several
major areas of care and serve as a valuable supplement to
face-to-face education with physicians.27

Table 2. Patient-directed Non-pharmacologic Interventions.

Goals Recommendations: EDUCATE patients on the following

Health Education Lifetime risk of hypertension

hypertension increases with advancing age
The higher the BP, the greater the chance of heart attack, HF, stroke, and kidney diseases
BP control For those >50 years of age, will reach the DBP goal once the SBP goal is achieved, the primary focus should be on attaining the SBP goal
BP goal In patients with hypertension and diabetes or renal disease, the BP goal is <130/80 mmHg
Treating SBP and DBP to targets that are <140/90 mmHg is associated with a decrease in CVD complications
Goal blood pressure targets should be reached within a month of starting treatment either by increasing the dose of an initial drug or by
using a combination of medications*
BP monitoring Clinicians should provide to patients, verbally and in writing, their specific BP numbers and the BP goal of their treatment
Compliance Emphasize that antihypertensive therapy has been associated with reductions in (1) stroke incidence, (2) myocardial infarction (MI),
and
(3) Heart Failure (HF), hence importance of compliance
Target weight Maintain normal body weight (body mass index 18,5-24.9 kg/m2
Weight loss of as little as
10 lbs (4.5 kg) reduces BP and/or prevents hypertension in a large proportion of overweight persons
Diet Adoption of the Dietary Approaches to Stop Hypertension (DASH) eating plan
Consume a diet rich in fruits, vegetables, and low fat dairy products with a reduced content of saturated and total fat
Dietary sodium should be reduced to no more than 100 mmol per day (2.4 g of sodium or 6 g sodium chloride)
Decrease portion sizes for meals and snacks
Decrease frequency and consumption of –containing beverages
Fitness (when able) Engage in regular aerobic physical activity such as brisk walking at least 30 minutes per day most days of the week
or
moderate to vigorous activity 3-4 days a week averaging 40 min per session*
Increase physical activity such as walking, biking, aerobic dancing basketball and other sports
Decrease time in sedentary activities such as watching television, playing videogames or on line
Moderation of alcohol Alcohol intake should be limited to no more than 1 oz (30 mL) of ethanol, the equivalent of two drinks per day in most men and no more
intake and smoking than 0.5 oz of ethanol (one drink) per day in women and lighter weight persons
cessation Patients should be strongly counseled to quit smoking
Others Control blood glucose and lipids*
Follow up most patients should return for follow up and adjustment of medications at monthly intervals or until the BP goal is reached

VOL. 55 NO. 3 JULY - SEPTEMBER, 2017 155

Table 3. Family-directed Non-pharmacologic Interventions.

Goals Recommendations

Lifestyle Encourage family meals adhering to DASH eating plan, wherein food served should be
Family Diet HIGH in: Fruits and vegetables (4-5 servings each per day; fiber (7-8 servings per day); low fat dairy products (2-3 servings per day); lean
meat (2 servings per day); calcium; magnesium; potassium
LOW in saturated fat, cholesterol, salt such as unsalted nuts, almonds, peanuts, chocolate, cocoa butter, coconut
Increase intake of polyunsaturated fatty acids such as *Foods and oils including walnuts, sunflower seeds, fish such as salmon, mackerel,
corn oil, soybean oil

Fitness Encourage family members engaging in physical activities

Family members should have physical activity of moderate intensity involving rhythmic movements with the lower limbs for 50-60
minutes, 3 or 4 times per week
Family members with mild hypertension should engage in 50-60 minutes of brisk walking or cycling, 3 or 4 times per week
Family members who do not have hypertension should also participate in regular exercise as it reduce the risk of coronary artery disease.

Table 4. Community-directed Non-pharmacologic Interventions

Goals Recommendations

Lifestyle Inquire if patient and family aware of existing community lifestyle activities
Family Diet

Community Programs Inquire if patient and family aware and willing to participate in existing local health center and programs on hypertension in the
community

Patient Outcomes Second Visit

Awareness by the patient on the diagnosis of

hypertension and its consequences is an important
patient outcome during the first visit. A study looked at
the association between patient-related determinants
(medication self-efficacy, beliefs about medication and
hypertension, social support, and satisfaction with care)
and treatment adherence. After follow-up medication
self-efficacy and fewer concerns about medication use
were associated with improved medication adherence.
Self-efficacy was also associated with adherence to
lifestyle recommendations at baseline.20 Thus an initial and
continuing adequate knowledge about the disease and the
purpose of the interventions lead to better adherence and
eventually control of hypertension.
History and Physical Examination and Laboratory Tests
The family doctors should review and complete the
needed information based on the checklist. The needed
laboratory and its results should be completed and
reviewed.
Pharmacologic Interventions
Based on the initial response to medications, the
physician may use the stepped care approach to control the
blood pressure.

156 THE FILIPINO FAMILY PHYSICIAN

Non-pharmacologic Interventions Patient Outcomes

During the second and continuing visits, repeated
delivery of educational intervention should be done. During
the first and second visits face-to-face, paper-based or
digital method of health education should be done. But
when opportunity arise, behavioral intervention such as
counselling may be done later. The use of patient diaries
may be helpful to monitor adherence.
With regards to exercise, once the patient is used to
rhythmic lower limb exercise, the patient may move up to
moderate to vigorous aerobic (endurance) activity up to
5 days/week. Resistance training (strength) on 2 or more
non-consecutive days/week. Vigorous exercise training
is generally safe and well tolerated by most people,
including those with hypertension, although some special
considerations are required for safety.28
The effectiveness of educational and organizational
strategies used to improve control of blood pressure was
examined in a systematic review of randomized controlled
trials. The following interventions were evaluated: self-
monitoring and educational interventions directed to the
patient. The results showed that a system of regular review
and self-monitoring of antihypertensive drug therapy was
shown to reduce blood pressure and all-cause mortality at
5 years follow-up. Antihypertensive drug therapy should be
monitored closely and adopt a stepped care approach when
patients do not reach target blood pressure levels.29
During the second visit, the patient should have
increased awareness about the diagnosis and potential risks
associated with hypertension. As a result of this awareness,
adherence to interventions should be achieved. Adherence
can be achieved by repeating/enhancing the interventions
done during the earlier visits.
Adherence to intervention may be a surrogate outcome
leading to successful management of hypertension. One
study evaluated the effect of adherence on cardiovascular
disease mortality, cerebral hemorrhage and cerebral
infarction. Adherence were classified into good (cumulative
medication adherence, ≥80%), intermediate (cumulative
medication adherence, 50%-80%), and poor (cumulative
medication adherence, <50%) adherence groups. The
results showed that patients with poor medication
adherence had worse mortality from ischemic heart disease
(hazard ratio, 1.64; 95% confidence interval, 1.16-2.31;
P for trend=0.005), cerebral hemorrhage (hazard ratio, 2.19;
95% confidence interval, 1.28-3.77; P for trend=0.004),
and cerebral infarction (hazard ratio, 1.92; 95% confidence
interval, 1.25-2.96; P for trend=0.003) than those with
good adherence. Similar findings were also noted with
hazard ratio for hospitalization.30
For those already prescribed with medications, the
goal should be a blood pressure lower than the baseline.
Based on guideline recommendations the goal differ among
patients above or below 60 years old. For patients less than

Table 5. Reinforcement of Goals.

Patient Family Community

Reinforce BP goals, self-monitoring and recording Encourage family members to adhere to healthy Encourage family members to join programs on
lifestyle hypertension in the community

Reinforce compliance to antihypertensives Compliance to healthy family meals Enrolment in existing community lifestyle activities

Reinforce adherence to lifestyle modification Adherence to family fitness activities Actively participating in hypertension support
(targeted weight, diet and fitness) groups in the community

VOL. 55 NO. 3 JULY - SEPTEMBER, 2017 157

60 years old, it is less than 140/90 mmHg and for 60 and
above, the goal is less than 150/90 mmHg towards a normal
of 120/80 mmHg. This goal is also implemented by several
outpatient Kaiser Permanente cliinics in the US.31
This goal is similar for all other specialties taking
care of hypertensive patients. In one study, there was no
difference in patient outcomes achieved in 2-year or 4-year
outcomes for patients with hypertension whether they were
being treated by endocrinologists, cardiologists or internal
medicine specialists. These findings must be viewed in
light of the historically higher costs of fee-for-service in
subspecialty physician practice.32
Continuing Visit
History and Physical Examination
During the continuing visit blood pressure monitoring
and continuing review of history and physical examination
should be done. Changes must be noted. Among those with
co-morbidity, adequate treatment of co-morbid condition
using the applicable clinical pathway should be done.
Pharmacologic Interventions
Pharmacologic treatment of hypertension reduces
risks of stroke, congestive heart failure, renal failure
and mortality. However there is a question of once blood
pressure is already controlled, can pharmacologic treatment
be discontinued? A survey of a random sample of practicing
physicians indicated that 79% tried to withdraw treatment.
Studies of antihypertensive medication withdrawal also
showed success rates of 40.3 percent after 1 year of follow-
up and 27.7 percent after 2 years of follow-up were achieved.
Similar findings were noted among elderly patients where
an average success rate of 26.2 percent was obtained for
periods of 2 or more years.33 It is therefore recommended
that after 1-2 years of follow-up and the blood pressure is
controlled with no symptoms attributed to hypertension or
to a target organ damage, the physician may try step down
or withdrawal treatment.
158 THE FILIPINO FAMILY PHYSICIAN
Non-pharmacologic Interventions
During first few visits, the physician is advised to
continue repeating and reinforcing health education and
non-pharmacologic intervention. During the continuing
visit, there may be a shift to peer-led or family treatment
partner interventions to improve self-management. In one
randomized controlled trial peer-led interventions were
found to have similar effect as physician-led intervention.
However, this may lower the cost of treatment.34
Health coaching by medical assistants can also be an
alternative to physician-led health education. In one study,
in-clinic health coaching by medical assistants improves
control of cardiovascular and metabolic risk factors when
compared with usual care. Patients who were given health
coaching were more likely to achieve the treatment goals.
Many coached patients achieved the hemoglobin A1c goal,
the LDL cholesterol goal and the systolic blood pressure
goal.35
Patient Outcomes
The Eighth Joint National Committee (JNC 8) guidelines
for blood pressure management recommend a blood
pressure goal of less than 140/90 mm Hg for all adults
except those 60 years or older. For those who are ≥60 years
a systolic blood pressure goal of less than 150 mm Hg is
recommended.36
The assessment of the risk of a cardiovascular’ event
is the most reliable and accurate way to measure the
benefits of anti-hypertensive therapy. Most studies that
have examined control of hypertension have relied solely
on the blood pressure level attained after treatment. Aside
from blood pressure, it is also recommended to control
the other risk factors. This is due to a finding in one study
where 40.9% of the hypertensive still had an absolute risk
exceeding 20% of having a cardiovascular event. The factors
independently associated with uncontrolled hypertension
were age, sex, past history of stroke, ischemic heart disease
and transient ischemic attack, a body mass index greater
than 30, diabetes, and current smoking.37 While age, sex
and past history are non-modifiable, body mass index,
blood sugar and smoking can be modified.
Recommendations for Implementation
Clinic Level
Education, training and audit has been used to improve
the quality of physician’s practice. In one randomized
controlled trial, an educational intervention designed to
improve the management of hypertension in the elderly
was tested in family practice. Educational visits, discussion
of barriers to implementing change in practice were
done. At the end of the educational visits, there was a
significant difference in the stated threshold for treating
systolic hypertension between intervention and control
groups. There was also a statistically significant difference
between the two groups, in their willingness to treat a
70-year-old male with mild hypertension. The effectiveness
of an educational intervention is significantly improved
by addressing the barriers preventing practitioners from
implementing the recommendations.38
Self-audit of medical records may also be an effective
way of implementing the clinical pathways. In this activity,
a family or community doctor randomly select medical
records of 10 hypertensive patients. Then he/she evaluates
the record if there is evidence that the recommendations in
the clinical pathway were followed. This method has been
shown to be a reliable way of identifying patients with
optimal or suboptimal management of blood pressure.39
After self-audits, a full quality improvement activity
may be done. In quality improvement, the family or
community medicine practitioner performs self-audit at
baseline. Then based on the self-audit he/she identifies
suboptimal performance based on the clinical pathway
recommendations. Self-initiated change in clinical
practice is then implemented to address the suboptimal
performance. This is followed by a repeat self-audit after
a period of time. This two-stage quality improvement
approach has been shown to be effective in achieving blood
pressure control among hypertensive patients.40
VOL. 55 NO. 3 JULY - SEPTEMBER, 2017 159
Health System Level
The effectiveness of educational and organizational
strategies at the health system level to improve control
of blood pressure was examined in a systematic review of
randomized controlled trials. The following interventions
were evaluated: (1) educational interventions directed to
the health professional, (4) health professional (nurse or
pharmacist) led care, (5) organizational interventions that
aimed to improve the delivery of care, (6) appointment
reminder systems. The results showed that an organized
system of regular review allied to vigorous antihypertensive
drug therapy was shown to reduce blood pressure and
all-cause mortality at 5 years follow-up. These findings
have important implications for recommendations
concerning implementation of structured delivery of care in
hypertension guidelines.41
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