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Clinical Practice Guidelines
CLINICAL
PRACTICE
GUIDELINES
2
DENGUE FEVER
Sources:
In 2009, the World Health Organization (WHO) set up criteria for classifying dengue into
levels of severity based on clinical and/or laboratory parameters (WHO 2009). Dengue patients are
classified as severe dengue or non-severe dengue, with the group of patients with non-severe
dengue subdivided into those with warning signs and those without warning signs.
Dengue infection is a systemic and dynamic disease. It has a wide clinical spectrum that
includes both severe and non-severe clinical manifestations. After an incubation period of 3 to 14
days, the illness begins abruptly and is followed by the three phases: febrile, critical and recovery.
The acute febrile phase of dengue usually lasts 2–7 days, often accompanied by generalized
body ache, muscle and joint pains, headache, retro-orbital pain, facial flushing, sore throat,
hyperemic pharynx, macular or maculopapular rash, petechiae and mild mucosal membrane
bleeding. A positive tourniquet test and progressive decrease in total white cell count are early
findings which could differentiate dengue from other acute febrile illnesses. These clinical features
are indistinguishable between severe and non-severe dengue cases. During fever defervescence,
usually on days 3–7 of illness, an increase in capillary permeability in parallel with increasing
hematocrit levels may occur, marking the beginning of the critical phase. The period of clinically
significant plasma leakage usually lasts 24–48 hours, followed by a convalescent phase with gradual
improvement and stabilization of the hemodynamic status.
Warning signs of progression to severe dengue occur in the late febrile phase and include
persistent vomiting, severe abdominal pain, mucosal bleeding, difficulty breathing, and early signs of
shock. Progressive leukopenia followed by a rapid decrease in platelet count usually precedes plasma
leakage. At this point patients with nonsevere disease begin to improve, but people with clinically
significant plasma leakage attributable to increased vascular permeability become worse and
develop severe dengue disease with pleural effusion and/or ascites, hypovolemic shock, severe
hemorrhage, or organ impairment.
Shock occurs when a critical volume of plasma is lost through leakage and is often preceded
by warning signs. With prolonged shock, the consequent organ hypoperfusion results in progressive
organ impairment, metabolic acidosis and disseminated intravascular coagulation. This in turn leads
to severe hemorrhage causing the hematocrit to decrease in severe shock. Severe organ impairment
such as severe hepatitis, encephalitis or myocarditis and/or severe bleeding may also develop
without obvious plasma leakage or shock. The group progressing from non-severe to severe disease
2
is difficult to define, but this is an important concern since appropriate treatment may prevent these
patients from developing more severe clinical conditions.
Therefore, monitoring for warning signs and other clinical parameters is crucial to
recognizing progression to the critical phase. This will enable appropriate treatment with intravenous
fluid therapy that may prevent these patients from developing more severe clinical conditions.
Question 1: Among patients with confirmed or presumptive diagnosis of dengue in the outpatient
setting, what clinical signs and symptoms warrant admission?
The criteria for admission should take into consideration the overall clinical condition of the
child rather than focusing on platelet count or hematocrit values alone.
It was emphasized that urine output should be one of the parameters to be evaluated in
considering admission. However, there were no studies that evaluated this outcome.
Question 2: Among patients with dengue, which risk factors are associated with mortality?
Recommendation 1: Patients with dengue who present with any one of the following clinical
findings may be at increased risk for mortality.
Recommendation 2: The presence of two or more of the following warning signs in patients with
dengue may increase the risk for mortality:
severe abdominal pain
arterial hypotension
neurologic manifestation
painful hepatomegaly
hypovolemic shock
liver failure
myocarditis
Recommendation 3: Patients with dengue who present with one or more of the following
laboratory findings may be at increased risk for mortality and warrant hospital admission for
close monitoring:
Recommendation 4: Prothrombin time (PT) and Partial Prothrombin Time (PTT) do not
differentiate those who may be at increased risk for mortality and are not recommended as
routine tests for patients with dengue.
2
Question 3: Among patients admitted because of dengue, which clinical signs and/or laboratory
findings indicate significant bleeding?
Recommendation 1: Among patients admitted because of dengue, the presence of one or more
of the following clinical or laboratory findings may increase the risk of bleeding:
Hypotension
Narrow pulse pressure
Hepatomegaly
Platelet count < 50,000/mm3
WBC count < 5000/mm3
Elevated ALT (> 3x the normal value)
Vomiting
Abdominal pain
Restlessness
Pleural effusion or ascites
Rash
Recommendation 3: Prothrombin Time (PT) and Partial Thromboplastin Time (PTT) were not
shown to be significantly associated with bleeding and should not be routinely done in patients
with dengue.
2
Maintenance intravenous fluids are commonly used in hospitalized children for maintaining
fluid and electrolyte balance and homeostasis. Hypotonic fluids are the most commonly used type of
fluids for children admitted in a hospital. Sick children are in a stressed state and secrete antidiuretic
hormone (ADH) more than healthy children. This increased ADH secretion leads to water retention
by the kidneys which in turn leads to hyponatremia defined as plasma sodium content (pNa < 136
mol/L). Early symptoms of hyponatremia include headache, nausea, and general malaise, progressing
to seizures and coma, or even death without appropriate management.
In the WHO 2009 guidelines, ambulatory patients are encouraged oral intake of oral
rehydration solution, fruit juice and other fluids containing electrolytes and sugar to replace losses
from fever and vomiting. Adequate oral fluid intake may reduce the number of hospitalizations.
However, fluids containing high sugar or glucose should be avoided because they can exacerbate
hyperglycemia of physiological stress from dengue. An ideal physiologic fluid is one that resembles
the extracellular and intracellular fluids closely. If the patient develops warning signs but without
shock, the recommendation is to give isotonic solutions such as 0.9% Saline or Ringer’s Lactate.
Frequent re-assessment of the clinical status and hematocrit should be done and fluid infusion rates
should be reviewed accordingly.
In patients with shock, the current recommendation of WHO is to start intravenous fluid
resuscitation with isotonic crystalloid solution, then reassess the patients’ condition (vital signs,
capillary refill time, hematocrit, urine output). The subsequent fluid management will depend on the
patient’s hemodynamic status. An IVF is classified as isotonic if it approximates the effective
osmolality of plasma and as hypotonic if its osmolality is lower than the effective plasma osmolality.
The intravenous fluids closely resembling the osmolality of plasma; the most readily available and
cheapest are 0.9 % NaCl and Ringer’s lactate solution, which are recommended by the WHO.
In patients with dengue, the critical period lasts for 24-48 hours only, and during this time,
patients should be frequently monitored until the danger period is over. In patients with hypotensive
shock, colloids may be the preferred choice over crystalloids if the blood pressure needs to be
restored urgently. However, crystalloids and colloids have their own limitations when used in large
quantities.
2
Question 4: Among Dengue patients without shock how effective are isotonic IVFs compared to
hypotonic IVFs in reducing mortality?
Recommendation:
There is insufficient evidence that the tonicity of the intravenous fluid has an effect on mortality in
dengue patients without shock.
Isotonic fluids can be used as maintenance for dengue patients without shock.
The use of hypotonic IVF is associated with hyponatremia among hospitalized pediatric patients.
Question 5: Among Dengue patients with shock, how effective are colloidal IVFs compared to
crystalloid IVFs in reducing mortality?
Recommendation:
In dengue patients with shock, either crystalloids or colloids may be used for fluid resuscitation.
There is insufficient evidence to say that the use of colloid IVF compared to crystalloids will affect
mortality.
The use of colloids may be associated with more adverse reactions (e.g. bleeding, allergic reactions)
compared to crystalloids.
Disseminated intravascular coagulation (DIC) leads to severe hemorrhage causing the hematocrit to
decrease. A physician should always be on alert to the possibility of concealed bleeding if the patient
continues to deteriorate with a serial decrease in the hematocrit in spite of the intravenous fluids.
Massive bleeding may also occur without prolonged shock in instances when acetylsalicylic acid
(aspirin), ibuprofen or corticosteroids have been taken.
Blood products are not routinely used in dengue fever unless there is profuse bleeding or clinical
deterioration refractory to vigorous fluid resuscitation. In such cases, blood transfusion is life saving
and should be given as soon as severe bleeding is suspected or recognized. The use of red cell
products such as fresh whole blood and packed red cells are the components of choice for those with
massive bleeding especially those emanating from the gastrointestinal tract and/or vagina in adult
females. The practice of platelet concentrate and plasma transfusion for severe bleeding remains
controversial and may further exacerbate fluid overload.
If hemorrhage persists despite red cell replacements with fresh whole blood or freshpacked cells or if
DIC is suspected, some clinicians may consider giving plasma products such as fresh frozen plasma or
cryoprecipitate. DIC should be suspected in cases of severe bleeding associated with low or rapid
decline in platelet count, prolongation of clotting times, such as the prothrombin time (PT) and
activated partial thromboplastin time (aPTT), presence of fibrin-degradation products in plasma, and
low levels of fibrinogen and coagulation inhibitors such as antithrombin III.
Inappropriate transfusion of platelet and fresh frozen plasma may cause fluid overload. Prophylactic
transfusion of plasma products including platelet concentrate in those without signs of bleeding is
unnecessary and is strongly discouraged due to the possibility of allergic reactions, transfusion-
related acute lung injury, and transmission of other diseases.
Question 6: Among patients with thrombocytopenia because of dengue, how effective is prophylactic
platelet transfusion in improving platelet count, preventing hemorrhage, and reducing mortality?
2
Recommendation:
There is insufficient evidence to say that prophylactic platelet transfusion in patients with minimal or
no active bleeding will improve platelet counts, prevent hemorrhage and reduce mortality.
Children with dengue who have platelet count <50,000/mm3 with minimal or no active bleeding
should not be given prophylactic platelet transfusion.
Question 7: Among Dengue patients with significant bleeding, how effective is plasma transfusion in
controlling bleeding and reducing mortality?
Recommendation:
Among dengue patients with significant bleeding, there is insufficient evidence that plasma
transfusion has an effect on controlling bleeding and reducing mortality.
The effect of plasma transfusion on platelet count recovery is not significant in dengue patients with
bleeding.
In children exhibiting signs of disseminated intravascular coagulopathy (DIC), plasma transfusion may
be considered.
Question 8: Among populations at risk for Dengue transmission, how effective are citronella-based
repellents compared to DEET-based repellents in reducing the incidence of Dengue?
Recommendation:
There is insufficient evidence to say that use of citronella-based repellents is more effective than
DEET-based repellents in reducing dengue transmission.
2
Recommendations for Fluid Therapy for Compensated Shock and Hypotensive Shock Based on the
2012 PPS Revised Guidelines on Fluid Management of Dengue Fever and Dengue Hemorrhagic Fever
1. Philippine Clinical Practice Guidelines on the Diagnosis and Management of Urinary Tract
Infections in Adults 2015 Update
Recommendations:
2. What are the indications for screening and treatment of asymptomatic bacteriuria?
a. Screening and treatment is recommended in the following to prevent bacteremia
and sepsis:
Patients who will undergo genitourinary manipulation or instrumentation
All pregnant women
b. The choice of antibiotic depends on culture results. A seven-day regimen is
recommended.
c. For specific antibiotic recommendations for ASB in pregnancy
* May cause hemolytic anemia, anophthalmia, hypoplastic left heart syndrome, ASD, cleft lip and palate. May be given on the second trimester of pregnancy until
32 weeks AOG. Use in the first trimester of pregnancy is appropriate when no other suitable alternative antibiotics are available.
2
Reccomendations:
Obstructive symptoms
Clinical impression of persistent infection
Infection with urea-splitting bacteria (Proteus, Morganella, Providencia)
History of pyelonephritis
History of or symptoms suggestive of urolithiasis
History of childhood UTI
Elevated serum creatinine
c. Patients with the above factors may benefit from further diagnostic evaluation as these
risk factors have been identified to be associated with a higher incidence of urologic
abnormalities.
d. All women with recurrent UTI should undergo a complete history and physical
examination to evaluate urogenital anatomy and estrogenization of vaginal tissues and
to detect prolapse. Post-void residual urine should be measured.
3. What diagnostic work-ups are indicated in women with recurrent UTI?
a. Radiologic or imaging studies and cystoscopy are not routinely indicated in patients
with recurrent UTI.
b. Renal ultrasound or CT scan/stonogram may be done to screen for urologic
abnormalities.
c. Patients with anatomical abnormalities should be referred to a specialist (nephrologist
or urologist) for further evaluation
4. When is prophylaxis for recurrent UTI indicated?
a. Prophylaxis is recommended in women whose frequency of recurrence is not
acceptable to the patient in terms of level of discomfort or interference with activities
of daily living. Prophylaxis may be withheld according to patient preference if the
frequency of recurrence is tolerable to the patient.
b. The following factors should guide the physician in determining the patient’s risk-
benefit profile and in deciding which prophylactic strategies will be used:
Frequency and pattern of recurrences
Patient’s lifestyle, compliance and willingness to commit to a specific regimen
Plans for a pregnancy
Antimicrobial resistance and susceptibility pattern of the organisms causing the
patient’s previous UTIs
Risk of adverse events and drug allergies
c. Prophylaxis should only be initiated after counseling and behavior modification have
been attempted in order to minimize antibiotic exposure and possible adverse effects.
d. Antibiotic prophylaxis should be limited to women with recurrent UTI in whom non-
antimicrobial strategies have not been effective and who prefer prophylactic
antimicrobial therapy.
5. How effective are non-antimicrobial strategies in preventing recurrent UTI?
a. Behavioral changes
i. Behavioral changes can be useful antimicrobial-sparing measures in the prevention
of recurrent UTI.
ii. These behavioral measures include the following:
post-defecation and anal cleansing antero-posteriorly always in women to avoid
contaminating the periurethral area with fecal flora
2
OR
Intermittent prophylaxis, defined as self-treatment with a single antibiotic dose
based on patient’s perceived need.
c. Any of the antibiotics in the Table given either continuously for 6 to 12 months or as
post-coital prophylaxis can reduce the clinical and microbiologic recurrence of UTI
episodes
and symptoms of UTI, are compliant with medical instructions and have a good
relationship with a medical provider.
c. Breakthrough infections during prophylaxis should be treated empirically with any of
the antibiotics recommended for uncomplicated cystitis other than the antibiotic being
given for prophylaxis. Request for a urine culture and modify the treatment accordingly.
8. How effective are non-pharmacologic interventions treating urinary tract infections?
a. Cranberry juice and cranberry products are not recommended for the treatment of
urinary tract infection.
b. There is evidence to recommend acupuncture for prevention of recurrent UTI among
women when antibiotic prophylaxis is contraindicated.
c. There is no available evidence to recommend coconut juice in the prevention or
treatment of UTI.
d. There is insufficient evidence to recommend oral water hydration (2 to 2.5 liters/day) in
the prevention or treatment of UTI.
e. There is insufficient evidence to recommend drinking more water and voiding before
and after intercourse to prevent UTI.
Reccomendations:
a. Urine culture should be repeated one to two weeks after completion of antibiotics.
b. If significant bacteriuria persists post-treatment, consider referral to specialists
(infectious diseases, nephrology, urology, etc.) to identify and correct any underlying
problem (anatomical, functional, or metabolic) that predisposes the patient to
complicated UTI.
Reccomendations:
Recommendations:
b. Screening and treatment of CA-ASB are recommended only for pregnant patients
and those who will undergo urologic procedures.
c. Data is insufficient to make any recommendations regarding screening and
treatment of CA-ASB among post-solid organ transplant and neutropenic patients.
3. In patients with suspected CA-UTI, what diagnostic tests should be done to assist the
physician in managing the infection effectively?
a. Similar with the general recommendations in complicated UTI (cUTI), it is necessary
to obtain urine gram stain and cultures BEFORE starting empiric antibiotic coverage
for CA-UTI.
b. In catheterized patients, pyuria alone is NOT diagnostic of CA-UTI and should not be
interpreted as an absolute indication for initiating empiric antibiotics.
c. The presence or absence of odorous or cloudy urine alone in catheterized patients is
also not an indication for antibiotic treatment.
4. How should urine for culture and sensitivity studies be collected from patients with
suspected CA-UTI?
a. For patients in whom catheterization is still indicated, the urine specimen should be
obtained from the freshly placed catheter prior to the initiation of antimicrobial
therapy. Urine sample should be aspirated from the catheter port, or if not present,
by puncturing at the distal end of the catheter with a sterile needle and syringe after
disinfecting the area WITHOUT disconnecting the junction of the catheter and
drainage tube
b. For individuals whose catheters can be or have been recently removed and requires
no further catheterization, a mid-stream, clean catch urine should be obtained.
Urine samples for culture should not be obtained from collection bags.
c. Urine specimens for culture should be processed as soon as possible, preferably
within one hour of obtaining the specimen. If this is not possible, the urine specimen
should be refrigerated. Refrigerated specimens should be processed within 24 hours.
1. ACG clinical guideline: diagnosis, treatment and prevention of acute diarrheal infections in adults.
3. www.psmid.org/wp-content/uploads/2022/07/CPG-acute-infectious-diarrhea_pocket-guide_v2
DIAGNOSTIC
III. What is the clinical utility of diagnostic tests in children and adults with acute infectious
diarrhea?
a. Diagnostic tests should be based on the assessment of the patient’s clinical status.
b. Routine stool examination should not be done in most cases of acute watery
diarrhea except in cases where parasitism is suspected or in the presence of bloody
diarrhea.
c. Stool cultures are indicated only for: severe cases (significant dehydration, high fever,
persistent vomiting or severe abdominal pain, dysenteric stool), high risk for
transmission of enteric pathogens (food handlers), increased risk of complications,
for epidemiologic purposes, where there is suspicion of an outbreak that is enteric in
origin. The yield is highest when requested within 3 days of symptoms and before
administration of antibiotics
d. There is insufficient evidence to support the use of biomarkers (CRP, calprotectin,
ESR, PCT, total serum WBC) in distinguishing the cause of acute infectious diarrhea.
e. Rapid diagnostic tests may be used during suspected outbreaks of diarrhea and
shigella, but confirmation with stool culture is still recommended
2
IV. What are the clinical parameters that would indicate presence of dehydration in children
with acute infectious diarrhea?
a. Physical examination findings indicative of hydration status include the following:
vital signs (tachycardia, tachypnea), level of consciousness (depressed sensorium),
presence of depressed fontanel, presence of sunken eyeballs, presence of tears, skin
turgor, capillary refill time, abnormal respiratory pattern, and history of urine output.
V. What are the clinical parameters that would indicate presence of dehydration in adults
with acute infectious diarrhea?
a. Clinical and laboratory parameters indicative of hydration status include the
following:
Clinical parameters: fatigue, thirst, sunken eyes, orthostatic hypotension,
increased respiratory rate, cold, clammy sin, lethargy, dry oral mucosa,
muscle weakness, decreased skin turgor (>2 seconds)
Laboratory parameters: Increased urine specific gravity (≥1.010), increased
urine osmolality (>800msom/kg), increased serum osmolality (≥ 295
msom/kg), increased BUN/creatinine ration (>20 mg/dL), metabolic acidosis
(pH < 22).
2
VI. What laboratory test should be done to assess for the presence of complications with
acute infectious diarrhea?
a. Complications such as acute kidney injury and electrolyte imbalances can occur in
pediatric and adult patients with acute infectious diarrhea. For patients suspected to
have complications of acute infectious diarrhea, the following laboratory tests may
be requested: complete blood count, urinalysis, serum electrolytes (Na, K, Cl), BUN
and creatinine, serum bicarbonate or total CO2 if available or ABG
TREATMENT: CHILDREN
A. Who should be admitted among children presenting with acute infectious diarrhea?
Children with acute infectious diarrhea with any of the following clinical history and
physical findings should be admitted:
2
D. What are the recommended antimicrobials for the following etiologies of acute infectious
diarrhea in children?
2
E. What non-specific medications may be given in children with acute infectious gastroenteritis?
Zinc supplementation (20mg/day for 10-14 days) should be given routinely as adjunctive
therapy for acute infectious diarrhea in children more than 6 months old.
Zinc supplementation is NOT routinely given as adjunctive therapy for acute infectious
diarrhea in children less than 6 months old.
Racecadotril (1.5 mg/kg/dose) 3 times a day during the first 3 days of watery diarrhea
may be given to infants and children as adjunctive therapy to shorten duration of
diarrhea.
Loperamide is NOT recommended for children with acute infectious gastroenteritis due
to serious adverse events.
F. What is the role of anti-emetics in the management of vomiting in children with acute infectious
diarrhea?
Anti-emetics are NOT recommended in children presenting with vomiting with acute
infectious diarrhea due to safety issues.
G. What is the role of probiotics in the management of acute infectious diarrhea in children?
Probiotics are recommended as an adjunct therapy in children throughout the duration
of the diarrhea in children. Probiotics have been shown to reduce symptom severity and
duration of diarrhea.
Probiotics may be extended for 7 more days after completion of antibiotics.
H. What is the recommended diet for children with acute infectious diarrhea?
Breastfeeding should be continued in breastfed infants.
In general, feeding should be continued. However, if feeding is not tolerated, early
refeeding may be started as soon as the child is able. Resumption of age-appropriate
usual diet is recommended during or immediately after rehydration process is
completed.
If diarrhea persists for more than 7 days, or for patients being treated in the hospital due
to severe diarrhea, lactose free diet may be given to children who are predominantly
bottle-fed to reduce treatment failure and decrease the duration of diarrhea.
2
TREATMENT: ADULT
Who should be admitted among adults presenting with acute infectious diarrhea?
The following adult patients with the following clinical history and physical findings
should be admitted:
• Poor tolerance to oral rehydration
•Moderate to severe dehydration
• Acute kidney injury and/or electrolyte abnormalities
• Unstable comorbid conditions (e.g. uncontrolled diabetes, congestive heart failure,
unstable coronary artery disease, chronic kidney disease, chronic liver disease,
immunocompromised conditions)
• Frail, elderly (60 years old and above) and/or with poor nutritional status
• Patients with unique social circumstances (living alone, with residence far from a
hospital)
What is the recommended management for dehydration in adults?
What are the indications for empiric antimicrobial treatment in adults with acute
infectious diarrhea?
Empiric antimicrobial treatment is NOT recommended for acute diarrhea with the
following clinical features: mild to moderate dehydration only, non-bloody stools,
symptoms less than 3 days.
Empiric antimicrobial treatment is recommended for patients with acute diarrhea
with moderate to severe dehydration plus any of the following clinical features: fever
alone, fever and bloody stools, symptoms persisting for more than 3.
The following antimicrobials are recommended for empiric treatment of acute
infectious diarrhea:
o Azithromycin 1g single dose OR
o Ciprofloxacin 500 mg twice daily for 3-5 days
o Once suspected organism is confirmed, antimicrobial therapy may be
modified accordingly
2
What are the recommended antimicrobials for the following etiologies of acute
infectious diarrhea in adults?
PREVENTION
2
OUTBREAK
HYPERTENSION
Source:
1. www.philippinesocietyofhypertension.org.ph/ClinicalPracticeGuidelines
2
RECOMMENDATIONS:
Clinical Question 2. Among adult Filipinos, what device is recommended for accurate blood pressure
determination and monitoring?
Clinical Question 3. Among adult Filipinos, what are the blood pressure thresholds for treatment and
BP targets for the prevention of cardiovascular disease?
Clinical Question 4. Among Filipinos with hypertension, what are the general treatment
recommendations?
Clinical Question 4.1. What non-pharmacologic approaches are recommended for persons with
hypertension?
2
A. Lifestyle modification remains the cornerstone for the management of hypertension. Robust
clinical trial evidence has shown that it can prevent or delay the onset of high blood pressure
and can reduce cardiovascular risk. Healthy lifestyle choices are the first line of
antihypertensive treatment and of course are synergistic to the effects of antihypertensive
medications. Lifestyle modifications should include the following:
a. Sodium restriction to as low as 1500 mg/day. The American Heart Association
recommends that sodium intake be limited to 2300 mg/d (about roughly half a
teaspoon of table salt) in most healthy individuals and 1500 mg/d in people with
prehypertension or hypertension.
b. Dietary Approaches to Stop Hypertension (DASH) meal plan which is low in sodium
and high in dietary potassium, can be recommended for all patients with
hypertension without renal insufficiency. The DASH diet is rich in fruits, vegetables,
low-fat dairy, fish, whole grains, fiber, potassium, and other minerals at
recommended levels and low in red and processed meat, sugar sweetened foods and
drinks, saturated fat, cholesterol, and sodium.
c. Aerobic physical activity and (dynamic) resistance exercises.
d. Abstinence from alcohol or moderate alcohol intake.
e. Significant weight loss of > 5% of the baseline weight for those who are overweight
or obese.
f. Smoking cessation
Clinical Question 4.2. What are the preferred drugs for the treatment of hypertension among adult
Filipinos for prevention of cardiovascular diseases?
Clinical Question 5. Among persons with diabetes, what is the threshold for treatment of elevated
blood pressure?
A. Among persons with diabetes and hypertension, it is recommended that drug therapy (along
with lifestyle change) be initiated at a blood pressure of > 140/90 mm Hg.
Clinical Question 6: Among persons with diabetes and hypertension, what nonpharmacologic
therapy is recommended?
A. The general advice for non-pharmacologic therapy for hypertension among persons with
diabetes is similar to the general population. Additionally, screening for obstructive sleep
2
apnea may be worthwhile as randomized studies of people with diabetes have shown that
treatment of OSA (by Continuous Positive Airway Pressure or CPAP) reduces blood pressure.
Clinical Question 7. Among persons with diabetes and hypertension, what are the blood pressure
targets for prevention of cardiovascular diseases (mortality and morbidity)?
A. A blood pressure target of <130/80 mm Hg is recommended for most persons with diabetes
mellitus and hypertension; however, do not lower down the blood pressure below 120/70
due to an increased risk for adverse events.
Clinical Question 8. Among persons with diabetes, what are the preferred drugs for the treatment of
hypertension?
Clinical Question 9. Among patients with CKD who are pre-dialysis, what is the level of blood
pressure to start pharmacotherapy to prevent cardiovascular complications and renal progression?
A. Patients with BP more than or equal to 140/90 mmHg should have prompt initiation and
timely titration of pharmacotherapy to achieve blood pressure goals.
Patients with BP more than or equal to 140/90 mmHg should have prompt initiation and timely
titration of pharmacotherapy to achieve blood pressure goals.
A. For routine office blood pressure measurement, maintain a BP target consistently less than
140 mmHg systolic and less than 90 mmHg diastolic in patients with low risk of
cardiovascular disease and CKD grade 4 and 5, or if with adverse effect on intensive target of
less than 130/80 mmHg. CKD patients with high cardiovascular risk or CKD grade 3 or earlier
is recommended to have a blood pressure target of less than less than 130/80 mmHg.
B. A systolic BP of less than 120 mmHg using a standardized office BP measurement is targeted,
when tolerated, among adults with high BP and non-dialysis CKD (ND-CKD). An individualized
treatment target is recommended for the following patient populations:
a. Diabetic Kidney Disease patients
b. CKD grade 4 and 5ND patients
c. patients with proteinuria of more than 1 g/day
d. individuals with baseline SBP of 120 to 129 mmHg
e. those with very low diastolic BP of less than 50 mmHg with CAD
2
Clinical Question 11. Among patients with CKD, what is the level of blood pressure to start initiation
with two antihypertensive drugs to prevent cardiovascular complications and renal progression?
A. Patients with confirmed office-based blood pressure or more than or equal to 160/100
mmHg should, in addition to lifestyle modification, have prompt initiation and timely
titration of two drugs or a single-pill combination of drugs demonstrated to reduce
cardiovascular events. A two-drug combination should consider these mechanisms in the
choice of anti-hypertensives: calcium channel blockers and diuretics to address volume
dependent type of hypertension, and ACE, ARB and beta blockers for the renin dependent
type.
Clinical Question 12. Among patients with CKD, what is the anti-hypertensive of choice to prevent
cardiovascular complications and renal progression?
Clinical Question 13. Among patients with CKD with albuminuria/proteinuria, what is the anti-
hypertensive of choice to prevent cardiovascular complications and renal progression?
B. Combinations of ACE inhibitor and Angiotensin receptor blocker and of ACE inhibitors or
angiotensin receptor blockers with direct renin inhibitors should not be used.
Clinical Question 14. Among patients with CKD with resistant hypertension, is the addition of
mineralocorticoid receptor antagonist beneficial in reducing albuminuria and cardiovascular events?
A. CKD patients with resistant hypertension not meeting blood pressure targets on three classes
of anti-hypertensive medications (including diuretic) should be considered for
mineralocorticoid receptor antagonist therapy
Clinical Question 15. Among patients with CKD, is giving anti-hypertensive at bedtime more
beneficial in reducing cardiovascular event?
Clinical Question 16.1 For adults with acute ischemic stroke (AIS) who are eligible for intravenous (IV)
thrombolysis but not for mechanical thrombectomy, what is the threshold for pharmacological
treatment and the target blood pressure (BP)?
A. For adults with AIS who are eligible for IV thrombolysis but not for mechanical
thrombectomy, a referral to a neurologist or stroke specialist is advised. It is recommended
that the BP be maintained < 185/110 mmHg prior to treatment and during infusion. For the
next 24 hours after treatment is given, the BP is recommended to be maintained < 180/105
mmHg.
Clinical Question 16.2 For adults with AIS who are eligible for IV thrombolysis but not for mechanical
thrombectomy, what are the pharmacologic agents of choice to reach the target BP?
Clinical Question 17.1 For adults with AIS who are not eligible for IV thrombolysis or mechanical
thrombectomy, what is the target BP and threshold for pharmacological treatment?
A. For adults with AIS who are not eligible for IV thrombolysis or mechanical thrombectomy, it
is recommended to maintain a target mean arterial pressure (MAP) of 110 to 130 mmHg. For
adults with AIS who are not eligible for IV thrombolysis or mechanical thrombectomy, the
threshold for urgent antihypertensive treatment is with severe hypertension of Systolic BP
2
>220 mmHg or Diastolic BP >120 mmHg. If with severe hypertension, it might be reasonable
to reduce the BP by 15% during the first 24 hours after the onset of stroke.
Clinical Question 17.2. For adults with AIS who are not eligible for IV thrombolysis or mechanical
thrombectomy, what pharmacological agent may be used to achieve target BP, when needed?
A. For adults with AIS who are not eligible for IV thrombolysis or mechanical thrombectomy, the
use of IV nicardipine to achieve the target BP may be considered
Clinical Question 18.1. For adult patients with acute hypertensive parenchymal intracerebral
hemorrhage (ICH), what is the threshold for BP lowering in the first few hours upon presentation at
the emergency room?
A. For adult patients with acute ICH, the threshold for BP lowering is SBP ≥ 180 mmHg.
Clinical Question 18.2 What would be the target BP when lowering the blood pressure in acute ICH?
A. The target SBP is <180 mmHg. In patients with SBP ≥180 mmHg, careful BP lowering to 140
to 160 mmHg should be considered. The magnitude of BP reduction is dependent on the
clinical context. It should be careful SBP lowering (avoiding reductions ≥60 mmHg in 1 hour).
o It is recommended to keep the blood pressure stable and avoid variability.
o It is also recommended not to lower the BP acutely to < 140 mmH
Clinical Question 18.3 What are the pharmacologic agents of choice and manner of administration?
Clinical Question 19. For adults who have a history of stroke, what is the target blood pressure level
for secondary prevention?
A. For adults with history of stroke, the target blood pressure level for secondary prevention is
less than or equal to 130/80 mm Hg. RAS blockers, CCBs and thiazide diuretics remain to be
the first-line pharmacologic agents in hypertension management for secondary stroke
prevention.
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Clinical Question 20. What are the different types of hypertensive disorders of pregnancy (HDP) and
what are the criteria for each?
E. Gestational Hypertension –
a. Systolic blood pressure 140 mm Hg or more or a diastolic blood pressure of 90 mm
Hg or more, or both, on two occasions at least 4 hours apart after 20 weeks of
gestation, in a woman with a previously normal blood pressure.
b. Hypertension without proteinuria or severe features develops after 20 weeks of
gestation and blood pressure
Clinical Question 21. What blood pressure threshold is used to define hypertension in pregnancy?
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Clinical Question 22. What antihypertensive agents can be used for urgent blood pressure control in
pregnancy?
Clinical Question 24. What are the pharmacologic treatment options in the OPD management of
hypertension in pregnancy?
A. The choice of antihypertensive drug for initial therapy should be based on the characteristics
of the patient, contraindications to a particular drug and physician and patient preferences.
The first line drugs are methyldopa, calcium channel blockers or beta blockers, and ACE-
inhibitors and angiotensin-receptor blockers (ARBs) are generally not recommended.
Antihypertensives may be used to keep systolic blood pressure at 130 to 155 mmHg and
diastolic blood pressure at 80 to 105 mmHg.
Clinical Question 25: How is hypertension managed during the immediate postpartum and
breastfeeding periods?
A. Blood pressure should be recorded shortly after birth and if normal again within 6 hours.
B. All women should have BP recorded and discharge deferred for at least 24 hours or until vital
signs are normal and/or treated or referred. Any woman with an obstetric complication
and/or newborn with complications should stay in the hospital until both are stable.
a. In hospital stay for at least 24 hours
b. Check up within 48-72 hours of the birth and again 7-14 days and at six weeks
postpartum.
c. All women should be reminded of the danger signs of preeclampsia following birth
including headaches, visual disturbances, nausea, vomiting, epigastric or
hypochondrial pain, feeling faint or convulsions
Clinical Question 26. Among pediatric patients, what is the threshold for commencing pharmacologic
treatment for Hypertension?
A. Pharmacologic treatment for hypertension (HTN) should be started for children with the
following conditions:
a. Children who remain hypertensive even after six (6) months of lifestyle modification
strategies*
b. Symptomatic hypertension or Stage 2 hypertension
c. Presence of co-morbidities like chronic kidney disease (CKD) or diabetes mellitus
(DM), or any evidence of target organ involvement (e.g. left ventricular hypertrophy).
B. The goal of pharmacologic therapy should be a reduction in systolic blood pressure (SBP) and
diastolic blood pressure (DBP) to <90th percentile for age, sex and height and <120/80 mm
Hg in adolescents ≥13 years of age.
C. For children with CKD, BP targets should be less than or equal to 50th percentile for age, sex
and height.
D. The goal of treatment of hypertension in the pediatric population is not only to reduce BP to
<90th percentile for age, sex and height and <130/80 mm Hg, but also to reduce
cardiovascularrisk factors, and prevent target organ damage.
E. Follow-up every 4-6 weeks is recommended for monitoring and evaluation of therapy
Clinical Question 27. What advice regarding nonpharmacologic treatment is recommended for
pediatric patients?
activity at least 3-5 days a week should be initiated in all pediatric patients consulting for the
first time for hypertension.
B. All children with hypertension should have their body mass index (BMI) measured during
each visit
C. Weight loss intervention is recommended for identified overweight and obese children until
a normal BMI is attained through dietary counselling and exercise (weight loss of 1 to 2 kg
per month).
Clinical Question 28. What are the BP targets for prevention of target organ complications?
A. The target BP for children is <90th percentile for age, sex and height or <120/<80 mmHg
whichever is lower
B. For CKD patients, BP target is less than or equal to the 50th percentile for age, sex and
height.
Clinical Question 29. What are the preferred medications for children?
A. Any of the following drugs may be used as initial treatment for children with hypertension:
ACE inhibitors (Enalapril, Captopril), ARBs (Losartan, Valsartan), or calcium channel blockers
(Amlodipine).
B. For children with co-existing chronic kidney disease, proteinuria or diabetes mellitus, an ACE-
inhibitor or ARB is recommended as the initial antihypertensive drug unless with absolute
contraindications. Referral to a specialist is highly recommended.
C. Therapy should start with a single drug at the lowest possible dose and titrated up every 2 to
4 weeks until target BP is achieved, or the maximal dose reached or adverse effects occur.
D. If BP is not controlled with a single agent (maximal dose is reached or adverse effects occur),
a second agent can be added to the regimen and titrated as with the initial drug. Because the
use of other anti-hypertensive agents can lead to compensatory salt and water retention, the
addition of a thiazide diuretic to an initial drug for uncontrolled hypertension is prudent.
E. In combining agents from different drug classes, it is preferable to give those with
complementary modes of action. Ideally, no two drugs which act separately on the RAAS,
should be used in combination because of the risk of hyperkalemia, impaired kidney function
and hypotension.
Clinical Question 30: What is the recommended technique and BP device for accurate BP
measurement in pediatric patients?
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A. The use of proper technique and appropriately-sized cuff is critical for the accurate
measurement of BP in children.
B. An auscultatory device using an aneroid non-mercury sphygmomanometer is recommended
for children.
C. An oscillometric device is a suitable alternative to auscultation for initial BP screening and
monitoring in the pediatric population.
D. Ambulatory BP monitoring (ABPM) is recommended in children (> 5 years old) and
adolescents with the following conditions:
a. Elevated office BP measurements for 1 or more years, or if with stage 1 hypertension
over 3 clinic visits, for confirmation of hypertension.
b. Those with high-risk conditions (e.g. obesity, CKD or structural renal abnormalities,
diabetes mellitus, those who have undergone solid organ transplant, obstructive
sleep apnea, repaired aortic coarctation) to document masked hypertension.
c. Those with suspected white coat hypertension.
E. Home BP monitoring should not be used to diagnose hypertension, MH, or WCH but may be
a useful adjunct to office and ambulatory BP measurement if clinically validated oscillometric
apparatus and appropriate-sized cuffs are used.
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