Hypertension, Telmisartan and Clinical Practice Guidelines in the Philippines: Upholding International Standards in Local Practice

Hypertension in the Philippine Setting

While the Expanded National Nutrition Survey (NNS) conducted by the Food and Nutrition Research Institute (FNRI) using cross-sectional questionnaire and a single-visit BP measurement has shown a significant decline in the prevalence of hypertension from 23.9% in 2013 to 19.2% in 2018, hypertension continues to impose a significant healthcare and socio-economic burden in the Philippines.¹

While it is acknowledged to be the most important modifiable risk factor for disability adjusted life-years worldwide, hypertension awareness in the Philippines is at 67.8% with only 75% of those who are aware receive treatment. Of those under treatment, only 27% have it under control.¹

Poor blood pressure control indeed continues to be a significant contributor to the 2 leading causes of death in the Philippines, which are heart disease and stroke. ¹ There were 250,000 identified cardiovascular deaths in the Philippines in 2019 and 53% of them were attributable to high blood pressure. There was an alarming 25% probability of premature deaths due to non-communicable diseases, including cardiovascular disease, in the same year.²

The economic burden of hypertension in 2020 was estimated to be around PHP 52.6 billion($1 billion). About 70% of the burden is accounted for by direct and indirect care. Productivity loss due to uncontrolled hypertension and premature mortality can account for up to 17% of the total economic cost.³

Traditional treatment of diseases, including hypertension, had always been part of culture especially in developing and third world countries like the Philippines. One study showed that 21% of the population have consulted non-physicians for their ailments, continually exposing a significant number of patients to inappropriate management.⁴

Clinical Practice Guidelines for the Management of Hypertension

The 2020 Clinical Practice Guideline for the Management of Hypertension in the Philippines is a collaborative effort of various medical specialty societies with a common aim of curbing the morbidity and mortality rates of hypertension in the country by presenting evidence-based recommendations on the management of hypertension adapted from international guidelines but with local consideration of local realities and medical practice.¹

In recognition of the unique profile of local risk factors, the guideline recommends lifestyle modification as the cornerstone and first-line of treatment of hypertension and includes sodium restriction, dietary management, physical activity, abstinence, or moderation of alcohol intake as appropriate, weight loss of >/= 5% of baseline and smoking cessation.¹

Among the identified first-line pharmacologic treatments are the angiotensin receptor blockers (ARBs) which includes telmisartan, either as monotherapy or in combination with other drug classes. Selection on the first line drugs was based on the CV outcomes of large clinical trials and prevention of cardiovascular disease through the control of hypertension. ARBs were recommended for uncomplicated hypertension, in persons with diabetes, patients with chronic kidney disease, for secondary prevention in adults with history of stroke, and for hypertension in children. ¹

The American College of Cardiology / American Heart Association Guidelines, while designed for use by US medical practitioners, has a global impact, and immensely influences Philippine guidelines and clinical practice. It has similar recommendations on the use of telmisartan and other ARBs across different clinical settings. In addition, the AHA/ ACC guideline recommends ARBs for treatment of hypertension in patients with stable ischemic heart disease (SIHD) and patients with heart failure with preserved ejection fraction.⁵

Telmisartan in the Philippines

Since 2013, the use of ARBs has increased tremendously. A local study has shown that usage rate of ARBs was leading all drug classes at 67% with 89% compliance rate. The increase in the usage of ARBs was noted in conjunction with the availability of fixed combination preparations. This can be potentially helpful in improving the poor control rates that has been cited to partly caused by a still prevalent use of monotherapy.⁶