Received: 23 May 2021 Revised: 16 July 2021 Accepted: 19 July 2021

DOI: 10.1111/jch.14335

GUIDELINES

Executive summary of the 2020 clinical practice guidelines for

the management of hypertension in the Philippines

Deborah Ignacia D. Ona1,2 Cecilia A. Jimeno1 Gabriel V. Jasul Jr.1,2

Ma. Lourdes E. Bunyi2 Raymond Oliva1 Lourdes Ella Gonzalez-Santos1
Leilani B. Mercado-Asis3 Vimar A. Luz2 Aurelia G. Leus4 Alejandro Bimbo F. Diaz3
Marjorie I. Santos5 Allan A. Belen6 Dolores D. Bonzon1 Jonnie Bote-Nunez7
Roberta Maria N. Cawed-Mende8 Arnel S. Chua9 Anne Marie Joyce T. Javier10
Dan Neftalie A. Juangco4 Carmela Madrigal-Dy11 Marlon B. Manicad12
Juan Miguel Gil R. Ortiz13 Christia S. Padolina13 Maria Concepcion C. Sison1
Ninfa J. Villanueva14
1
University of the Philippines College of Medicine, Philippine General Hospital, Philippines
2
St. Luke’s Medical Center, Quezon City, Philippines
3
University of Santo Tomas Hospital, Philippines
4
Makati Medical Center, Philippines
5
Manila Central University- Filemon D. Tanchoco Medical Foundation College of Medicine, Philippines
6
Community General Hospital of San Pablo City Inc., Philippines
7
Philippine Heart Center, Philippines
8
Ospital ng Paranaque, Philippines
9
National Kidney and Transplant Institute, Philippines
10
Mary Mediatrix Medical Center, Lipa City, Philippines
11
Cardinal Santos Medical Center, Philippines
12
Commonwealth Hospital & Medical Center, Philippines
13
University of the East Ramon Magsaysay Memorial Medical Center, Philippines
14
Davao Medical School Foundation, Philippines

Correspondence
Deborah Ignacia D. Ona, University of the Abstract
Philippines College of Medicine Philippine
General Hospital.
Hypertension is the most common cause of death and disability worldwide with its
Email: debbiedavidona@gmail.com prevalence rising in low to middle income countries. It remains to be an important
cause of morbidity and mortality in the Philippines with poor BP control as one of
the main causes. Different societies and groups worked and collaborated together to
develop the 2020 Philippine Clinical Practice Guidelines of hypertension arising for
the need to come up with a comprehensive local practice guideline for the diagnosis,
treatment, and follow up of persons with hypertension. A technical working group was

This is an open access article under the terms of the Creative Commons Attribution License, which permits use, distribution and reproduction in any medium, provided
the original work is properly cited.
© 2021 The Authors. The Journal of Clinical Hypertension published by Wiley Periodicals LLC

J Clin Hypertens. 2021;23:1637–1650. wileyonlinelibrary.com/journal/jch 1637

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1638 ONA ET AL.

organized into six clusters that analyzed the 30 clinical questions commonly asked
in practice, looking into the definition of hypertension, treatment thresholds, blood
pressure targets, and appropriate medications to reach targets. This guideline also
includes recommendations for the specific management of hypertension among indi-
viduals with uncomplicated hypertension, hypertension among those with diabetes,
stroke, chronic kidney disease, as well as hypertension among pregnant women and
pediatric populations. It also looked into the appropriate screening and monitoring of
patients when managing hypertension, and identification of groups who are at high
risk for cardiovascular (CV) events. The ADAPTE process was used in developing the
statements and recommendations which were then presented to a panel of experts
for discussion and approval to come up with the final statements. This guideline aims
to aid Filipino healthcare professionals to provide evidence-based care for persons
with hypertension and help those with hypertension adequately control their blood
pressure and reduce their CV risk

KEYWORDS
hypertension—general, lifestyle modification/hypertension, treatment and diagnosis/guidelines

1 INTRODUCTION are adapted from international practice guidelines, but which take into
consideration local realities and the practice of doctors in the Philip-
Hypertension is a major cause of premature death worldwide and is the pines. It is intended to help physicians make sound clinical decisions in
most important modifiable risk factor for disability adjusted life-years the management of hypertension by presenting the latest information
lost worldwide.1,2 The prevalence of hypertension in low and middle about diagnosis, treatment, and follow-up of persons with hyperten-
income countries has been seen to be steadily rising, but in the Philip- sion. The primary targets for these guidelines are physicians in general
pines, the latest National Nutrition Survey (NNS) conducted by the practice, but these recommendations are also useful for all healthcare
Food and Nutrition Research Institute (FNRI) in 2018 showed a down- professionals in the Philippines.
ward trend in hypertension prevalence for the age group 20–59 years The guideline includes statements and recommendations on the
old, from a previous of 23.9% in 2013 to 19.2% in 2018. The preva- definition of hypertension, treatment thresholds, and blood pressure
lence though for older persons aged 60 years old and above, while also targets, appropriate medications to reach targets, and specific man-
decreasing, is still 35% in 2018 from 41.2% in 2015.3 However, hyper- agement of hypertension among individuals with uncomplicated hyper-
tension awareness in the Philippines is around 67.8% and out of those tension, hypertension among those with diabetes, stroke, chronic kid-
who are aware, only 75% are treated with only 27% of those who are ney disease, as well as the hypertension among pregnant women
treated have it under control.4 and pediatric populations. It also includes statements on the appro-
Despite the decreasing trends in hypertension prevalence in the priate screening and monitoring when managing hypertension, and
country, poor blood pressure control continues to contribute to the top identification of groups who are at high risk for cardiovascular (CV)
two causes of mortality in the Philippines, which are heart disease and events.
stroke. This, therefore, is the reason for the urgency of developing local
practice guidelines for the management of this common disease. While
there are many international practice guidelines which can be adopted 2 METHODOLOGY
in its totality, this guideline is meant to address issues that are unique
and relevant to the Filipino population and when available, include local The project to develop the Philippine Practice Guideline was
research in the development of the recommendations. spearheaded by the Philippine Society of Hypertension and the
This guideline is a collaborative work of different specialties in the Philippine Heart Association, in collaboration with experts from
interest of curbing the morbidity and mortality due to hypertension in various fields including pediatricians and pediatric cardiologists,
the country, by providing a set of recommendations that could guide obstetrician-gynecologists, endocrinologists, nephrologists, and neu-
the Filipino physician in the management of elevated blood pressure. rologists/stroke specialists. The administrative group organized a
The objective of the guidelines is to present evidence-based rec- technical writing group comprised of these experts who decided in
ommendations on the diagnosis and treatment of hypertension that consensus to use the ADAPTE process in developing the 2020 Clinical
 17517176, 2021, 9, Downloaded from https://onlinelibrary.wiley.com/doi/10.1111/jch.14335 by Cochrane Philippines, Wiley Online Library on [09/05/2023]. See the Terms and Conditions (https://onlinelibrary.wiley.com/terms-and-conditions) on Wiley Online Library for rules of use; OA articles are governed by the applicable Creative Commons License
ONA ET AL. 1639

Practice Guidelines (CPG) on Hypertension.5 This decision was based 3 RECOMMENDATIONS FOR THE
not only on previous experience by other local medical societies on the MANAGEMENT OF HYPERTENSION
use of the process for developing practice guidelines, but also because
it was deemed to be an efficient, cost-effective and evidence-based I. Diagnosis and management of hypertension in adult population
method of making guidelines. Clinical question 1. Among adult Filipinos, what is the definition of
The rationale for guideline adaptation rather than de-novo guide- hypertension?
line development is to allow efficient use of current information, that Statements:
is, already available in existing practice guidelines, abbreviating the
1.1 Hypertension is defined as an office blood pressure (BP) of
process of identifying individual studies that apply to specific research
140/90 mm Hg or above, typically at least twice taken on two sep-
questions, appraising them, evaluating individual study quality and
arate days.
finally, developing specific recommendations. This methodology also
1.2 It is recommended that office BP be classified as Normal, Border-
still allows for customizing or modifying existing guideline recom-
line, Hypertension.
mendations to suit the local context, and to add any local researches
1.3 Out of office BP measurements are recommended to confirm the
or new information on the question as they become available. The
diagnosis of hypertension, with ambulatory blood pressure moni-
methodology for guideline adaptation using the ADAPTE process is
toring (ABPM) as the preferred method, and home blood pressure
available on the website of the Guidelines International Network at
monitoring (HBPM) as an acceptable alternative.
https://g-i-n.net . The process of adaptation is systematic, allowing
for transparent and explicit reporting and typically allows the use
The TWG also decided to adopt the joint position statement of
of multiple guidelines and their contents, to develop a new set of
the Philippine Heart Association (PHA) and the Philippine Society of
guidelines, that is, locally relevant.
Hypertension (PSH)6 which was a response to the 2017 ACC/AHA
Each of the organizations involved in the process of guideline devel-
Guideline for the Prevention, Detection, and Management of High
opment nominated a group of experts who will comprise the techni-
Blood Pressure on adults.7 The 2020 Philippine Clinical Practice Guide-
cal working group (TWG). The TWG was organized into clusters that
lines (CPG) has adopted this blood pressure classification from the con-
developed the six areas that were covered by the CPG: general recom-
sensus statement as shown in Table 1.
mendations for adults with hypertension; blood pressure management
This guideline defines hypertension as an office BP of 140/90 mm
among persons with diabetes, chronic kidney disease; and stroke; and
Hg or above taken in accordance with the proper standard BP measure-
hypertension among Pregnant women and children.
ment. A cut-off value has been set to simplify the diagnosis of hyperten-
sion and to rationalize the treatment decisions surrounding it. The con-
tinuum between BP level and the occurrence of CV and renal events
2.1 Literature search is not clear, making the setting of a cut off value arbitrary. Neverthe-
less, hypertension is defined here as the level of BP at which the ben-
The TWG searched for all published guidelines, both local and inter-
efit of pharmacologic treatment supported by lifestyle interventions
national, pertaining to the clinical questions, with the use of elec-
far outweigh the risks/costs of treatment as documented by clinical
tronic search engines and manual search. Literature search was done
studies.
by each of the working groups using search engines such as Pubmed
All the guidelines reviewed define hypertension as a BP level of
(Medline), Google Scholar, other medical search engines using key
≥140/90 mm Hg, except for the AHA/ACC guideline which pegs
words relevant to each clinical question. The full listing of guide-
hypertension at a BP level of ≥130/80 mm Hg. All the guidelines
lines that were retrieved, appraised and included for each research
except for NICE and the Indian guideline include different stages and
question for each of the TWG clusters can be found in the full
grades for hypertension. This Philippine recommendation opted to
guideline.
keep it simple, and the definition of hypertension remains unchanged
from the 2011 Philippine guideline8 because there is no compelling
reason for a change. The national surveys and prevalence stud-
2.2 Development of guideline recommendations ies done in the Philippines use the same definition of hypertension
and evidence summaries and maintaining the same criteria would avoid confusion in disease
surveillance.
Each cluster then developed and presented their draft recommenda-
tions for approval to the panel of experts for discussion and approval
TA B L E 1 Blood pressure classification for adult filipinos
by consensus of the majority. These draft recommendations were then
revised and presented again to the panel and were finalized. Sev- Category Blood pressure range
eral public presentations have also been made to further elicit feed- Normal BP < 120/80 mm Hg
back from various stakeholders on the details of the guidelines. The Borderline BP 120–139/ 80–89 mm Hg
recommendations presented here are the result of these iterative
Hypertension ≥140/90 mm Hg
processes.
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1640 ONA ET AL.

Clinical question 2. Among adult Filipinos, what device is recom- effects of antihypertensive medications. Lifestyle modifications
mended for accurate blood pressure determination and monitoring? should include the following:
Statements:
2.1 A properly validated automated oscillometric sphygmomanome- Sodium restriction to as low as 1500 mg/day. The American Heart

ter (digital device) is recommended for in office or out of Association recommends that sodium intake be limited to 2300 mg/day
office use. (about roughly half a teaspoon of table salt) in most healthy individuals
2.2 The aneroid sphygmomanometer (manual device) may be used in and 1500 mg/day in people with prehypertension or hypertension.
office or out of office provided the examiner is efficient and well 4.1.1 Dietary Approaches to Stop Hypertension (DASH) meal plan
trained, and the device is periodically checked according to stan- which is low in sodium and high in dietary potassium, can be
dard maintenance procedures. recommended for all patients with hypertension without renal
2.3 The aneroid sphygmomanometer is recommended for special insufficiency.13–16 The DASH diet is rich in fruits, vegetables,
cases like the presence of arrhythmias or extremes in BP levels. low-fat dairy, fish, whole grains, fiber, potassium, and other min-
erals at recommended levels and low in red and processed meat,
The guideline acknowledges the greater accuracy of a validated dig- sugar sweetened foods and drinks, saturated fat, cholesterol,
ital sphygmomanometer. However, the aneroid sphygmomanometer is and sodium
still a widely available, cheaper, and accessible device for which many 4.12 Aerobic physical activity and (dynamic) resistance exercises
health care professionals have been trained. Thus, it may still be used in 4.13 Abstinence from alcohol or moderate alcohol intake
areas of the country where the digital device is not available, provided 4.14 Significant weight loss of ≥ 5% of the baseline weight for those
that there is proper training of personnel, and calibration and mainte- who are overweight or obese
nance of the device is done regularly. 4.15 Smoking cessation
Clinical question 3. Among adult Filipinos, what are the blood pres-
sure thresholds for treatment and BP targets for the prevention of CV Effective CV protection for hypertensive patients requires achieve-
disease? ment of blood pressure targets with appropriate lifestyle measures and
Statements: anti-hypertensive medications. The goal of treatment strategies is to
3.1 A therapeutic threshold of 140/90 mm Hg to achieve a goal of less reduce excess CV morbidity and mortality from chronically elevated
than 130/80 is recommended for most adults with hypertension. blood pressure.
3.2 For the very elderly, defined as 80 years old and above, a therapeu- Clinical question 4.2. What are the preferred drugs for the treat-
tic threshold of 150/90 mm Hg to achieve a goal BP of less than ment of hypertension among adult Filipinos for prevention of CV dis-
140/90 mm Hg is recommended. eases?
Statements:
All guidelines agree that patients with hypertension should receive
4.2.1 Among persons with uncomplicated hypertension, angiotensin-
anti-hypertensive treatment on top of diet and lifestyle modification to
converting enzyme (ACE) inhibitors or angiotensin-receptor
reduce blood pressure to treatment targets. Lowering blood pressure
blockers (ARBs), calcium channel blockers, thiazide/thiazide-like
to less than 140/90 has been shown repeatedly to reduce morbidity
diuretics are all suitable first-line antihypertensive drugs, either
and mortality.9–12
as monotherapy or combination.
This local guideline takes a practical approach to BP targets in rec- 4.2.2 Ideal combination therapy includes renin-angiotensin-
ommending a threshold of greater than 140/90 mm Hg to start ther- system (RAS) blocker with calcium channel-blocker (CCB)
apy. This can be addressed with diet and lifestyle modifications alone or thiazide/thiazide-like diuretics. Other combinations of the
in low-risk hypertensives or concomitant lifestyle changes with medi- five major classes may also be used in patients with compelling
cal treatment in high-risk individuals. We recommend these interven- indications for the use of specific drug classes.
tions to achieve a blood pressure of < 130/80 mm Hg in Filipino adults 4.2.3 ACE inhibitors & ARBs are not recommended to be used in com-
with hypertension. bination. Likewise, combinations of ACE-I or ARBs with direct
Clinical question 4. Among Filipinos with hypertension, what are renin inhibitors should not be used.
the general treatment recommendations? 4.2.4 The use of free combinations is recommended if single-pill com-
Clinical question 4.1. What non-pharmacologic approaches are bination therapy is not available or not affordable.
recommended for persons with hypertension? 4.2.5 Beta blockers are suitable as initial therapy in hypertensive
Statements: patients with coronary artery disease, acute coronary syn-
4.1 Lifestyle modification remains the cornerstone for the manage- drome, high sympathetic drive and pregnant women. Beta block-
ment of hypertension. Robust clinical trial evidence has shown ers for those with congestive heart failure was specified to be
that it can prevent or delay the onset of high blood pressure and bisoprolol, carvedilol, metoprolol succinate or nebivolol.
can reduce CV risk. Healthy lifestyle choices are the first line of 4.2.6 Among patients with BP > 150/100 mm Hg (or >160/100 mm
antihypertensive treatment and of course are synergistic to the Hg in the elderly), a combination of two agents, preferably
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ONA ET AL. 1641

combination of a RAAS inhibitor (ARB/ACE-is) and CCB or lines on the management of hypertension among persons with dia-
diuretic, should be given initially since it is unlikely that any sin- betes, the threshold for treatment continues to be 140/90 mm Hg.
gle agent would be sufficient to achieve the BP target. Clinical question 6: Among persons with diabetes and hyperten-
sion, what non-pharmacologic therapy is recommended?
Guideline recommendations include risk-factor identification to Statement:
stratify hypertensive patients since the presence of one or more 6. The general advice for non-pharmacologic therapy for hyperten-
additional CV risk factors proportionally increases the risk of coro- sion among persons with diabetes is similar to the general popula-
nary, cerebrovascular, and renal diseases. Risk stratification directs the tion. Additionally, screening for obstructive sleep apnea may be worth-
degree of aggressiveness in setting BP targets and in using pharmaco- while as randomized studies of people with diabetes have shown that
logic treatment on top of diet and lifestyle modifications. Risk stratifi- treatment of OSA (by Continuous Positive Airway Pressure or CPAP)
cation involves identification of risk factors, presence of hypertension- reduces blood pressure.
mediated organ damage (HMOD) and established CV and related dis- Clinical question 7. Among persons with diabetes and hyperten-
eases. sion, what are the blood pressure targets for prevention of CV dis-
Cardiovascular risk factors include advanced age (>65 years), male eases (mortality and morbidity)?
sex, increased body weight (BMI ≥25 kg/m2 ), diabetes, high LDL-C Statement:
(>130 mg/dl) and high triglyceride (>150 mg/dl), family history of 7. A blood pressure target of <130/80 mm Hg is recommended for
CVD, family history of hypertension, early-onset menopause, smok- most persons with diabetes mellitus and hypertension; however, do not
ing, and various psychosocial or socioeconomic factors (poverty). lower down the blood pressure below 120/70 due to an increased risk
HMOD include LVH (LVH with ECG), moderate-severe CKD (CKD; for adverse events.
eGFR <60 ml/min/1.73m2 ), and any other available measure of While CV risk reduction (myocardial infarction, CV death) is already
organ damage. Finally, take note of established CV and related dis- significant for BP <140/90 mm Hg (with no additional benefit for
eases such as previous coronary heart disease (CHD), heart fail- <120 mm Hg), a lower blood pressure target of <130/80 mm Hg
ure, stroke, peripheral vascular disease, atrial fibrillation, and CKD has additional benefit for stroke reduction and decreased risk for
stage 3+. nephropathy.
The therapeutic strategy must include lifestyle changes, effective Clinical question 8. Among persons with diabetes, what are the
treatment of the risk factors and aggressive BP control to reach target preferred drugs for the treatment of hypertension?
levels to reduce the residual CV risk. Drug treatment is recommended Statements:
among those with sustained systolic BP ≥140 mm Hg or diastolic BP 8.1 It is recommended to initiate treatment with a low-dose com-
≥90 mm Hg despite lifestyle modification for 3 months or if HMOD is bination of a RAAS blocker (ACE-I or ARB) with a CCB or
present. Patients with HMOD on screening should be started on drug thiazide/thiazide-like diuretic, preferably using a single-pill com-
treatment simultaneously with lifestyle interventions.17 bination (SPC). Free tablet combinations may also be given if SPCs
On the basis of evidence from large-scale clinical studies ACE are not available.
inhibitors, ARBs, CCBs, and diuretics are selected as first-line
drugs.18–20 Overall, major CV outcomes and mortality were similar As already stated in the general guidelines, the choice for starting on
with treatment based on initial therapy with all five major classes initial combination therapy results in greater achievement of BP lower-
of treatment. All five major first-line drug classes can be combined ing at the shortest amount of time. Low-dose combination therapy has
with one another except for ACE inhibitors and ARBs. Combinations been shown to be more effective than maximal dose monotherapy in
of ACE inhibitors or ARBs with either a CCB or thiazide/thiazide-like the general population of persons with hypertension.
diuretic are complementary because CCBs and diuretics activate the 8.2 The combination of ACE and ARB is not recommended due to a
RAS and will also limit adverse effects associated with diuretic or CCB higher risk of hyperkalemia and renal failure.
monotherapy. The choice for starting on initial combination therapy
results in greater achievement of BP lowering at the shortest amount III. Management of hypertension in persons with chronic kidney
of time. Low-dose combination therapy has been shown to be more disease
effective than maximal dose monotherapy21 Hypertension is highly prevalent in individuals with chronic kidney
Clinical question 5. Among persons with diabetes, what is the disease The prevalence of hypertension increases from 36% in stage 1
threshold for treatment of elevated blood pressure? to 84% in chronic kidney disease stage 4 and 5. Needless to say, blood
Statement: pressure control is fundamental to the care of patients with chronic
5. Among persons with diabetes and hypertension, it is recom- kidney disease and is relevant at all stages of chronic kidney disease
mended that drug therapy (along with lifestyle change) be initiated at regardless of underlying cause.
a blood pressure of ≥ 140/90 mm Hg. Clinical question 9. Among patients with CKD who are pre-dialysis,
Consistent then with the section on general guidelines for treat- what is the level of blood pressure to start pharmacotherapy to pre-
ment, plus the recommendations of majority of the international guide- vent CV complications and renal progression?
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1642 ONA ET AL.

FIGURE 1 Algorithm for the management of hypertension among adults

Statement: or if with adverse effect on intensive target of <130/80 mm Hg.

9. Patients with BP ≥140/90 mm Hg should have prompt initia- CKD patients with high CV risk or CKD grade 3 or earlier is rec-
tion and timely titration of pharmacotherapy to achieve blood pressure ommended to have a blood pressure target of <130/80 mm Hg.

goals. 10.2 A systolic BP of <120 mm Hg using a standardized office BP mea-

Clinical question 10. Among patients with CKD who are pre- surement is targeted, when tolerated, among adults with high

dialysis, what is the target blood pressure to prevent CV complica- BP and non-dialysis CKD (ND-CKD). An individualized treat-
tions and renal progression? ment target is recommended for the following patient popula-
Statements: tions: Diabetic Kidney Disease patients, CKD grade 4 and 5ND
patients, patients with proteinuria of more than 1 g/day, individ-
10.1 For routine office blood pressure measurement, maintain a BP tar-
uals with baseline SBP of 120 to 129 mm Hg, those with very low
get consistently <140 mm Hg systolic and <90 mm Hg diastolic
diastolic BP of less than 50 mm Hg with CAD, those with white
in patients with low risk of CV disease and CKD grade 4 and 5,
coat or severe hypertension, stroke patients, those with age less
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ONA ET AL. 1643

than 50 with low absolute risk for CV disease or those individuals Statement:
above 90 years of age, very frail patients, those with limited life 14. CKD patients with resistant hypertension not meeting blood
expectancy and those with symptomatic postural hypotension. pressure targets on three classes of anti-hypertensive medications
For these patient populations, a specialist referral is suggested. (including diuretic) should be considered for mineralocorticoid recep-
10.3 If unable to obtain a standardized BP measure, maintain a blood tor antagonist therapy
pressure target consistently ≤130 mm Hg systolic and ≤80 mm Clinical question 15. Among patients with CKD, is giving anti-
Hg diastolic in patients with urine albumin excretion of >30 mg hypertensive at bedtime more beneficial in reducing CV event?
per 24 h unless adverse event occurs with achievement of this Statement:
target. 15. Administer one or more antihypertensive medications at bed-
time
Clinical question 11. Among patients with CKD, what is the level of IV. Blood pressure management among persons with stroke
blood pressure to start initiation with two antihypertensive drugs to The relationship between hypertension and stroke is very dynamic
prevent CV complications and renal progression? and multifaceted. Management of hypertension during the acute onset
Statement: of stroke (whether ischemic or hemorrhagic) and during the secondary
11. Patients with confirmed office-based blood pressure or prevention phase poses a challenge due to the intricacies of how ele-
≥160/100 mm Hg should, in addition to lifestyle modification, have vated BP must be handled.
prompt initiation and timely titration of two drugs or a single-pill Clinical question 16.1. For adults with acute ischemic stroke
combination of drugs demonstrated to reduce CV events. (AIS) who are eligible for intravenous (IV) thrombolysis but not for
A two-drug combination should consider these mechanisms in the mechanical thrombectomy, what is the threshold for pharmacologi-
choice of anti-hypertensives: calcium channel blockers and diuretics to cal treatment and the target blood pressure (BP)?
address volume dependent type of hypertension, and ACE, ARB and Statement:
beta blockers for the renin dependent type.
Clinical question 12. Among patients with CKD, what is the anti- 16.1 For adults with AIS who are eligible for IV thrombolysis but
hypertensive of choice to prevent CV complications and renal pro- not for mechanical thrombectomy, a referral to a neurologist or
gression? stroke specialist is advised. It is recommended that the BP be
Statement: maintained to <185/110 mm Hg prior to treatment and during
12. Treatment for hypertension should include drug classes demon- infusion. For the next 24 h after treatment is given, the BP is rec-
strated to reduce CV events in patients with CKD such as ACE ommended to be maintained at <180/105 mm Hg.
inhibitors, Angiotensin Receptor Blockers, Thiazide-like diuretics, and
dihydropyridine calcium channel blockers. Clinical question 16.2. For adults with AIS who are eligible for IV
Clinical question 13. Among patients with CKD with albumin- thrombolysis but not for mechanical thrombectomy, what are the
uria/proteinuria, what is the anti-hypertensive of choice to prevent pharmacologic agents of choice to reach the target BP?
CV complications and renal progression? Statement:
Statements: 16.2 It is recommended to use a titratable intravenous medication
13.1 An ACE inhibitor or Angiotensin receptor blocker, at maxi- to allow dynamic adjustment of the drug depending on the cur-
mally tolerated dose is the recommended first-line treatment rent BP. For patients with acute ischemic stroke otherwise eli-
for hypertension in CKD patients with urinary albumin-to- gible for intravenous thrombolysis with BP > 185/110 mm Hg
creatinine ratio ≥30 mg/g (or equivalent). If one class is not before or during infusion, or BP > 180/105 mm Hg after treat-
tolerated, the other is substituted. These medications should ment, the recommended pharmacologic agent is Nicardipine 1–
not be discontinued unless serum creatinine level rise above 5 mg/h. IV, titrated up by 2.5 mg/h. every 5–15 min, with maxi-
30% over baseline during the first 2 months of treatment or mum of 15 mg/h. If available, labetalol 10 mg IV over 1–2 min fol-
hyperkalemia (serum potassium level ≥ 5.6 mmol/L). If the lowed by continuous IV infusion of 2–8 mg/min may also be used.
patient is intolerant to both ACE inhibitor and angiotensin recep-
tor blocker, a non-dihydropyridine calcium channel blocker (ver- Clinical question 17.1. For adults with AIS who are not eligible for
apamil or diltiazem) may be used as first line treatment in this IV thrombolysis or mechanical thrombectomy, what is the target BP
setting. and threshold for pharmacological treatment?
13.2 Combinations of ACE inhibitor and Angiotensin receptor blocker Statement:
and of ACE inhibitors or angiotensin receptor blockers with 17.1 For adults with AIS who are not eligible for IV thrombolysis or
direct renin inhibitors should not be used. mechanical thrombectomy, it is recommended to maintain a tar-
get mean arterial pressure (MAP) of 110–130 mm Hg.
Clinical question 14. Among patients with CKD with resistant
hypertension, is the addition of mineralocorticoid receptor antago- For adults with AIS who are not eligible for IV thrombolysis or
nist beneficial in reducing albuminuria and CV events? mechanical thrombectomy, the threshold for urgent antihypertensive
 17517176, 2021, 9, Downloaded from https://onlinelibrary.wiley.com/doi/10.1111/jch.14335 by Cochrane Philippines, Wiley Online Library on [09/05/2023]. See the Terms and Conditions (https://onlinelibrary.wiley.com/terms-and-conditions) on Wiley Online Library for rules of use; OA articles are governed by the applicable Creative Commons License
1644 ONA ET AL.

treatment is with severe hypertension of Systolic BP >220 mm Hg or to be the most important risk factor for both ischemic and hemorrhagic
Diastolic BP >120 mm Hg. If with severe hypertension, it might be rea- strokes. Therefore, adequate BP control plays a significant role in sec-
sonable to reduce the BP by 15% during the first 24 h after the onset of ondary stroke prevention.
stroke. V. Management of hypertension in pregnancy
Clinical question 17.2. For adults with AIS who are not eligible for Hypertensive disorders of pregnancy constitute one of the major
IV thrombolysis or mechanical thrombectomy, what pharmacological causes of maternal and perinatal morbidity and mortality worldwide.
agent may be used to achieve target BP, when needed? It has been estimated that preeclampsia complicates 2–8% of all preg-
Statement: nancies globally.
17.2 For adults with AIS who are not eligible for IV thrombolysis or Clinical question 20. What are the different types of hyperten-
mechanical thrombectomy, the use of IV nicardipine to achieve sive disorders of pregnancy (HDP) and what are the criteria for
the target BP may be considered. each?24,25

Clinical question 18.1. For adult patients with acute hypertensive 1. Pre-eclampsia- Elevated blood pressure and proteinuria.
parenchymal intracerebral hemorrhage (ICH), what is the threshold 1.1 Elevated blood pressure defined as
for BP lowering in the first few hours upon presentation at the emer- 1.1.1 Systolic blood pressure of 140 mm Hg or more or dias-
gency room? tolic blood pressure of 90 mm Hg or more on two occa-
Statement: sions at least 4 h apart after 20 weeks of gestation in a
woman with a previously normal blood pressure.
18.1 For adult patients with acute ICH, the threshold for BP lowering
1.1.2 Systolic blood pressure of 160 mm Hg or more diastolic
is SBP ≥ 180 mm Hg.
blood pressure of 110 m Hg or more. (Severe hyperten-
sion can be confirmed within a short interval (minutes)
Clinical question 18.2. What would be the target BP when lowering
to facilitate timely antihypertensive therapy).
the blood pressure in acute ICH?
1.2 Proteinuria (26)
Statement:
1.2.1 300 mg or more per 24 h urine collection (or this amount
18.2 The target SBP is <180 mm Hg. In patients with SBP ≥180 mm
extrapolated from a timed collection), or
Hg, careful BP lowering to 140 to 160 mm Hg should be consid-
1.2.2 Protein/creatinine ratio of 0.3 mg/dl or more or
ered. The magnitude of BP reduction is dependent on the clinical
1.2.3 Dipstick reading of 2+ (used only if other quantitative
context. It should be careful SBP lowering (avoiding reductions
methods not available)
≥60 mm Hg in 1 h).
1.3 Or in the absence of proteinuria, new onset hypertension with
■ It is recommended to keep the blood pressure stable and
the new onset of any of the following:
avoid variability.
1.3.1 Thrombocytopenia: Platelet count < 100,000 × 109 /L
■ It is also recommended not to lower the BP acutely to
1.3.2 Renal insufficiency: Serum creatinine concentrations
<140 mm Hg
>1.1 mg/dl or a doubling of the serum creatinine con-
centration in the absence of other renal disease
Clinical question 18.3. What are the pharmacologic agents of
1.3.3 Impaired liver function: Elevated blood concentrations
choice and manner of administration?
of liver transaminases to twice normal concentration
Statement:
1.3.4 Pulmonary edema
18.3 It is recommended to use intravenous antihypertensive agents 1.3.5 New-onset headache unresponsive to medication and
that can easily be titrated to lower the BP to the desired level. not accounted for by alternative diagnoses or visual
The 1st line drug of choice is IV Nicardipine. Alternative treat- symptoms
ment choice would be labetalol, when available. 1.4 Eclampsia- New-onset tonic-clonic, focal, or multifocal
seizures in the absence of other causative conditions such as
Clinical question 19. For adults who have a history of stroke, what epilepsy, cerebral arterial ischemia and infarction, intracranial
is the target blood pressure level for secondary prevention? hemorrhage, or drug use.
Statement: 1.5 Chronic Hypertension- Hypertension of any cause, that pre-
19. For adults with history of stroke, the target blood pressure level dates pregnancy. BP ≥ 140/90 mm Hg before pregnancy or
for secondary prevention is ≤ 130/80 mm Hg. RAS blockers, CCBs and before 20 weeks gestation or both.
thiazide diuretics remain to be the first-line pharmacologic agents in 1.6 Chronic Hypertension with Superimposed Pre-eclampsia-
hypertension management for secondary stroke prevention.22 Chronic hypertension in association with preeclampsia. Oth-
A patient with a history of stroke will most likely have another stroke ers define it as worsening baseline hypertension accompa-
in his lifetime. In the United States, recurrent strokes make up almost nied by new-onset proteinuria or other findings supportive of
25% of the nearly 800,000 strokes annually.23 Hypertension remains preeclampsia.
 17517176, 2021, 9, Downloaded from https://onlinelibrary.wiley.com/doi/10.1111/jch.14335 by Cochrane Philippines, Wiley Online Library on [09/05/2023]. See the Terms and Conditions (https://onlinelibrary.wiley.com/terms-and-conditions) on Wiley Online Library for rules of use; OA articles are governed by the applicable Creative Commons License
ONA ET AL. 1645

TA B L E 2 Summary of blood pressure thresholds and targets for persons with stroke

BP threshold for initiating

Context pharmacotherapy Blood pressure targets Preferred agents
In-hospital Mgt Refer to Neurologist for Intravenous titratable anti-hypertensives
specialist management
Acute Ischemic Stroke (AIS), >185/110 mm Hg <185/110 mm Hg prior to Nicardipine 1–5 mg/h IV, titrate up by
eligible for IV thrombolysis thrombolysis and during infusion; 2.5 mg/h every 5–15 min, with maximum
but not for mechanical 180/105 mm Hg in the next 24 h of 15 mg/h.
thrombectomy If available: alternative of labetalol 10 mg
IV over 1–2 min followed by continuous
IV infusion of 2–8 mg/min.
AIS, not eligible for IV Severe hypertension: If with severe hypertension, reduce IV Nicardipine as indicated above
thrombolysis or mechanical SBP of > 220 mm Hg the BP by 15% during the first
thrombectomy DBP of > 120 mm Hg 24 h after the onset of stroke
Intracerebral Hemorrhage SBP ≥180 mm Hg <180 mm Hg First choice: IV NicardipineSecond choice:
(ICH) Careful SBP lowering, avoiding IV labetalol
reductions ≥60 mm Hg in 1 h
Do not lower the BP acutely to
<140 mm Hg
Secondary preventionAdults 140/90 mm Hg ≤ 130/80 mm Hg First line: RAS blockers (ACE-Inh, ARB),
with history of stroke CCBs and thiazide diuretics

FIGURE 2 Algorithm for blood pressure management at the emergency room in acute stroke patients
 17517176, 2021, 9, Downloaded from https://onlinelibrary.wiley.com/doi/10.1111/jch.14335 by Cochrane Philippines, Wiley Online Library on [09/05/2023]. See the Terms and Conditions (https://onlinelibrary.wiley.com/terms-and-conditions) on Wiley Online Library for rules of use; OA articles are governed by the applicable Creative Commons License
1646 ONA ET AL.

For patients with chronic hypertension, it can be difficult to differen- Statement:

tiate worsening of the hypertension from superimposed preeclampsia. 24. The choice of antihypertensive drug for initial therapy should be
Conditions that may indicate superimposed preeclampsia, that war- based on the characteristics of the patient, contraindications to a par-
rants a referral to a maternal fetal medicine specialist/perinatologist, ticular drug and physician and patient preferences. The first line drugs
include the following: are methyldopa, calcium channel blockers or beta blockers, and ACE-
inhibitors and angiotensin-receptor blockers (ARBs) are generally not
1. Acute, severe, and persistent elevations in blood pressure. recommended. Antihypertensives may be used to keep systolic blood
2. Sudden increase in baseline hypertension. pressure at 130 to 155 mm Hg and diastolic blood pressure at 80 to
3. New-onset proteinuria or sudden increase in proteinuria. 105 mm Hg.
1.7 Gestational Hypertension – Clinical question 25: How is hypertension managed during the
1.7.1 Systolic blood pressure 140 mm Hg or more or a dias- immediate postpartum and breastfeeding periods?
tolic blood pressure of 90 mm Hg or more, or both, on Statement:
two occasions at least 4 h apart after 20 weeks of ges- 25. Blood pressure should be recorded shortly after birth and if nor-
tation, in a woman with a previously normal blood pres- mal again within 6 h.
sure. All women should have BP recorded and discharge deferred for at
1.7.2 Hypertension without proteinuria or severe features least 24 h or until vital signs are normal and/or treated or referred. Any
develops after 20 weeks of gestation and blood pressure woman with an obstetric complication and/or newborn with complica-
tions should stay in the hospital until both are stable.
Clinical question 21. What blood pressure threshold is used to
define hypertension in pregnancy? ∙ In hospital stay for at least 24 h
Statement: ∙ Checkup within 48–72 h of the birth and again 7–14 days and at
21. Hypertension is diagnosed empirically when appropriately taken 6 weeks post-partum.
blood pressure is 140 mm Hg systolic or 90 mm Hg diastolic or above. ∙ All women should be reminded of the danger signs of preeclamp-
Korotkoff phase V is used to define diastolic pressure. sia following birth including headaches, visual disturbances, nausea,
Clinical question 22. What antihypertensive agents can be used for vomiting, epigastric or hypochondrial pain, feeling faint or convul-
urgent blood pressure control in pregnancy? sions.
Statement:
22. Acute-onset severe hypertension (systolic BP of 160 mm Hg or VI. Blood pressure management in the pediatric population
more or diastolic BP of 110 mm Hg or more, or both) can occur in Clinical question 26. Among pediatric patients, what is the thresh-
the prenatal, intrapartum and postpartum period. It is accurately mea- old for commencing pharmacologic treatment for Hypertension?
sured using standard techniques and is persistent for 15 min or more. Statements:
The first line of treatment is intravenous (IV) hydralazine and labetalol; 26.1 Pharmacologic treatment for hypertension (HTN) should be
intravenous nicardipine is also an option. Extended release oral nifedip- started for children with the following conditions:
ine also may be considered as a first line therapy, particularly when
IV access is not available. Use of these drugs does not require cardiac 26.1.1 Children who remain hypertensive even after 6 months of
monitoring. lifestyle modification strategies* (see Table 3
Clinical question 23. When do we treat hypertension during preg- 26.1.2 Symptomatic hypertension or Stage 2 hypertension
nancy? 26.1.3 Presence of co-morbidities like chronic kidney disease
Statement: (CKD) or diabetes mellitus (DM), or any evidence of target
23. Treatment of severe hypertension (blood pressure organ involvement (eg, left ventricular hypertrophy).
of ≥ 160/100 mm Hg) is always recommended as it prevents seri-
ous maternal and fetal complications to set in. 26.2. The goal of pharmacologic therapy should be a reduction in
Initiating therapy in non-severe disease, however, is a patient of systolic blood pressure (SBP) and diastolic blood pressure (DBP) to
controversy. The NICE, ISSHP and SOGC recommends therapy when <90th percentile for age, sex and height and <120/80 mm Hg in ado-
the blood pressure remains above 140/90 mm Hg but SOGC sug- lescents ≥13 years of age.
gests a lower threshold in patients with other co-morbidities.26–29 The 26.3. For children with CKD, BP targets should be less than or equal
ACOG recommends conservative management of non-severe disease to 50th percentile for age, sex and height.
but stressed on the importance of control in the severe type.30 It is also 26.4. The goal of treatment of hypertension in the pediatric popula-
important to avoid hypotension because the degree by which placental tion is not only to reduce BP to <90th percentile for age, sex and height
blood flow is auto-regulated is not established, and aggressive lowering and <130/80 mm Hg, but also to reduce CV risk factors, and prevent
may cause fetal distress. target organ damage.
Clinical question 24. What are the pharmacologic treatment 26.5. Follow-up every 4–6 weeks is recommended for monitoring
options in the OPD management of hypertension in pregnancy? and evaluation of therapy.
 17517176, 2021, 9, Downloaded from https://onlinelibrary.wiley.com/doi/10.1111/jch.14335 by Cochrane Philippines, Wiley Online Library on [09/05/2023]. See the Terms and Conditions (https://onlinelibrary.wiley.com/terms-and-conditions) on Wiley Online Library for rules of use; OA articles are governed by the applicable Creative Commons License
ONA ET AL. 1647

TA B L E 3 Blood pressure stages in filipino pediatric population31 )

Filipino children 1–13 years Filipino children ≥ 13 years

Normal BP: <90th percentile Normal BP: <120/<80 mm Hg
Elevated BP: ≥90th percentile to <95th percentile or 120/80 mm Hg to <95th Elevated BP: 120/<80 to 129/<80 mm Hg
percentile (whichever is lower)
Stage 1 HTN: ≥95th percentile to <95th percentile + 12 mm Hg, or 130/80 to Stage 1 HTN: 130/80 to 139/89 mm Hg
139/89 mm Hg (whichever is lower)
Stage 2 HTN: ≥95th percentile + 12 mm Hg, or ≥140/90 mm Hg (whichever is lower) Stage 2 HTN: ≥140/90 mm H

Clinical question 27. What advice regarding nonpharmacologic as the initial antihypertensive drug unless with absolute contraindica-
treatment is recommended for pediatric patients? tions. Referral to a specialist is highly recommended.
Statements: 29.3 Therapy should start with a single drug at the lowest possible
27.1 Non-pharmacologic therapy of lifestyle modification which dose and titrated up every 2–4 weeks until target BP is achieved, or the
include Dietary Approaches to Stop Hypertension (DASH) and engag- maximal dose reached, or adverse effects occur.
ing in 30–60 min of moderate to vigorous physical activity at least 3–5 29.4 If BP is not controlled with a single agent (maximal dose is
days a week should be initiated in all pediatric patients consulting for reached or adverse effects occur), a second agent can be added to the
the first time for hypertension. regimen and titrated as with the initial drug. Because the use of other
27.2 All children with hypertension should have their body mass anti-hypertensive agents can lead to compensatory salt and water
index (BMI) measured during each visit. retention, the addition of a thiazide diuretic to an initial drug for uncon-
27.3 Weight loss intervention is recommended for identified over- trolled hypertension is prudent.
weight and obese children until a normal BMI is attained through 29.5 In combining agents from different drug classes, it is prefer-
dietary counselling and exercise (weight loss of 1 to 2 kg per month). able to give those with complementary modes of action. Ideally, no two
27.4 All children diagnosed to have hypertension or elevated BP drugs which act separately on the RAAS, should be used in combina-
should be advised to do the following: tion because of the risk of hyperkalemia, impaired kidney function and
hypotension.
27.4.1 Decrease intake of high sodium content and calorie-dense Clinical question 30: What is the recommended technique and BP
food and beverages, and to increase intake of fruits and veg- device for accurate BP measurement in pediatric patients?
etable to 3–5 servings per day. Statements:
27.4.2 Engage in moderate-to-vigorous exercise 30–60 min at 30.1 The use of proper technique and appropriately-sized cuff is
least 3–5 times a week but preferably daily, unless with medi- critical for the accurate measurement of BP in children.
cal contraindication. 30.2 An auscultatory device using an aneroid non-mercury sphyg-
27.4.3 Avoid smoking including electronic cigarettes and expo- momanometer is recommended for children.
sure to tobacco smoke. 30.3 An oscillometric device is a suitable alternative to auscultation
27.4.4 Avoid alcohol intake and caffeinated energy drinks. for initial BP screening and monitoring in the pediatric population.
30.4 Ambulatory BP monitoring (ABPM) is recommended in chil-
Clinical question 28. What are the BP targets for prevention of tar- dren (> 5 years old) and adolescents with the following conditions:
get organ complications?
Statements: 30.4.1 Elevated office BP measurements for one or more years, or
28.1 The target BP for children is <90th percentile for age, sex and if with stage 1 hypertension over 3 clinic visits, for confirma-
height or <120/<80 mm Hg whichever is lower. tion of hypertension.
28.2 For CKD patients, BP target is less than or equal to the 50th 30.4.2 Those with high-risk conditions (eg, obesity, CKD or struc-
percentile for age, sex and height. tural renal abnormalities, diabetes mellitus, those who have
Clinical question 29. What are the preferred medications for chil- undergone solid organ transplant, obstructive sleep apnea,
dren? repaired aortic coarctation) to document masked hyperten-
Statements: sion.
29.1 Any of the following drugs may be used as initial treat- 30.4.3 Those with suspected white coat hypertension (WCH).
ment for children with hypertension: ACE inhibitors (Enalapril, Cap-
topril), ARBs (Losartan, Valsartan), or calcium channel blockers 30.5 Home BP monitoring should not be used to diagnose hyperten-
(Amlodipine). sion, MH, or WCH but may be a useful adjunct to office and ambula-
29.2 For children with co-existing chronic kidney disease, protein- tory BP measurement if clinically validated oscillometric apparatus and
uria or diabetes mellitus, an ACE-inhibitor or ARB is recommended appropriate-sized cuffs are used.
 17517176, 2021, 9, Downloaded from https://onlinelibrary.wiley.com/doi/10.1111/jch.14335 by Cochrane Philippines, Wiley Online Library on [09/05/2023]. See the Terms and Conditions (https://onlinelibrary.wiley.com/terms-and-conditions) on Wiley Online Library for rules of use; OA articles are governed by the applicable Creative Commons License
1648 ONA ET AL.

FIGURE 3 Treatment algorithm for hypertension in the pediatric population

4 CONCLUSIONS The 2020 CPG is designed to be a guide for clinicians in managing

hypertension for the Filipino patient. This, however, should not replace
The clinical questions and statements in this clinical practice guideline sound clinical judgment, and the ultimate decision for treatment should
allow us to holistically manage the Filipino hypertensive individual. We be shared by both clinician and the patient.
recommend that the diagnosis of hypertension among adults should be
based on a BP reading of equal or more than 140/90 mm Hg. The tar- ACKNOWLEDGMENTS
get BP should be less than 130/80 mm Hg to prevent hypertension- The authors would like to express their gratitude to the members of
mediated organ damage. We also recommend that lifestyle modifica- the steering committee and the representatives of the different med-
tion be advised to all persons with hypertension. The use of appropri- ical organizations who comprised the expert panel, for their valuable
ate anti-hypertensive medications depending on the co-morbidity of inputs during the creation of the guidelines.
the individual is recommended. We also recommended management
for the pediatric and the pregnant hypertensive. Simplified algorithms STEERING COMMITTEE
are provided to serve as a quick reference guide to clinicians. There was Dr. Gilbert C. Vilela (Philippine Heart Association)
limited Filipino data, particularly in the pediatric population thus, local Dr. Alberto A. Atilano (Philippine Society of Hypertension)
studies are needed to collect real-world data on the use of various med- Dr. Aurelia G. Leus (Philippine Heart Association)
ications in various populations, and even of the utility of this practice Dr. Felix Eduardo R. Punzalan (Philippine Society of Hypertension)
guideline. Expert Panel
 17517176, 2021, 9, Downloaded from https://onlinelibrary.wiley.com/doi/10.1111/jch.14335 by Cochrane Philippines, Wiley Online Library on [09/05/2023]. See the Terms and Conditions (https://onlinelibrary.wiley.com/terms-and-conditions) on Wiley Online Library for rules of use; OA articles are governed by the applicable Creative Commons License
ONA ET AL. 1649

(Cardiology Group) Dr Gabriel Jasul reports honorari as part of the speaker’s bureau
Joanna Cosare-San Pedro, MD of Boehringer Ingelheim , MSD, Sanofi-Aventis, Novo Nordisk, LRI-
Julius Caesar D. De Vera, MD Therapharma, Abbott Nutrition, Umed, Astra Zeneca, and J &J
Ramanaya D. Garcia, MD Dr. Ma. Lourdes Bunyi receives speaking grants from Omron.
Joanna Teresa Margarita L. Manalo, MD Dr. Raymond Oliva reports connection to Astellas Pharma Philip-
Irma Marie P. Yape, MD pines, outside the submitted work.
Christian Michael H. Pawhay, MD Dr. Lourdes Ella Gonzalez-Santos reports personal fees for speaking
Eduardo O. Yambao Jr., MD engagements from LRI-Therapharma, Sanofi-Aventis, Servier Philip-
(Nephrology Group) pines, Merck Sharpe and Dohme, Astra Zeneca, Menarini, Novartis,
Christine V. Pascual, MD Natrapharm, Pascual, Amgen; research grant from Cardinal Santos
Marichel Pile-Coronel, MD Medical Center, outside the submitted work.
Gelen Vestalez Umali-Sunga, MD Dr. Dolores Bonzon is receiving speaking grants from Viatris.
(Pediatrics Group) All authors of this manuscript fulfilled the ICMJR criteria for author-
Emely G. Anupol, MD ship:
Juliet J. Balderas, MD
Jose Jonas D. Del Rosario, MD ∙ Substantial contributions to the conception or design; or the acqui-
Bee Jane T. Martinez, MD sition, analysis or interpretation of data for the work
Leah Patricia A. Plucena, MD ∙ Drafting the work or revising it critically for important intellectual
Andrea Orel S. Valle, MD content
Eleanor C. Du, MD (Philippine Society of Pediatric Metabolism and ∙ Final approval of the version to be published
Endocrinology) ∙ Agreement to be accountable for all aspects of the work in ensuring
Sylvia C. Estrada, MD (Philippine Society of Pediatric Metabolism that questions related to the accuracy or integrity of any part of the
and Endocrinology) work are properly investigated and resolved
Maria Rosario F. Cabansag, MD (Pediatric Nephrology Society of the
Philippines ) ORCID
Lorna Lourdes L. Simangan, MD (Pediatric Nephrology Society of Deborah Ignacia D. Ona https://orcid.org/0000-0002-7150-1051
the Philippines )
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