Hypertension Drug Prescriptions and Blood Pressure Management in Singapore's GPs and Polyclinics
10 min read | for healthy hearts
A Health Guide to High Blood Pressure in Singapore
Digital Health Clinic
21 May 2024
Background
Hypertension, or high blood pressure, is a prevalent condition affecting approximately 37% of Singapore residents aged 18 to 74, according to the 2022 National Population Health Survey. This chronic condition significantly increases the risk of cardiovascular diseases (CVD) such as stroke, heart failure, and kidney damage. Effective management through lifestyle interventions, hypertension drug prescriptions, and regular monitoring is critical. In Singapore, general practitioners (GPs) and polyclinics play a pivotal role in diagnosing, treating, and managing hypertension, ensuring patients achieve optimal blood pressure control. This article explores hypertension management, prescription refills, and the role of primary care in Singapore, with a focus on SEO-friendly terms such as hypertension treatment Singapore, blood pressure management, and antihypertensive medications.
Understanding Hypertension and Its Impact in Singapore
Hypertension is defined as a clinic blood pressure (BP) reading of ≥140/90 mmHg (Grade 1 hypertension) or high-normal BP of 130-139/85-89 mmHg. Globally, it affects 1.28 billion people, and in Singapore, over half of those with hypertension were previously undiagnosed, highlighting the need for robust screening and management systems. Uncontrolled hypertension can lead to severe complications, making timely intervention crucial.Primary care settings, including GPs and polyclinics, are the first point of contact for most patients. These facilities are equipped to conduct comprehensive cardiovascular risk assessments, prescribe antihypertensive medications, and provide lifestyle counseling. The Agency for Care Effectiveness (ACE) Clinical Guidance (ACG) on hypertension, published on 15 December 2023, serves as a cornerstone for standardizing care across Singapore’s healthcare system.
Role of GPs and Polyclinics in Hypertension Management
GPs and polyclinics are integral to Singapore’s healthcare ecosystem, offering accessible and cost-effective care. They provide:
- Screening and Diagnosis: Accurate diagnosis is essential, as hypertension management is often lifelong. Clinic BP readings are compared with home or ambulatory BP monitoring (ABPM) to confirm elevated BP. For instance, a clinic BP of 140/90 mmHg corresponds to a home BP of 135/85 mmHg.
- Cardiovascular Risk Assessment: The Singapore-modified Framingham Risk Score (SG-FRS-2023) is used to estimate a patient’s 10-year CVD risk, considering factors like age, sex, smoking status, and comorbidities such as diabetes mellitus (DM) or chronic kidney disease (CKD).
- Patient Education: Engaging patients in discussions about BP management, including the importance of adherence to medications and lifestyle changes, is a key component of care.
- Prescription and Follow-Up: GPs and polyclinics prescribe antihypertensive medications and schedule regular follow-ups to monitor BP and adjust treatment plans.
Hypertension Drug Prescriptions: First-Line Antihypertensives
The ACG recommends angiotensin-converting enzyme (ACE) inhibitors, angiotensin receptor blockers (ARBs), calcium channel blockers (CCBs), or thiazide/thiazide-like diuretics as first-line antihypertensive medications. These drugs have comparable BP-lowering efficacy and are effective in reducing cardiovascular events. Key considerations for prescribing include:
- ACE Inhibitors and ARBs: Preferred for patients with DM or CKD, especially with albuminuria, due to their renoprotective effects. Common drugs include enalapril, lisinopril, losartan, and telmisartan. Side effects may include dry cough (more common with ACE inhibitors) and hyperkalemia.
- CCBs: Dihydropyridine CCBs like amlodipine are suitable for most patients but may cause peripheral edema or flushing. Non-dihydropyridine CCBs (e.g., diltiazem) are avoided in heart failure patients.
- Thiazide/Thiazide-Like Diuretics: An alternative first-line option, preferred for patients with osteoporosis or edema. However, they carry risks of electrolyte imbalance and insulin resistance, particularly in the elderly.
- Beta Blockers (BBs): Not recommended as first-line therapy unless indicated for comorbidities like stable ischemic heart disease or heart failure. Cardioselective BBs (e.g., bisoprolol) are preferred over non-selective ones (e.g., propranolol) for patients with respiratory conditions.
Dual Therapy and Treatment Intensification
For patients requiring significant BP reduction (e.g., systolic BP ≥20 mmHg or diastolic BP ≥10 mmHg above target), low-dose dual therapy with two different antihypertensive classes is recommended. Effective combinations include:
- ACE inhibitor/ARB + dihydropyridine CCB (e.g., lisinopril + amlodipine)
- ACE inhibitor/ARB + thiazide-like diuretic (e.g., losartan + hydrochlorothiazide)
Dual therapy offers greater BP reduction and a better safety profile compared to high-dose monotherapy. Single-pill combinations enhance adherence by reducing pill burden, though they may not suit patients needing individualized dose adjustments.
If BP targets are not achieved within three months, treatment intensification is advised. This may involve increasing the dose, adding another drug class, or switching medications. Before intensification, GPs assess adherence, salt intake, and potential secondary hypertension causes (e.g., renal disease or medication-induced hypertension).
Managing Prescription Refills in Singapore
Prescription refills are a critical aspect of hypertension management, ensuring continuity of care. In Singapore, GPs and polyclinics streamline this process through:
- Electronic Health Records (EHRs): The National Electronic Health Record (NEHR) system allows seamless sharing of patient data, enabling GPs to review medication history and issue refills efficiently.
- Telemedicine and E-Prescriptions: Many polyclinics and private GPs offer teleconsultations, allowing patients to request refills remotely.
- High Cholesterol: Lower LDL cholesterol to below 1.8 mmol/L (or 1.4 mmol/L if you’re at high risk) with statins, ezetimibe, or PCSK9 inhibitors.
- Medication Delivery Services: Pharmacies like Unity and Guardian offer home delivery for prescription refills, particularly beneficial for elderly or mobility-impaired patients.
- Healthier SG Initiative: This program encourages enrollment with a primary care provider for chronic disease management, including regular BP monitoring and prescription refills. Patients can access subsidized medications at polyclinics or participating GPs.
Patients are advised to schedule follow-ups every six months, with more frequent visits (e.g., every three months) for those with high-risk conditions or recent treatment changes. Home BP monitoring complements clinic visits, enabling patients to track trends and share data with their healthcare provider.
Lifestyle Interventions and Adherence Strategies
Lifestyle interventions are foundational to hypertension management. GPs and polyclinics provide personalized advice on:
- Healthy Diet: Reducing sodium intake and alcohol consumption. Resources like the High Blood Pressure: Healthy Eating Guide are recommended.
- Physical Activity: Programs like MOVEIT encourage regular exercise, tailored to patients’ fitness levels.
- Weight Management and Smoking Cessation: Addressing obesity and smoking significantly lowers CVD risk.
To enhance medication adherence, GPs employ strategies such as:
- Patient Education: Explaining how antihypertensives work and the importance of consistent use.
- Simplified Regimens: Prescribing once-daily medications or single-pill combinations
- Reminders: Encouraging the use of pill boxes, smartphone apps, or night-time dosing to minimize side effects.
Specialist Referrals and Resistant Hypertension
GPs and polyclinics refer patients to specialists in cases of:
- Malignant or resistant hypertension (uncontrolled BP despite three or more medications)
- Suspected secondary hypertension (e.g., due to primary aldosteronism or renal disease)
- Hypertension in special populations (e.g., pregnant women or children)
- Acute cardiovascular complications
Resistant hypertension requires careful evaluation of adherence, standardized BP measurement, and exclusion of substances that elevate BP (e.g., NSAIDs or oral contraceptives). Specialist input ensures tailored management for complex cases.
Home BP Monitoring and Follow-Up
Home BP monitoring is encouraged to:
- Track long-term BP trends
- Reduce clinic visits through telemonitoring
- Identify white-coat or masked hypertension
- Enhance patient engagement and adherence
Patients are educated on proper techniques, with resources accessible via QR codes in the ACG. Follow-up schedules are tailored to clinical needs, with high-risk patients requiring more frequent reviews.
Conclusion: Taking Control of Your Health
Hypertension management in Singapore’s GPs and polyclinics is comprehensive, integrating cardiovascular risk assessment, evidence-based pharmacotherapy, and lifestyle interventions. The ACG provides a standardized framework, recommending ACE inhibitors, ARBs, CCBs, or thiazide diuretics as first-line treatments, with dual therapy for significant BP reduction. Prescription refills are streamlined through EHRs, telemedicine, and delivery services, while the Healthier SG initiative enhances chronic disease care. By combining medical expertise with patient-centered strategies, Singapore’s primary care system effectively controls hypertension, reducing the burden of cardiovascular disease.
