BACKGROUND

Diabetes mellitus (DM) is a significant and growing global health concern. Worldwide, 537 million adults have diabetes and 206 million of them are from the Western Pacific Region1. Local prevalence continues to remain high at 7.5%, with 4,303,899 adult Filipinos suffering from diabetes in 2021. DM significantly contributes to the growing burden of chronic kidney disease (CKD) worldwide with about 50% of end-stage renal disease (ESRD) being due to diabetic nephropathy alone. Likewise, 60% of Filipinos on maintenance dialysis have ESRD due to DM and hypertension. The primary care setting is the initial point of contact between healthcare providers and patients with type 2 diabetes, hence, the development of clinical practice guidelines that will provide guidance in caring for patients with stable complications of diabetes. The guideline is the first of 3 that are being developed by the Philippine Academy of Family Physicians for the diagnosis and management of adult patients with type 2 diabetes and stable microvascular complications – nephropathy, retinopathy and neuropathy.

OBJECTIVE

This guideline aims to provide evidence-based recommendations on the diagnosis and management of adults with type 2 diabetes mellitus (T2DM) and early stage CKD and is divided into 5 main sections – Clinical Assessment, Diagnostic Tests, Pharmacologic Treatment, Non-pharmacologic Treatment and Patient Outcomes.

METHODS

The method of guideline development followed the ADAPTE process. The Technical Working Group identified 19 key questions after consultation with colleagues and patients. Recommendations were adopted from high-quality clinical practice guidelines whenever applicable for most of the key clinical questions. On the other hand, the De Novo method of evidence review was used to answer key clinical questions for which recommendations from reviewed guidelines were not available. A modified GRADEPro was used in assessing the quality of evidence – high, moderate, low or very low. Following external review by a nephrologist, the draft recommendations were sent to the members of the consensus panel. Voting on whether to include or not by the consensus panel was facilitated to determine the strength of each recommendation – strong, moderate or weak.

RECOMMENDATIONS

After reviewing 3 high-quality clinical practice guidelines and the current evidence, the technical working group was able to develop 40 recommendations for the 19 key clinical questions.

Human ; Diabetes Mellitus, Type 2 ; Kidney Failure, Chronic ; Practice Guideline

Research agenda are identified following the process of research priority setting which generally serves to guide resource allocation, address the identified needs of the stakeholders, and reinforce the link between research and actions and policies. The 2023-2028 PAFP Research Agenda was developed in three (3) phases - preparation, implementation and dissemination. An online survey was sent to the general membership through the regions, chapters and training institutions to determine priority research topics based on the National Unified Health Research Agenda and World Organization of Family Doctors (NUHRA and WONCA) research themes. Responses were collated and categorized in the appropriate research themes through an iterative process. A research agenda setting workshop was held with participants from the different stakeholders, which was facilitated by members of the working committee on research agenda and grants. Research themes and research questions were generated and compiled. There were forty-four (44) sub themes generated which align with the research themes of the 2023-2028 NUHRA and with the goal of the universal healthcare act. Majority of these sub themes fall under the themes, disease management and health systems strengthening towards UHC and support information generation on topic areas that are pertinent to the PAFP’s organizational missions - use of clinical pathways and clinical practice guidelines, continuous quality improvement, Patient-centered, Family-focused and Community-oriented approach to care, patient education and counseling, primary care models, family and community practice, family medicine in basic medical education and the role of a Family Physician in UHC.

Introduction: Uncontrolled hypertension can lead to increased morbidity and mortality secondary to end-organ damage. Community-based health interventions promote health changes in a community setting and have been shown to promote better and more cost-effective healthcare. Existing meta-analyses on community-based interventions in hypertension control are confined to a certain country, have high risks of bias, and have shown heterogeneous results. A gap in the applicability of these conclusions necessitates the present study Objective: Synthesize available evidence on the effectiveness of community-based interventions in addition to standard of care in the control of blood pressure among hypertensive adults. Methods: A meta-analysis of randomized and non-randomized controlled trials among hypertensive adults was conducted. A literature search from various search engines and electronic databases such as PubMed, Cochrane Central Register of Controlled Trials (CENTRAL) in The Cochrane Library, Google Scholar, Proquest, medRvix, and Grey literature was done by the investigators. Separate forest plots were generated for each desired outcome. Results: Six studies were included. The pooled estimates showed a trend in favor of community-based interventions in the control of blood pressure [RR = 0.86, 95% CI 0.62 to 1.19, p = 0.37], reduction of systolic blood pressure, reduction of diastolic blood pressure [MD = -2.52, 95% CI -3.64 to -1.28, p < 0.001] and medication adherence [RR = 0.82, 95% CI 0.72 to 0.93, p = 0.0025]. However, there was high heterogeneity across studies. Subgroup analysis showed a favorable trend with lower heterogeneity in decreasing diastolic BP in particular, among community health worker-led interventions, and those involving health education and/or physical activity Conclusions/Recommendations Adherence to the current standard of care in the management of hypertension is still advised. There appears to be a trend towards control of blood pressure with community-based interventions; and a reduction of diastolic blood pressure with interventions that are led by community health workers involving health education and/or physical activity. There is a need to empower community health workers and conduct additional studies on the specific community-based interventions targeting communities as a whole whenever resources and current health restrictions allow
Hypertension ; Systematic Review ; Meta-Analysis

Background: Diarrhea is among the common causes of morbidity and mortality in children. It is defined as the passage of three or more loose or liquid stools per day (or more frequent passage than is normal for the individual). It does not include frequent passing of formed stool and passing of loose, pasty stools by breastfed babies. It is usually a symptom of an infection in the intestinal tract, caused by variety of organisms, which is spread through contaminated food or drinking water, or from person-to-person as a result of poor hygiene. Diarrhea can last several days and can leave the body without the water and salts that are necessary for survival causing significant number of mortality and morbidity among children. At the level of primary care, diagnosis, management and treatment of food- and waterborne-diseases, which commonly present as diarrhea, lack the necessary protocols and standards, thus, the creation of this clinical pathway. Objective: The main goal of this clinical pathway was to provide guidance to family and community physicians, and other primary care physicians in managing acute diarrhea among immunocompetent pediatric patients. Methods: ADAPTE process was used in CPG development. Existing guidelines on acute diarrhea among pediatric patients were retrieved and appraised using the AGREE II tool. Recommendation statements from the guidelines that passed the AGREE II tool were reviewed. Recommendation statements that will help answer the clinical questions posed in the creation of the clinical pathway were adapted. For clinical questions were not answered by the available guideline recommendations, a de novo method was conducted. The adapted recommendation statements and the supporting summary of evidences were sent for external review prior to consensus development. Suggestions provided in both steps were discussed and incorporated in the final manuscript, as appropriate. Key Recommendation Statements: These key recommendation statements addressing the clinical assessment, diagnosis, interventions (pharmacologic and nonpharmacologic), and patient outcomes that are relevant in the outpatient or primary care setting in the Philippines were based on the summarized key evidences from the systematic review of literature conducted using the ADAPTE process. Clinical Assessment Recommendation 1. A focused medical history that includes questions on duration, frequency, characteristics, associated symptoms, consumption of raw, ill-prepared, or rotten food; intake of antibiotics, contaminated food or water; and history of travel should be obtained. (Strong recommendation, High quality evidence) Recommendation 2. Physical examination should be done to assess the nutritional status, degree of dehydration, severity of disease, and presence of complications and comorbid conditions. (Strong recommendation, High quality evidence) Recommendation 3. Degree of dehydration should be classified into No Dehydration, Mild to Moderate Dehydration, or Severe Dehydration. (Weak recommendation, Moderate quality evidence) Recommendation 4. Children with acute infectious diarrhea who have any of the following conditions should be admitted to the hospital: severe dehydration, inability to tolerate fluids orally, suspected electrolyte abnormalities, altered consciousness, abdominal distention, respiratory distress, pneumonia, meningitis/encephalitis, sepsis, moderate to severe malnutrition, suspected surgical condition, or conditions for safe follow-up and home management are not met. (Strong recommendation, High quality evidence) Diagnostic Tests Recommendation 5. Routine diagnostic tests are not necessary among children with acute diarrhea. (Strong recommendation, Low quality evidence) Recommendation 6. Stool examination may only be requested if the patient present with moderate to severe condition, bloody diarrhea, or amoebiasis and parasitism is being considered at time of epidemic. (Strong recommendation, High quality evidence) Recommendation 7. Diagnostic tests may be requested if concomitant conditions like pneumonia, urinary tract infection, sepsis or meningitis are suspected; or if abdominal distension is observed post-hydration. (Strong recommendation, High quality evidence) Recommendation 8. Stool culture, serologic test, rapid diagnostic test, PCR determination and serum biomarkers are not recommended in family and community practice. (Strong recommendation, High quality evidence) Pharmacologic Treatment Recommendation 9. Reduced osmolarity oral rehydration solution (ORS), commercial or home-made is recommended to replace previous and ongoing losses. (Strong recommendation, High quality evidence) Recommendation 10. The volume and frequency of reduced osmolarity oral rehydration solution (ORS) should be dependent on patient’s age or weight, severity of dehydration and ongoing losses. (Strong recommendation, High quality evidence) Recommendation 11. Severe dehydration should be managed in the hospital with intravenous hydration. (Strong recommendation, High quality of evidence) Recommendation 12. Routine empiric antibiotic treatment is not recommended in children with acute infectious diarrhea. (Strong recommendation, Very low quality evidence) Recommendation 13. Antibiotic treatment may be given to children with Cholera, Shigella, typhoidal Salmonella, amoebiasis, and giardiasis. The choice of antibiotic must be guided by the local Antibiotic Surveillance Program. (Strong recommendation, High quality evidence) Recommendation 14. In general, antibiotic treatment should not be given in children with non-typhoidal Salmonella. It may be given in children with underlying conditions i.e., immunodeficiency, corticosteroid or immunosuppressive therapy. (Strong recommendation, Very low quality evidence) Recommendation 15. Among children older than six months, zinc supplementation of 10-20 mg per day for 10-14 days may be offered to reduce the duration and severity of diarrhea, and recurrence in the next two to three months (Strong recommendation, High quality evidence) Recommendation 16. Racecadotril may be offered to reduce ongoing loss of water and electrolytes. (Strong recommendation, High quality evidence) Recommendation 17. Probiotics may be offered to reduce the duration of diarrhea. Lactobacillus rhamnosus GG (LGG), Saccharomyces boulardii and Lactobacillus reuteri are strains with evidence of effectiveness. (Strong recommendation, High quality evidence) Recommendation 18. Anti-emetics and antidiarrheal drugs are generally not recommended because of their side-effects. (Strong recommendation, High quality evidence) Non-pharmacologic Interventions Recommendation 19. Among children with acute diarrhea, age-appropriate feeding should be continued. There is no need to modify or restrict diet. (Strong recommendation, Moderate quality of evidence) Recommendation 20. Among infants with diarrhea, breastfeeding must be continued. (Strong recommendation, High quality evidence) Recommendation 21. If diet was restricted because of frequent vomiting, early refeeding must be done. (Strong recommendation, Moderate quality evidence) Recommendation 22. All members of the family must be encouraged regular hand washing with soap and water. (Strong recommendation, Moderate quality evidence) Recommendation 23. Family members must observe proper food handling, have access to safe drinking water, and observe proper waste disposal. (Strong recommendation, Low quality evidence) Recommendation 24. Community level intervention that encourages hand washing, proper food handling, appropriate waste disposal and ensuring safe drinking water must be done. (Strong recommendation, Low quality evidence) Expected Patient Outcomes Recommendation 25. After each encounter the patient or guardian must understand the nature of acute diarrhea, its management and potential complications. (Strong recommendation, Low quality evidence) Recommendation 26. The management plan must be a mutual agreement between the family physician and the guardian. (Strong recommendation, Low quality evidence) Recommendation 27. For the management of a child with acute diarrhea, the family physician must target for resolution of dehydration, resolution of diarrhea, prevention of relapse, hospitalization, complications and early detection of adverse events. (Strong recommendation, High quality evidence) Dissemination and Implementation This clinical pathway will be published in the “The Filipino Family Physician” journal, which is accessible in the PAFP journal website. PAFP’s Committee on Research will disseminate the clinical pathway through distribution to its subspecialty and affiliate societies, chapters, training programs, and primary care practitioners; and continuing development sessions of the PAFP. Monitoring of the uptake of the clinical pathway will be through the number of downloads at the website and requests for copies. This clinical pathway may be used as a guide by family and community physician and primary care physicians in a primary care setting. Tabular presentation of the clinical pathway was included as a tool for implementation. Monitoring of implementation will be via continuous quality improvements activities, which can be a self-initiated activity of the member as recommended in the Universal Healthcare, or as a chapter or group activity.