Standard Treatment Guidelines (STG) and The National Essential Drug List for Tanzania (NEDLIT): Standard Treatment Guidelines (STG): 4. CARDIOVASCULAR DISEASES: 4.4 Hypertension: 4.4.2 Moderate/Severe Hypertension

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Standard Treatment Guidelines (STG) and The National Essential Drug List for Tanzania (NEDLIT) (WHO; 1997; 210 pages)
	FOREWORD
	ACKNOWLEDGMENTS
	INTRODUCTION
	Standard Treatment Guidelines (STG)
		1. GASTROINTESTINAL CONDITIONS
			1.1 Parasitic Diseases
				1.1.1 Amoebiasis
				1.1.2 Ascariasis (Round Worms)
				1.1.3 Ancylostomiasis (Hookworm Disease)
				1.1.4 Cestodiasis (Tapeworms)
				1.1.5 Filariasis
				1.1.6 Giardiasis
				1.1.7 Strongyloidiasis
				1.1.8 Typhoid and paratyphoid
				1.1.9 Schistosomiasis
			1.2 Bacillary Dysentery
			1.3 Diarrhoea
				1.3.1 Management of diarrhoea in children
				1.3.2 Special Notes on Management
			1.4 Cholera
				1.4.1 Moderate Dehydration
				1.4.2 Severe Dehydration
			1.5 Ulcers and related conditions
				1.5.1 Peptic Ulcer-General Measures
				1.5.2 Oesophageal Ulcer
				1.5.3 Gastric Ulcer
				1.5.4 Duodenal Ulcer
				1.5.5 Non-Ulcer Dyspepsia
				1.5.6 Acute Gastritis
				1.5.7 Gastro-Enteritis (Food Poisoning Viral)
				1.5.8 Ulcerative colitis
			1.6 Other gastro-intestinal problems
				1.6.1 Irritable Bowel Syndrome
				1.6.2 Malabsorption Syndrome
				1.6.3 Tropical Sprue
				1.6.4 Pernicious Anaemia
				1.6.5 Chronic Pancreatitis
				1.6.6 Disaccharides Deficiency
				1.6.7 Peritonitis
				1.6.8 Constipation
				1.6.9 Haemorrhoids and other Peri-Anal Conditions
			1.7 Liver Diseases Conditions
				1.7.1 Liver Cirrhosis
				1.7.2 Acute Liver Failure/Hepatic Encephalopathy
		2. RESPIRATORY DISEASES
			2.1 Acute Respiratory Infections (ARI)
				2.1.1 Pneumonia
				2.1.2 ARI in Children
				2.1.3 Wheezing
				2.1.4 Croup
				2.1.5 Laryngeal Diphtheria
				2.1.6 ARI in Adult
					2.1.6.1 Community Acquired Infections
					2.1.6.2 Hospital Acquired Infections
				2.1.7 Chronic Bronchitis
				2.1.8 Other Respiratory Infections
				2.1.9 Asthma
					2.1.9.1 Chronic Asthma in Adults
					2.1.9.2 Moderate Asthma in Adults
					2.1.9.3 Severe Asthma in Adults
					2.1.9.4 Maintenance therapy in children
				2.1.10 Cough
				2.1.11 Whooping Cough
				2.1.12 Allergic rhinitis
		3. OBSTETRIC AND GYNAECOLOGICAL CONDITIONS AND CONTRACEPTION
			3.1 Infection of the Genital Urinary Tact
				3.1.1 Urinary Tract Infection During Pregnancy
				3.1.2 Positive RPR or Syphilis during pregnancy
				3.1.3 Vaginal Discharge During Pregnancy
			3.2 Abortion
			3.3 Prolonged Rupture Of Membrane (PROM)
			3.4 Prophylaxis for Caesarian Section
			3.5 Nausea and Vomiting in Pregnancy
			3.6 Anaemia During Pregnancy
			3.7 Hypertension in Pregnancy
				3.7.1 Essential Hypertension
				3.7.2 Pregnancy Induced hypertension (PIH)
				3.7.3 Mild PIH
				3.7.4 Moderate PIH
				3.7.5 Severe PIH
				3.7.6 Pre-Eclamptic Toxaemia (Proteinuria PIH)
				3.7.7 Imminent Eclampsia
				3.7.8 Eclampsia (Proteinuria PIH with Fits)
			3.8 Diabetes in Pregnancy
			3.9 Anaesthesia, Analgesia, Antacids
			3.10 Steroids in Respiratory Distress Syndrome
			3.11 Myometrial Stimulants (Oxytocics)
			3.12 Uterine Stimulation After Delivery
			3.13 Myometrial Relaxants (Stimulants)
			3.14 Termination of Pregnancy
			3.15 Drugs in Pregnancy and Lactation
			3.16 Pelvic Inflammatory Diseases
			3.17 Hormonal Contraceptives
				3.17.1 Check List Questions
				3.17.2 Oral Contraceptives
				3.17.3 Drugs Reducing Effect of Oral Contraceptives
				3.17.4 Drugs made less Effective by Oral Contraceptives
				3.17.5 Post Coital Contraception (“morning-after pill”)
				3.17.6 Long Term Hormonal Contraceptives
				3.17.7 Implant Contraceptive
			3.18 Antepartum Haemorrhage (APH)
			3.19 Dysmenorrhoea
			3.20 Infertility
		4. CARDIOVASCULAR DISEASES
			4.1 Infections
				4.1.1 Prophylaxis of Bacterial Endocarditis
				4.1.2 Dental and upper Respiratory Tract Procedure
				4.1.3 Parenteral Regimen Required for Genital-Urinary Procedures
				4.1.4 Patient with Prosthetic Valve
			4.2 Rheumatic Heart Disease
				4.2.1 Rheumatic Fever
				4.2.2 Antibiotics Prophylaxis after Rheumatic Fever
			4.3 Treatment of Acute Arthritis and Carditis
			4.4 Hypertension
				4.4.1 Mild Hypertension
				4.4.2 Moderate/Severe Hypertension
			4.5 Cardiac failure
				4.5.1 Mild to Moderate and Severe Cardiac Failure
				4.5.2 Acute Pulmonary Oedema
				4.5.3 Resistant cardiac failure
			4.6 Angina Pectoris
				4.6.1 Stable Angina/Infrequent Attacks
				4.6.2 Frequent Attacks
			4.7 Myocardial Infarction (Ml)
				4.7.1 General Measures
				4.7.2 Left Ventricular (Pump) Failure
				4.7.3 Arrhythmias
				4.7.4 Tachycardia
				4.7.5 Rehabilitation
				4.7.6 Prevention of Re-infarction
		5. MALARIA
			5.1 General Guidelines
			5.2 Uncomplicated Malaria, Chloroquine Sensitive
			5.3 Uncomplicated Malaria, Chloroquine resistant
			5.4 Malaria due to vivax/ovale
			5.5 Complicated Malaria
				5.5.1 General measure
		6. SKIN DISEASES
			6.1 Bacterial Phyzogenic Skin Infections
				6.1.1 Impetigo
				6.1.2 Folliculitis
				6.1.3 Furunculosis
				6.1.4 Erysipelas
				6.1.5 Acute Cellulitis
				6.1.6 Acne
				6.1.7 Paranychia
			6.2 SKIN FUNGAL INFECTIONS
				6.2.1 Dermatophytosis (Ringworm)
				6.2.2 Tinea Corporis (Body Ringworm)
				6.2.3 Tinea Capitis (Scalp Ringworm)
				6.2.4 Tinea Versicolor (Pityrias Versicolor)
				6.2.5 Tinea Pedis (Athlete's Foot)
			6.3 OTHER FUNGAL DISEASES
				6.3.1 Candidiasis
				6.3.2 Deep Fungal Infections
			6.4 Scabies
			6.5 Herpes Simplex
			6.6 Herpes Zoster (Shingles)
			6.7 Chicken Pox
			6.8 OTHER SKIN DISEASES
				6.8.1 Allergic Contact Dermatitis
				6.8.2 Eczema
				6.8.3 Urticaria
				6.8.4 Psoriasis
				6.8.5 Pellagra
				6.8.6 Depigmented Skin
				6.8.7 Brucellosis (Undulant Fever)
				6.8.8 Lichen Planus
		7. SEXUALLY TRANSMITTED INFECTIONS / DISEASES (STD)
			7.1 General Guidelines
			7.2 Reasoning Behind STD Drug Treatment Regimens
			7.3 Gonorrhoea
			7.4 Chancroid
			7.5 Epididymo-Orchitis
			7.6 Chlamydia Infections
			7.7 Syphilis
			7.8 Genital Warts
			7.9 Trichomoniasis
			7.10 The Syndrome Treatment of STD
				7.10.1 In Men
				7.10.2 In Women
		8. DENTAL AND ORAL CONDITIONS
			8.1 Dental Infections
				8.1.1 Periapical Abscess
				8.1.2 Infected (Dry) Socket
				8.1.3 Periodontal Conditions
				8.1.4 Oral/Mucosal Ulcerations
				8.1.5 Infections of the Oral cavity
				8.1.6 Pericoronitis
				8.1.7 Ludwig's Angina
				8.1.8 Dental Abscess
			8.2 Post Extraction Bleeding
			8.3 Tooth Sensitivities
			8.4 Dental Caries
			8.5 Aphthous Ulcerations
				8.5.1 Minor aphthous ulcers
				8.5.2 Major aphthous ulcers
			8.6 Edentulousness
			8.7 Malocclusions
			8.8 Traumatic Injuries to Teeth in Children
			8.9 Tumours of the Oral Cavity
				8.9.1 Benign Odontogenic Tumours
				8.9.2 Malignant Odontogenic Tumours
				8.9.3 Soft Tissue and Bone Tumours (Non-Odontogenic)
				8.9.4 Lymphomas
			8.10 Shedding of Primary (Milk) Teeth
			8.11 Eruption of Teeth
		9. GENITO-URINARY DISEASES: KIDNEY CONDITIONS
			9.1 Glomerulonephritis
			9.2 Pyelonephritis
			9.3 Nephrotic Syndrome
		10. EAR, NOSE AND THROAT CONDITIONS
			10.1 Otitis (External and Media)
				10.1.1 Otitis External
				10.1.2 Otitis Media
			10.2 Acute Rhinitis and Sinusitis
			10.3 Pharyngotonsillitis
			10.4 Laryngitis
			10.5 Acute Epiglotitis (AE)
		11. EYE CONDITIONS
			11.1 Prevention/Management
			11.2 Red Eye
			11.3 Corneal Abrasion
			11.4 Penetrating Injury
			11.5 Chemical Burns
			11.6 Conjunctivitis
				11.6.1 Conjunctivitis of the Newborn
			11.7 Unilateral
			11.8 Trachoma
			11.9 Xerophthalmia/Vitamin A Deficiency
		12. TUBERCULOSIS AND LEPROSY
			12.1 Tuberculosis
				12.1.1 Control of Tuberculosis
				12.1.2 Case Management
				12.1.3 Treatment Categories
					12.1.3.1 Treatment Guidelines Catagory I
					12.1.3.2 Treatment guidelines Category II
				12.1.4 New Cases Other Than Smear Positive (PT)
				12.1.5 Chronic Cases
			12.2 Leprosy
				12.2.1 General Information about Leprosy
					12.2.1.1 When Leprosy Should be Suspected
					12.2.1.2 Diagnosis of Leprosy
				12.2.2 Classification of Leprosy
					12.2.2.1 Tuberculoid Leprosy
					12.2.2.2 Borderline Leprosy
					12.2.2.3 Borderline Tuberculoid (BT) Leprosy
					12.2.2.4 Borderline Lepromatous (BL) Leprosy
					12.2.2.5 Lepromatous (LL) leprosy
			12.3 Treatment of Leprosy
				12.3.1 Categories of Patients
				12.3.2 Where the Patient should be Treated
				12.3.3 Duration of Treatment
				12.3.4 Procedures During and After Treatment
				12.3.5 Responsibilities During Treatment
			12.4 Prevention of Disabilities and rehabilitation
			12.5 Signs and Treatment of Severe Reversal Reaction (RR)
				12.5.1 Signs and Treatment of severe Erythema Nodosum Leprosum (ENL) Reaction
				12.5.2 Treatment of Mild reaction
				12.5.3 Precautions with Prednisolone
			12.6 Responsibilities
			12.7 How to Look After Ulcers
			12.8 Surveillance of Patients After Release from MDT
			12.9 Referral Criteria of Leprosy Patients
		13. MUSCULOSKELETAL CONDITIONS AND JOINT DISEASES
			13.1 Infections
				13.1.1 Osteomyelitis
				13.1.2 Tropical Pyomyositis
			13.2 Inflammatory Conditions
				13.2.1 General Guidelines
				13.2.2 Rheumatoid Arthritis
				13.2.3 Gout
				13.2.4 Osteoarthritis
		14. METABOLIC AND ENDOCRINE SYSTEM CONDITIONS
			14.1 Diabetes Mellitus
			14.2 Thyroid Diseases
				14.2.1 Hyperthyroidism
				14.2.2 Hypothyroidism
		15. CENTRAL NERVOUS SYSTEM DISEASE CONDITIONS
			15.1 Infections
				15.1.1 Meningitis
				15.1.2 Other CNS Infections
				15.1.3 Tetanus
				15.1.4 Rabies
			15.2 Vascular Headaches
			15.3 Anxiety Neurosis
			15.4 Depressive Psychosis
			15.5 Epilepsies
				15.5.1 Status Epilepticus
				15.5.2 Serial Epilepsy
			15.6 Schizophrenia
			15.7 Alcohol Dependence Syndrome
			15.8 Substance Abuse
		16. OTHER DISEASE CONDITIONS
			16.1 Leishmaniasis
			16.2 Trypanosomiasis
			16.3 Anthrax
			16.4 Mastitis (Breast Abscess)
		17. VIRAL INFECTIONS
			17.1 Measles
			17.2 Poliomyelitis
			17.3 Viral Hepatitis
			17.4 HIV
		18. ALLERGIC REACTIONS
			18.1 Anaphylaxis (Acute Hypersensitivity)
		19. NUTRITIONAL AND HAEMATOLOGIC CONDITIONS
			HAEMATOLOGICAL DISEASE CONDITIONS
				19.1 Anaemia
				19.2 Sickle Cell Anaemia
				19.3 Q6PD deficiency
				19.4 Bleeding Disorders
					19.4.1 Hereditary Bleeding Disorders
					19.4.2 Haemophilia A (Factor VIII deficiency)
					19.4.3 Haemophilia B (Factor IX deficiency)
				19.5 Von Willebrand Disease (VWD)
				19.6 Acquired Bleeding Disorders/Platelet Disorders
				19.7 Haemorrhagic Disease of the Newborn
				19.8 Anticoagulation
			NUTRITIONAL DISEASE CONDITIONS
				19.1 Avitaminosis
					19.1.1 Vitamin A Deficiency
					19.1.2 Vitamin D Deficiency
					19.3 Nicotinic Acid Deficiency (Pellagra)
					19.1.4 Thiamine Deficiency (Beriberi)
					19.1.5 Riboflavin Deficiency
					19.1.6 Pyridoxine Deficiency
					19.1.7 Ascorbic Acid Deficiency
					19.1.8 Vitamin K Deficiency
		20. MALIGNANT DISEASE CONDITIONS
			20.1 Hepatoma
			20.2 Cancer of the Cervix
			20.3 Cancer of the Breast
			20.4 Kaposi's Sarcoma
			20.5 Leukemia
			20.6 Burkitt's Tumour
		21. INJURIES AND TRAUMA
			BITES
				21.1 Animal Bites
				21.2 Insect Bites
				21.3 Snake Bites
			BURNS
		22. FOREIGN BODIES
		23. PAIN
		24. POISONING
		25. NORMAL LABORATORY VALUES
	NATIONAL ESSENTIAL DRUG LIST
		1. ANAESTHETICS
		2. MUSCLE RELAXANTS AND CHOLINESTERASE INHIBITORS
		3. ANALGESICS, ANTIPYRETICS
		4. ANTIMIGRAINE DRUGS
		5. ANTI-ALLERGICS AND DRUGS USED IN ANAPHYLAXIS AND SHOCK
		6. ANTIDOTES
		7. ANTIEPILEPTICS AND ANTICONVULSANTS
		8. ANTI-INFECTIVE DRUGS
		9. ANTINEOPLASTIC DRUGS AND IMMUNOSUPPRESSIVE DRUGS
		10. ANTI-PARKINSONISM DRUGS
		11. DRUGS AFFECTING THE BLOOD
		12. PLASMA SUBSTITUTES, BLOOD PRODUCTS
		13. CARDIOVASCULAR DRUGS
		14. DERMATOLOGICAL DRUGS
		15. DIURETICS
		16. GASTROINTESTINAL DRUGS
		17. HORMONES, ANTIDIABETIC AGENTS, ENDOCRINE DRUGS, CONTRACEPTIVES
		18. DIAGNOSTIC AGENTS
		19. IMMUNOLOGICALS
		20. OPHTHALMOLOGICAL PREPARATIONS
		21. DRUGS USED IN EAR, NOSE AND THROAT (ENT)
		22. OXYTOCICS & ANTI-OXYTOCICS
		23. PSYCHOTHERAPEUTIC DRUGS
		24. RESPIRATORY TRACT DRUGS
		25. SOLUTION, CORRECTING WATER ELECTROLYTE AND ACID BASE DISTURBANCES
		26. DISINFECTANTS and ANTISEPTICS
		27. VITAMINS & MINERALS
		28. DENTAL DRUGS/SUPPLIES
		29. VILLAGE HEALTH POSTS
		30. ESSENTIAL LABORATORY DIAGNOSTIC REAGENT
	ABBREVIATIONS AND SYMBOLS

4.4.2 Moderate/Severe Hypertension

Consider drug therapy only in patients with average DBP over 100 mm Hg checked on at least 3 occasions over 6 months in spite of changed lifestyle. Drug therapy is indicated for all those with end organ damage. A stepped approach is recommended for choice of antihypertensive drugs.

Recommended Step-up Care

Step One	*Hydrochlorothiazide (O)* 12.5-25 mg once daily.
Step Two	*Hydrochlorothiazide (O)* 25 mg daily
	Plus
	*Methyldopa (O)* 250 mg two to three times a day
	OR
	*Propranolol (O)* 160-320 mg once daily
*Step Three*	*Captopril (O)* 12.5-25 mg 3 times per day

NOTE ß-blockers may be tried but efficacy in black patients is believed to be unreliable.

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