What are the considerations for an African American patient taking an Angiotensin Receptor Blocker (ARB) inhibitor?

From the Guidelines

African American patients should not be started on ARB inhibitors as the initial treatment for hypertension, but rather consider a thiazide-type diuretic or CCB as first-line therapy, according to the 2017 ACC/AHA/AAPA/ABC/ACPM/AGS/APhA/ASH/ASPC/NMA/PCNA guideline 1.

Key Considerations

• The guideline recommends initial antihypertensive treatment with a thiazide-type diuretic or CCB in black adults with hypertension but without HF or CKD, including those with DM 1.
• Two or more antihypertensive medications are recommended to achieve a BP target of less than 130/80 mm Hg in most adults with hypertension, especially in black adults with hypertension 1.
• However, the 2020 International Society of Hypertension global hypertension practice guidelines suggest that among RAS-inhibitors, ARBs may be preferred as angioedema is about 3 times more likely to occur with ACE inhibitors among black patients 1.

Treatment Approach

• If an ARB is considered, common options include losartan, valsartan, olmesartan, and candesartan, typically starting at lower doses and titrating up as needed.
• ARBs work by blocking the angiotensin II receptor, relaxing blood vessels and lowering blood pressure.
• They're particularly beneficial for African American patients with certain comorbidities like diabetes or kidney disease.

Monitoring and Side Effects

• Individual response to antihypertensive medications varies, so blood pressure should be monitored regularly after starting an ARB.
• These medications should be taken consistently at the same time each day, and patients should be aware of potential side effects including dizziness, elevated potassium levels, and the need to avoid pregnancy while taking ARBs due to potential fetal harm.

From the FDA Drug Label

In the LIFE study, Black patients with hypertension and left ventricular hypertrophy treated with atenolol were at lower risk of experiencing the primary composite endpoint compared with Black patients treated with losartan (both cotreated with hydrochlorothiazide in the majority of patients) The primary endpoint was the first occurrence of stroke, myocardial infarction or cardiovascular death, analyzed using an intention-to-treat (ITT) approach In the subgroup of Black patients (n=533,6% of the LIFE study patients), there were 29 primary endpoints among 263 patients on atenolol (11%, 26 per 1000 patient-years) and 46 primary endpoints among 270 patients (17%, 42 per 1000 patient-years) on losartan This finding could not be explained on the basis of differences in the populations other than race or on any imbalances between treatment groups. However, the LIFE study provides no evidence that the benefits of losartan on reducing the risk of cardiovascular events in hypertensive patients with left ventricular hypertrophy apply to Black patients [see CLINICAL STUDIES (14.2)].

The use of losartan, an ARB inhibitor, in African American patients may not provide the same level of benefit in reducing the risk of cardiovascular events as it does in other populations. The LIFE study found that Black patients treated with losartan had a higher risk of experiencing the primary composite endpoint (stroke, myocardial infarction, or cardiovascular death) compared to those treated with atenolol. Key points to consider:

• Losartan may not be as effective in reducing cardiovascular risk in African American patients.
• Alternative treatments may be necessary to achieve optimal blood pressure control and reduce cardiovascular risk in this population.
• The LIFE study highlights the importance of considering race when selecting antihypertensive therapy 2.

From the Research

African American Patients Taking ARB Inhibitors

• The Eighth Joint National Committee (JNC-8) published hypertension guidelines that varied depending on patient race, with different treatment recommendations for Black and non-Black patients 3.
• For Black patients, the recommendation removed ACE inhibitors and ARBs from the algorithm, suggesting alternative treatments such as thiazide diuretics or calcium channel blockers 3.
• A study found that among Black/African American patients, 18.6% were treated with ACE/ARB monotherapy, compared to 42.3% of non-Black patients 4.
• Research suggests that ACE inhibitors can effectively lower blood pressure in African Americans, albeit at a higher average dose than in whites, and that modest reductions in dietary sodium intake can augment the blood pressure-lowering effect of ACE inhibitors 5.
• A review of current guidelines and recent data evaluating the efficacy and safety of ACE inhibitors and ARBs in Black hypertensive patients found that numerous monotherapy trials indicate a reduced blood pressure response with ACE inhibitors or ARBs compared to white patients 6.
• However, combination therapy with an ARB, a calcium channel blocker, and a thiazide diuretic may be an effective treatment strategy for hypertension in Black patients, as it has been shown to improve blood pressure control and reduce cardiovascular risk 7.