Do differences exist in the initiation of antihypertensive (high blood pressure) medications, specifically between the black population and the white population?

From the Guidelines

Yes, there is a difference in initial antihypertensive medication recommendations for Black versus White populations, with calcium channel blockers (like amlodipine) or thiazide diuretics (like hydrochlorothiazide or chlorthalidone) being preferred as first-line treatments for Black patients. For Black patients, these medications are typically started at standard doses - for example, amlodipine 5mg daily or hydrochlorothiazide 12.5-25mg daily 1. In contrast, White patients often respond better to angiotensin-converting enzyme (ACE) inhibitors (like lisinopril), angiotensin receptor blockers (ARBs, like losartan), or beta-blockers (like metoprolol) as initial therapy.

Key Considerations

• Black patients generally have lower renin levels and are more likely to have salt-sensitive hypertension, making them more responsive to medications that address volume and calcium channel activity 1.
• ACE inhibitors were less effective than thiazide diuretics and CCBs in lowering BP and in prevention of stroke, particularly in Black patients 1.
• ARBs may be better tolerated than ACE inhibitors in Black patients, with less cough and angioedema, but offer no proven advantage over ACE inhibitors in preventing stroke or CVD in this population 1.

Treatment Approach

When treating Black patients with hypertension, it's essential to monitor blood pressure response within 2-4 weeks of starting therapy and adjust medications accordingly. If blood pressure goals aren't achieved with a single agent, combination therapy may be necessary, potentially adding an ACE inhibitor or ARB as a second agent. The choice of initial medication should be guided by the presence of comorbid conditions, such as heart failure or chronic kidney disease, for which specific classes of BP-lowering medication are indicated 1.

From the FDA Drug Label

Some antihypertensive drugs have smaller blood pressure effects (as monotherapy) in black patients, and many antihypertensive drugs have additional approved indications and effects (e.g., on angina, heart failure, or diabetic kidney disease). These considerations may guide selection of therapy.

The choice of anti-hypertensive medication may differ between black and white populations due to varying responses to certain medications.

• Black patients may experience smaller blood pressure effects from some anti-hypertensive drugs.
• This difference should be considered when selecting therapy for hypertension in these populations 2.

From the Research

Differences in Anti-Hypertensive Medications for Black and White Populations

• The choice of anti-hypertensive medication may differ between black and white populations due to variations in the incidence and morbidity of hypertension among ethnic populations 3.
• Studies have shown that diuretics, such as chlorthalidone, may be more effective in reducing blood pressure in black patients compared to angiotensin-converting enzyme (ACE) inhibitors 3, 4.
• Calcium channel blockers have also been found to be effective in reducing blood pressure in black patients, and may be a suitable alternative to diuretics 4.
• 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 5.

Treatment Recommendations for Black Patients

• The JNC-8 guidelines recommend initial therapy with thiazide diuretics or calcium channel blockers for black patients, rather than ACE inhibitors or angiotensin receptor blockers (ARBs) 5.
• Combination therapy with a calcium antagonist and an ACE inhibitor, or a thiazide diuretic and an ACE inhibitor, may be effective in controlling blood pressure in black patients 6, 3.
• However, some studies suggest that an individualized approach to hypertension therapy, rather than a race-based approach, may be more effective in achieving blood pressure control 7.

Comparison of Treatment Outcomes

• Studies have found that black patients are more likely to have uncontrolled hypertension compared to non-black patients, despite similar treatment regimens 7.
• The use of ACE inhibitors and ARBs may be less effective in reducing blood pressure in black patients, and may be associated with a higher risk of cardiovascular events 4.
• Diuretics, such as thiazide diuretics, may be more effective in reducing blood pressure in black patients, but may be associated with a higher risk of diabetes 4.