What are the most effective antihypertensive (blood pressure) medications for uncontrolled Hypertension (HTN) in African Americans?

From the Guidelines

For African Americans with uncontrolled hypertension, calcium channel blockers (like amlodipine 5-10mg daily) and thiazide diuretics (such as hydrochlorothiazide 12.5-25mg daily or chlorthalidone 12.5-25mg daily) are typically the most effective first-line medications. These are often more effective than ACE inhibitors or ARBs when used alone in this population 1. If blood pressure remains uncontrolled on a single agent, combining a calcium channel blocker with a thiazide diuretic is recommended. For patients with more severe hypertension, adding an ACE inhibitor (like lisinopril 10-40mg daily) or an ARB (such as losartan 50-100mg daily) as part of a three-drug regimen can be effective, particularly in those with diabetes or kidney disease 1.

Key Considerations

• African Americans tend to have lower renin levels and may be more salt-sensitive, which explains why diuretics and calcium channel blockers work particularly well 1.
• It's essential to monitor for side effects, ensure medication adherence, and encourage lifestyle modifications like reducing sodium intake, maintaining healthy weight, regular exercise, and limiting alcohol consumption to optimize blood pressure control.
• The principles of antihypertensive drug selection should be considered, and racial and ethnic differences should not be the basis for excluding any class of antihypertensive agent in combination therapy 1.

Medication Options

• Calcium channel blockers: amlodipine 5-10mg daily
• Thiazide diuretics: hydrochlorothiazide 12.5-25mg daily or chlorthalidone 12.5-25mg daily
• ACE inhibitors: lisinopril 10-40mg daily
• ARBs: losartan 50-100mg daily

Lifestyle Modifications

• Reducing sodium intake
• Maintaining healthy weight
• Regular exercise
• Limiting alcohol consumption

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). ACE inhibitors, including lisinopril, have an effect on blood pressure that is less in black patients than in non-blacks. Losartan is indicated to reduce the risk of stroke in patients with hypertension and left ventricular hypertrophy, but there is evidence that this benefit does not apply to Black patients

The best BP medications for uncontrolled hypertension in African Americans are not explicitly stated in the provided drug labels. However, it is noted that:

• ACE inhibitors, such as lisinopril, have a lesser effect on blood pressure in black patients compared to non-black patients 2.
• Losartan may not provide the same benefit in reducing the risk of stroke in black patients with hypertension and left ventricular hypertrophy as it does in other populations 3.
• Amlodipine may be used alone or in combination with other antihypertensive agents, but its effectiveness in black patients is not specifically stated 4. It is essential to consider these factors when selecting therapy for African American patients with uncontrolled hypertension.

From the Research

Best BP Medications for Uncontrolled HTN in African Americans

• The treatment of hypertension in African Americans presents a therapeutic challenge, and several studies have investigated the best medications for uncontrolled hypertension in this population 5, 6, 7, 8, 9.
• Thiazide diuretics are often recommended as the first-line treatment for hypertension in African Americans, as they have been shown to be effective in reducing blood pressure and preventing cardiovascular disease 5, 6, 9.
• Calcium channel blockers (CCBs) are also considered a good option for African Americans with hypertension, particularly for those who are uncontrolled on or intolerant of thiazides, or who have specific indications for these agents such as angina or severe diastolic dysfunction 5, 6.
• Beta-blockers may be less effective as monotherapy in African Americans, but can be effective when used in combination with a diuretic 5.
• Angiotensin-converting enzyme inhibitors (ACEIs) and angiotensin receptor blockers (ARBs) may be less effective in African Americans when used as monotherapy, but can be useful in patients with concomitant congestive heart failure or diabetic nephropathy 5, 8.
• A study published in 2022 found that African American patients with hypertension were more likely to be treated with thiazide diuretics or CCBs, and were less likely to achieve blood pressure control compared to non-African American patients 7.
• The Eighth Joint National Committee (JNC-8) guidelines recommend different treatment approaches for African American and non-African American patients with hypertension, with a focus on thiazide diuretics and CCBs for African American patients 8.
• The Antihypertensive and Lipid-Lowering Treatment to Prevent Heart Attack Trial (ALLHAT) found that thiazide-type diuretics were superior to calcium channel blockers and ACEIs in preventing major forms of cardiovascular disease in high-risk hypertensive patients, including African Americans 9.