What should be added to the treatment regimen of a 68-year-old African American male with hypertension, currently on lisinopril (angiotensin-converting enzyme inhibitor) 20mg?

From the Guidelines

For a 68-year-old African American male with hypertension currently on lisinopril 20 mg, I recommend adding a thiazide diuretic such as hydrochlorothiazide 12.5-25 mg daily or chlorthalidone 12.5-25 mg daily. This recommendation is based on the most recent and highest quality study, which suggests that African American patients often have a better blood pressure response to combination therapy that includes a diuretic 1. The addition of a thiazide diuretic works synergistically with the ACE inhibitor (lisinopril) by addressing different mechanisms of blood pressure control - while lisinopril blocks the renin-angiotensin-aldosterone system, the thiazide diuretic reduces blood volume and vascular resistance.

Key Considerations

• The combination of an ACE inhibitor and a thiazide diuretic is particularly effective in older African American patients who tend to have lower renin levels and may be salt-sensitive 1.
• When starting the diuretic, monitor electrolytes (particularly potassium and sodium) within 1-2 weeks, as the combination can affect these levels.
• Also check renal function and assess for any side effects such as dizziness, especially with position changes.
• Blood pressure should be rechecked within 2-4 weeks to evaluate the effectiveness of the combination therapy and adjust dosing if needed.

Supporting Evidence

• The 2024 ESC guidelines for the management of elevated blood pressure and hypertension recommend that initial antihypertensive treatment in black patients should include a diuretic or a CCB, either in combination or with a RAS blocker 1.
• The 2017 ACC/AHA/AAPA/ABC/ACPM/AGS/APhA/ASH/ASPC/NMA/PCNA guideline for the prevention, detection, evaluation, and management of high blood pressure in adults also supports the use of thiazide diuretics or CCBs in African American patients 1.
• The KDOQI US commentary on the 2017 ACC/AHA hypertension guideline recommends that initial antihypertensive treatment in black adults with hypertension but without HF or CKD should include a thiazide-type diuretic or CCB 1.

From the FDA Drug Label

In controlled clinical studies of patients with mild to moderate hypertension, patients were treated with lisinopril 20 mg to 80 mg daily, hydrochlorothiazide 12. 5 mg to 50 mg daily or atenolol 50 mg to 200 mg daily; and in other studies of patients with moderate to severe hypertension, patients were treated with lisinopril 20 mg to 80 mg daily or metoprolol 100 mg to 200 mg daily.

The patient is already on lisinopril 20 mg, and the goal is to add another medication to manage hypertension.

• Adding a diuretic such as hydrochlorothiazide could be considered, as it was used in combination with lisinopril in clinical studies.
• Adding a calcium channel blocker such as amlodipine could also be considered, as it is indicated for the treatment of hypertension and can be used in combination with other antihypertensive agents 2.
• Adding a beta-blocker such as atenolol or metoprolol could be considered, as they were used in combination with lisinopril in clinical studies. It is essential to consult the patient's medical history, current medications, and other factors to determine the best course of treatment 3.

From the Research

Treatment Options for Hypertension

The patient is a 68-year-old American male with hypertension, currently on lisinopril 20. To determine the best course of action, let's consider the following options:

• Adding a calcium channel blocker (CCB) such as amlodipine, as combination therapy with agents having complementary mechanisms of action can be a useful therapeutic option 4
• Adding a thiazide diuretic such as hydrochlorothiazide (HCTZ), as diuretics or CCBs are recommended as first-line agents in African-American patients 5, 6
• Considering a fixed-dose combination of amlodipine, valsartan, and HCTZ, which has been shown to be effective in reducing blood pressure and providing overall blood pressure control 7

Racial Considerations

As the patient is African-American, it's essential to consider the specific guidelines for hypertension management in this population:

• The Eighth Joint National Committee (JNC-8) guidelines recommend different treatment approaches for Black and non-Black patients, with a focus on diuretics and CCBs for Black patients 5, 6
• Targeted identification, medication management, and close follow-up have been shown to result in greater control of blood pressure in Black men 8

Potential Next Steps

Based on the available evidence, potential next steps for the patient could include:

• Adding amlodipine or HCTZ to the current lisinopril regimen, as these combinations have been shown to be effective in reducing blood pressure 4, 7
• Considering alternative treatment options, such as a fixed-dose combination of amlodipine, valsartan, and HCTZ, which may provide improved blood pressure control 7
• Ensuring close follow-up and monitoring to adjust the treatment plan as needed to achieve optimal blood pressure control 8