What are the best blood pressure medications for Afro-Caribbeans with uncontrolled hypertension on bendroflumethiazide (thiazide diuretic) and amlodipine (calcium channel blocker)?

From the Guidelines

For Afro-Caribbean patients with uncontrolled hypertension despite being on bendroflumethiazide and amlodipine, the best next medication to add would typically be an angiotensin receptor blocker (ARB) such as losartan (starting at 50mg daily, increasing to 100mg if needed). This recommendation is based on the most recent guidelines, including the 2024 ESC guidelines for the management of elevated blood pressure and hypertension 1, which suggest that in black patients, initial antihypertensive treatment should include a diuretic or a CCB, either in combination or with a RAS blocker. The 2020 International Society of Hypertension global hypertension practice guidelines also support the use of ARBs in combination with CCBs or diuretics for black patients 1. Regular monitoring of kidney function and electrolytes is essential when adding these medications, particularly within 1-2 weeks of starting therapy. Key considerations in managing hypertension in Afro-Caribbean patients include:

• Lifestyle modification, such as salt restriction, increased intake of vegetables and fruits, weight management, and reducing alcohol intake 1
• The potential for increased risk of angioedema with ACE inhibitors in black patients 1
• The importance of combination therapy, including a diuretic or CCB, to achieve adequate blood pressure control 1
• The need for regular monitoring and adjustment of treatment to minimize cardiovascular and renal risk.

From the FDA Drug Label

Losartan may be administered with other antihypertensive agents. 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 best blood pressure medications for Afro-Caribbeans with uncontrolled hypertension on bendroflumethiazide and amlodipine are not explicitly stated in the provided drug label. However, it is mentioned that some antihypertensive drugs have smaller blood pressure effects in Black patients.

• Losartan can be administered with other antihypertensive agents, but its effectiveness in Afro-Caribbean patients with uncontrolled hypertension is not directly addressed.
• The label suggests that selection of therapy should consider additional approved indications and effects of antihypertensive drugs, but does not provide specific guidance for Afro-Caribbean patients. 2

From the Research

Best Blood Pressure Medications for Afro-Caribbeans

• The best blood pressure medications for Afro-Caribbeans with uncontrolled hypertension on bendroflumethiazide and amlodipine are not explicitly stated in the provided studies, but some insights can be gained from the available evidence.
• A study published in 2019 3 compared the effectiveness of different two-drug combinations for lowering blood pressure in black African patients, including amlodipine plus hydrochlorothiazide, amlodipine plus perindopril, and perindopril plus hydrochlorothiazide.
• The results showed that amlodipine plus hydrochlorothiazide and amlodipine plus perindopril were more effective than perindopril plus hydrochlorothiazide at lowering blood pressure at 6 months.

Alternative Treatment Options

• Another study published in 2023 4 found that antihypertensive initiation does not vary by ethnicity, but subsequent blood pressure control was notably lower among people of African/African Caribbean ethnicity, potentially associated with being less likely to remain on regular treatment.
• A review of the management of hypertensive disease in black patients published in 1999 5 suggested that diuretics and calcium antagonists are suitable first-line agents in black hypertensives, whilst beta-blockers and ACE inhibitors tend to be less effective at lowering blood pressure.
• A review of ACE inhibitors and ARBs in black patients with hypertension published in 2018 6 found that numerous monotherapy trials indicate that black patients may have a reduced blood pressure response with ACE inhibitors or ARBs compared with white patients, but reduced efficacy is not observed in trials involving combination therapy.

Combination Therapy

• A study published in 2023 7 examined the combination of beta-blockers and ACE inhibitors across the spectrum of cardiovascular diseases and found that combining these established antihypertensive agents into a single pill continues to provide effective blood pressure lowering and improved cardiovascular outcomes.
• However, it is essential to note that the provided studies do not directly address the best blood pressure medications for Afro-Caribbeans with uncontrolled hypertension on bendroflumethiazide and amlodipine, and more research is needed to determine the most effective treatment options for this specific population.