What is the effectiveness of Angiotensin Receptor Blockers (ARBs) in the African American population for managing hypertension?

From the Guidelines

Angiotensin Receptor Blockers (ARBs) are generally less effective as monotherapy for hypertension management in African American patients compared to other racial groups, and are often recommended in combination with other agents such as thiazide diuretics or calcium channel blockers. For African American patients with hypertension, calcium channel blockers (like amlodipine) and thiazide diuretics (like hydrochlorothiazide or chlorthalidone) are typically recommended as first-line treatments 1. When ARBs are used in this population, they often require combination therapy to achieve adequate blood pressure control. Common ARBs include losartan (50-100 mg daily), valsartan (80-320 mg daily), olmesartan (20-40 mg daily), and irbesartan (150-300 mg daily). The reduced effectiveness of ARBs in African Americans is attributed to physiological differences in the renin-angiotensin-aldosterone system, as this population tends to have lower renin levels and different patterns of salt sensitivity 1. Despite their reduced efficacy as monotherapy, ARBs remain important for African American patients with certain comorbidities such as diabetic nephropathy, heart failure, or chronic kidney disease, where they provide benefits beyond blood pressure control 1.

Some key points to consider when managing hypertension in African American patients include:

• Annual screening for hypertension is advised for adults 18 years and older 1
• Lifestyle modification should place additional focus on salt restriction, increased intake of vegetables and fruits (potassium intake), weight management, and reducing alcohol intake 1
• First-line pharmacological therapy is recommended as a single pill combination including a thiazide-like diuretic plus CCB or CCB plus ARB 1
• Among RAS-inhibitors, ARBs may be preferred as angioedema is about 3 times more likely to occur with ACE inhibitors among black patients 1

When prescribing ARBs to African American patients, clinicians should monitor blood pressure closely and be prepared to add a thiazide diuretic or calcium channel blocker if blood pressure goals aren't met. It's also important to consider the potential benefits of ARBs in patients with certain comorbidities, and to weigh these benefits against the potential risks and limitations of ARB therapy in this population.

From the FDA Drug Label

The antihypertensive effect is independent of age, gender or race The latter finding regarding race is based on pooled data and should be viewed with caution, because antihypertensive drugs that affect the renin-angiotensin system (that is, ACE inhibitors and angiotensin-II blockers) have generally been found to be less effective in low-renin hypertensives (frequently blacks) than in high-renin hypertensives (frequently whites) In pooled, randomized, controlled trials of valsartan tablets that included a total of 140 blacks and 830 whites, valsartan and an ACE-inhibitor control were generally at least as effective in blacks as whites.

The effectiveness of Angiotensin Receptor Blockers (ARBs) in the African American population for managing hypertension is generally at least as effective as in whites, based on pooled data from trials of valsartan tablets 2. However, this finding should be viewed with caution due to the general trend of reduced effectiveness of renin-angiotensin system affecting drugs in low-renin hypertensives, which are more common in African Americans.

• Key points:
  • ARBs may be effective in African Americans for hypertension management
  • Effectiveness may be similar to that in whites, based on limited data
  • Caution is advised due to potential for reduced effectiveness in low-renin hypertensives
• Main consideration: The available data suggests that ARBs can be effective in African Americans, but the evidence is not conclusive, and more research may be needed to fully understand their effectiveness in this population.

From the Research

Effectiveness of Angiotensin Receptor Blockers (ARBs) in African Americans

• The effectiveness of ARBs in the African American population for managing hypertension is a topic of interest due to the high prevalence of hypertension in this group 3, 4, 5.
• Studies have shown that African Americans may respond less well to monotherapy with ARBs compared to diuretics and calcium channel blockers 3, 5.
• However, when combined with a diuretic, African Americans respond as well to ARBs as other racial groups 3, 4.
• The International Society of Hypertension in Blacks guidelines recommend combination therapy, including ARBs, as a first-line treatment for African Americans with hypertension, especially those with diabetes mellitus and renal disease 4, 5.
• The choice of ARBs as part of combination therapy may be effective in achieving blood pressure goals in African Americans, although the responsiveness to monotherapy may be less than other classes of antihypertensive agents 5.

Comparison with Other Antihypertensive Agents

• Diuretics and calcium channel blockers may be relatively more effective in lowering blood pressure in African Americans than beta blockers, angiotensin-converting enzyme inhibitors, and ARBs when used as monotherapy 3.
• Combination therapy using antihypertensive agents with differing modes of action, including ARBs, provides additive antihypertensive efficacy and is well tolerated 3, 4.
• The use of ARBs in combination with other agents, such as diuretics, may be an effective strategy for achieving blood pressure control in African Americans 4, 5.

Clinical Implications

• The high prevalence of hypertension and its consequences in African Americans highlights the need for effective management strategies, including the use of ARBs as part of combination therapy 3, 4, 5.
• Healthcare providers should consider the use of ARBs, either alone or in combination with other agents, as part of a comprehensive approach to managing hypertension in African Americans 4, 5.
• Further research is needed to fully understand the effectiveness of ARBs in the African American population and to identify the most effective strategies for achieving blood pressure control in this group 3, 4, 5.