What is the recommended initial pharmacological treatment for a 61-year-old African male with hypertension (High Blood Pressure), Chronic Kidney Disease (CKD), and prediabetes?

From the Guidelines

For a 61-year-old African male with hypertension, chronic kidney disease (CKD), and prediabetes, the recommended initial pharmacological treatment is a low dose ARB, with a potential addition of a dihydropyridine calcium channel blocker (DHP-CCB) or a DHP-CCB with a thiazide/thiazide-like diuretic. This recommendation is based on the most recent guidelines, specifically the 2020 International Society of Hypertension Global Hypertension Practice Guidelines 1 and the 2024 ESC Guidelines for the management of elevated blood pressure and hypertension 1. The initial treatment with an ARB is preferred due to its renoprotective effects, which are beneficial for patients with CKD. Some key points to consider in the management of this patient include:

• Monitoring kidney function and potassium levels within 2-4 weeks of starting therapy, as ARBs can cause hyperkalemia or acute kidney injury in some patients.
• Adding a DHP-CCB or a DHP-CCB with a thiazide/thiazide-like diuretic if blood pressure goals are not achieved with the ARB alone.
• Targeting a blood pressure of <130/80 mmHg, given the patient's CKD and prediabetes.
• Implementing lifestyle modifications, including sodium restriction, regular physical activity, and weight management, to accompany pharmacological treatment. It's also important to note that, according to the 2024 ESC Guidelines, in black patients, initial antihypertensive treatment should include a diuretic or a CCB, either in combination or with a RAS blocker 1. However, the 2020 International Society of Hypertension Global Hypertension Practice Guidelines recommend a low dose ARB as the initial treatment for black patients with hypertension 1. Given the patient's CKD and prediabetes, the use of an ARB is preferred due to its renoprotective effects. The patient's treatment plan should be individualized, and regular follow-up appointments should be scheduled to monitor blood pressure, kidney function, and potassium levels.

From the FDA Drug Label

Losartan potassium tablets are indicated for the treatment of hypertension in adults and pediatric patients 6 years of age and older, to lower blood pressure. The usual starting dose of losartan potassium tablet is 50 mg once daily. 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). Losartan potassium tablets are indicated for the treatment of diabetic nephropathy with an elevated serum creatinine and proteinuria (urinary albumin to creatinine ratio ≥300 mg/g) in patients with type 2 diabetes and a history of hypertension

The recommended initial pharmacological treatment for a 61-year-old African male with hypertension, Chronic Kidney Disease (CKD), and prediabetes is losartan, starting with a dose of 50 mg once daily.

• The patient's CKD and prediabetes status may require careful consideration of the treatment plan, but losartan is indicated for the treatment of hypertension and diabetic nephropathy.
• It is essential to monitor the patient's blood pressure response and adjust the dosage as needed to control blood pressure.
• The patient's African background may affect the blood pressure response to losartan, as some antihypertensive drugs have smaller blood pressure effects in Black patients 2.

From the Research

Recommended Initial Pharmacological Treatment

For a 61-year-old African male with hypertension, Chronic Kidney Disease (CKD), and prediabetes, the recommended initial pharmacological treatment should be carefully considered based on the patient's specific conditions.

• The patient's African background is important to consider, as some studies suggest that ACE inhibitors may be less effective in African-Americans at lower doses due to higher levels of dietary sodium intake 3.
• However, ACE inhibitors like lisinopril have been shown to be effective in lowering blood pressure and preserving renal function in patients with diabetes, including those with CKD 4.
• The presence of CKD and prediabetes in this patient makes it essential to choose an antihypertensive agent that is renoprotective and does not adversely affect glycemic control or lipid profiles.
• Some studies suggest that ACE inhibitors, such as lisinopril, can be effective in patients with CKD and diabetes, and may even have a broader role in managing diabetic vascular complications 4.
• The choice of antihypertensive agent should also take into account the patient's individual characteristics, such as age, comorbidities, and potential drug interactions 5.
• Combination therapy with an ACE inhibitor and a calcium channel blocker, such as amlodipine, may be considered if monotherapy is not effective, as this combination has been shown to have a marked additional effect on blood pressure compared to either agent alone 6.

Key Considerations

• The patient's dietary sodium intake should be considered, as high levels of sodium intake may affect the efficacy of ACE inhibitors 3.
• Regular monitoring of blood pressure, renal function, and glycemic control is essential to adjust the treatment plan as needed.
• The patient's response to treatment should be closely monitored, and adjustments made based on individual characteristics, such as plasma renin activity and severity of hypertension 6.