What is the initial treatment approach for a black male starting on hypertension (htn) medications?

From the Guidelines

For Black males starting hypertension treatment, a calcium channel blocker (such as amlodipine 5-10 mg daily) or a thiazide diuretic (such as hydrochlorothiazide 12.5-25 mg daily or chlorthalidone 12.5-25 mg daily) is recommended as first-line therapy. These medication classes have shown superior efficacy in Black patients compared to ACE inhibitors or ARBs when used as monotherapy, as noted in 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 1. This difference in response is due to physiological variations in the renin-angiotensin system, as Black patients often have lower renin levels and may be more salt-sensitive.

Key Considerations

• Treatment should begin with a low dose and be titrated upward if blood pressure remains above goal (typically <130/80 mmHg) after 2-4 weeks.
• Lifestyle modifications should accompany medication therapy, including:
  • Reduced sodium intake
  • Increased physical activity
  • Weight management
  • Limited alcohol consumption
• Regular blood pressure monitoring is essential, and patients should be evaluated for medication side effects at follow-up visits.
• If blood pressure control is inadequate with a single agent, combination therapy may be necessary, potentially adding an ACE inhibitor or ARB as a second agent, as supported by the guideline 1.

Rationale

The recommendation for using calcium channel blockers or thiazide diuretics as first-line therapy in Black males is based on their effectiveness in lowering blood pressure and reducing cardiovascular disease events in this population, as compared to other medication classes 1. The guideline also notes that ACE inhibitors or ARBs may be added as a second agent if blood pressure control is not achieved with a single agent, particularly in patients with comorbid conditions such as diabetes or chronic kidney disease 1.

Clinical Implications

In clinical practice, the choice of initial therapy for hypertension in Black males should be individualized based on the patient's specific needs and medical history. However, calcium channel blockers or thiazide diuretics are generally recommended as first-line therapy, with ACE inhibitors or ARBs considered as add-on therapy if necessary, as supported by the guideline 1.

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). These considerations may guide selection of therapy. The initial treatment approach for a black male starting on hypertension (htn) medications should consider that some antihypertensive drugs have smaller blood pressure effects in Black patients. The selection of therapy should be guided by these considerations, and published guidelines, such as those of the National High Blood Pressure Education Program’s Joint National Committee on Prevention, Detection, Evaluation, and Treatment of High Blood Pressure (JNC), should be consulted for specific advice on goals and management 2.

From the Research

Initial Treatment Approach for Black Male Starting on Hypertension Medications

• The initial treatment approach for a black male starting on hypertension medications may involve the use of angiotensin converting enzyme (ACE) inhibitors, despite previous concerns about their efficacy in African-American patients 3.
• Studies have shown that ACE inhibitors can effectively lower blood pressure in African-Americans, although they may require higher doses and modest reductions in dietary sodium intake 3.
• Other options for initial treatment may include thiazide diuretics, which have been shown to be effective in reducing mortality and morbidity in hypertensive patients, including those without diabetes or cardiovascular or renal disease 4.
• The choice of initial treatment may also depend on individual patient characteristics, such as age, comorbidities, and lifestyle factors, as well as the presence of any contraindications or potential interactions with other medications.
• Pharmacogenomic and metabolomic factors may also play a role in determining the effectiveness and safety of ACE inhibitors and other antihypertensive medications in individual patients 5.

Considerations for ACE Inhibitor Use in Black Males

• ACE inhibitors may be less effective at low doses in African-American patients, but higher doses may be more effective 3.
• Dietary sodium intake may also affect the efficacy of ACE inhibitors in African-American patients, with higher sodium intake potentially reducing their effectiveness 3.
• The use of ACE inhibitors in combination with other medications, such as diuretics or calcium channel blockers, may also be effective in treating hypertension in black males 6, 7.

Alternative Treatment Options

• Thiazide diuretics, such as chlortalidone or hydrochlorothiazide, may be effective alternative treatment options for black males with hypertension 4.
• Other classes of antihypertensive medications, such as calcium channel blockers or beta-blockers, may also be considered, although their efficacy and safety may vary depending on individual patient characteristics and comorbidities 7, 4.