What is the recommended blood pressure regimen for a 31-year-old African American female with severe hypertension (blood pressure 182/111 mmHg) and allergies to lisinopril (angiotensin-converting enzyme inhibitor) and amlodipine (calcium channel blocker)?

From the Guidelines

For a 31-year-old African American female with severe hypertension (182/111 mmHg) and allergies to lisinopril and amlodipine, I recommend initiating therapy with a thiazide-type diuretic such as chlorthalidone 25 mg daily or hydrochlorothiazide 25-50 mg daily, combined with a beta-blocker like metoprolol succinate 50-100 mg daily. This severe hypertension requires immediate treatment with a two-drug regimen to effectively lower blood pressure to safer levels. Given the patient's African American ethnicity, thiazide diuretics are particularly effective as first-line agents, as supported by the 2024 ESC guidelines for the management of elevated blood pressure and hypertension 1. Since ACE inhibitors (lisinopril) and calcium channel blockers (amlodipine) are contraindicated due to allergies, alternative drug classes must be used. Some key points to consider in the management of this patient include:

• The importance of prompt treatment for stage 2 hypertension, as outlined 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
• The recommendation for initial antihypertensive treatment in black patients to include a diuretic or a CCB, either in combination or with a RAS blocker, as stated in the 2024 ESC guidelines 1
• The need for lifestyle modifications, including sodium restriction, weight management, regular physical activity, and limiting alcohol consumption, to be strongly emphasized alongside pharmacological treatment If this combination doesn't achieve adequate control within 2-4 weeks, adding a third agent such as a mineralocorticoid receptor antagonist (spironolactone 25-50 mg daily) or an angiotensin II receptor blocker (if no cross-reactivity with ACE inhibitor allergy exists) would be appropriate. The patient should be monitored closely with follow-up within 1-2 weeks to assess response and adjust medications as needed. It's also important to consider the patient's overall cardiovascular risk and to tailor the treatment approach accordingly, as suggested in the 2018 synopsis of the 2017 American College of Cardiology/American Heart Association hypertension guideline 1.

From the Research

Blood Pressure Regimen Options

Given the patient's severe hypertension (182/111 mmHg) and allergies to lisinopril and amlodipine, alternative treatment options must be considered.

• The patient's blood pressure is significantly higher than the recommended target blood pressure of <140/90 mmHg 2.
• Combination therapy with agents having complementary mechanisms of action may be a useful therapeutic option 2.
• However, since the patient is allergic to lisinopril (an angiotensin-converting enzyme inhibitor) and amlodipine (a calcium channel blocker), other classes of antihypertensive drugs should be considered.

Alternative Treatment Options

• Beta-blockers, such as metoprolol, may be considered as an alternative treatment option 3.
• Diuretics, such as chlorthalidone, have been shown to be effective in reducing cardiovascular disease incidence in hypertensive patients, including African Americans 4.
• Angiotensin II-receptor blockers (ARBs) may also be considered as an alternative to ACE inhibitors, as they have a similar mechanism of action but may be better tolerated in patients with ACE inhibitor allergies.

Dosing Considerations

• The dosing of alternative antihypertensive medications will depend on the specific medication and the patient's response to treatment.
• It is essential to monitor the patient's blood pressure regularly and adjust the dosage as needed to achieve the target blood pressure.

Special Considerations for African American Patients

• African American patients may respond differently to certain antihypertensive medications, such as ACE inhibitors, compared to non-African American patients 5, 4.
• Diuretics, such as chlorthalidone, may be a good option for African American patients with hypertension, as they have been shown to be effective in reducing cardiovascular disease incidence in this population 4.