What is the recommended initial treatment for hypertension (HTN) in an African American patient?

From the Guidelines

The recommended initial treatment for hypertension in African American patients is a thiazide diuretic or calcium channel blocker (CCB). Specific options include hydrochlorothiazide (12.5-25 mg daily), chlorthalidone (12.5-25 mg daily), or amlodipine (5-10 mg daily) 1. These medications are preferred first-line agents because African American patients typically have lower renin levels and are more responsive to these classes of antihypertensives compared to ACE inhibitors or ARBs when used as monotherapy.

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

• Thiazide diuretics and CCBs are more effective in lowering blood pressure and reducing cardiovascular disease events in African American patients compared to ACE inhibitors or ARBs 1.
• Lifestyle modifications should always accompany pharmacological treatment, including sodium restriction (less than 2.3g daily), regular physical activity (150 minutes of moderate exercise weekly), weight management, limited alcohol consumption, and a diet rich in fruits and vegetables.
• Blood pressure should be monitored regularly, with a goal of less than 130/80 mmHg for most patients.
• Combination therapy may be necessary if blood pressure remains uncontrolled on a single agent, and an ACE inhibitor or ARB can be considered as a second agent, though these are generally less effective as monotherapy in this population.

It's worth noting that the most recent and highest quality study, 1, published in 2019, supports the use of thiazide diuretics or CCBs as initial antihypertensive treatment in black adults with hypertension but without heart failure or chronic kidney disease, including those with diabetes.

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). Amlodipine besylate tablets may be used alone or in combination with other antihypertensive agents.

The recommended initial treatment for hypertension (HTN) in an African American patient is not explicitly stated in the provided drug labels. However, it is mentioned that some antihypertensive drugs have smaller blood pressure effects in Black patients.

• The usual starting dose of losartan potassium tablet is 50 mg once daily 2.
• Amlodipine besylate tablets may be used alone or in combination with other antihypertensive agents 3. Considering the information provided, calcium channel blockers (such as amlodipine) are often recommended as initial therapy for hypertension in African American patients.

From the Research

Initial Treatment for Hypertension in African Americans

The recommended initial treatment for hypertension (HTN) in African American patients involves a comprehensive approach that includes lifestyle modifications and drug therapy 4, 5, 6.

• Lifestyle modifications:
  • Weight loss
  • Salt and alcohol restriction
  • Increased physical activity
  • Dietary changes, such as increased potassium intake 6
• Drug therapy:
  • Combination antihypertensive drug therapy is often required to maintain blood pressure consistently below target levels 4, 6
  • Preferred combinations include:
    • Calcium antagonist/angiotensin-converting enzyme inhibitor
    • Thiazide diuretic/angiotensin-converting inhibitor 4
    • Beta-adrenoceptor antagonist/diuretic
    • ACE inhibitor/diuretic
    • ACE inhibitor/calcium channel antagonist
    • Angiotensin receptor antagonist/diuretic 6

Choice of Antihypertensive Agents

The choice of antihypertensive agents for African American patients has been guided by the response to different classes of drugs.

• Thiazide diuretics and calcium antagonists have been recommended over renin-angiotensin system (RAS) inhibitors and beta blockers for Black patients 5
• However, current recommendations suggest that race may not be a necessary or sufficient consideration for the selection of effective drug therapy, and a race-agnostic approach may be more effective 5
• Studies have shown that dihydropyridine calcium channel blockers, such as amlodipine, nifedipine, and nifedipine GITS, have equivalent efficacy, safety, and tolerability in African American patients with hypertension 7
• The ALLHAT study found that chlorthalidone, a thiazide-type diuretic, was superior to amlodipine and lisinopril in reducing cardiovascular disease incidence in both black and nonblack patients 8

Considerations for Treatment

When treating hypertension in African American patients, it is essential to consider the following:

• The high prevalence of comorbid factors, such as obesity, diabetes mellitus, and kidney disease, which can affect treatment outcomes 4, 6
• The need for combination drug therapy to achieve blood pressure control 4, 6
• The importance of lifestyle modifications in achieving blood pressure control 4, 5, 6