What are the first-line antihypertensive (high blood pressure) medications for African American patients?

From the Guidelines

For African American patients with hypertension, the first-line antihypertensive medications recommended are calcium channel blockers (such as amlodipine 5-10 mg daily) or thiazide diuretics (such as hydrochlorothiazide 12.5-25 mg daily or chlorthalidone 12.5-25 mg daily). These medications have demonstrated superior efficacy in blood pressure reduction in this population compared to other antihypertensive classes, as supported by 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, 2, 3, 4. ACE inhibitors and ARBs are generally less effective when used as monotherapy in African American patients unless there are compelling indications such as diabetic nephropathy or heart failure. This recommendation is based on physiological differences in the renin-angiotensin-aldosterone system, as African American patients often have lower renin levels and may be more salt-sensitive.

When starting treatment, begin with the lower dose and titrate upward if blood pressure goals are not achieved after 2-4 weeks. Combination therapy may be necessary for patients with stage 2 hypertension (BP ≥140/90 mmHg) or those who don't achieve target blood pressure with monotherapy. Regular monitoring of electrolytes is important when using diuretics, and patients should be counseled on maintaining adequate hydration and reducing dietary sodium. The guideline recommends a BP target of less than 130/80 mm Hg in most adults with hypertension, especially in black adults with hypertension 3, 4.

Key points to consider when treating African American patients with hypertension include:

• Initial antihypertensive treatment should include a thiazide-type diuretic or CCB 3, 4
• Two or more antihypertensive medications may be recommended to achieve a BP target of less than 130/80 mm Hg in most adults with hypertension, especially in black adults with hypertension 3, 4
• Regular monitoring and adjustment of the treatment regimen is crucial to achieve blood pressure control and reduce the risk of cardiovascular and renal outcomes.

From the FDA Drug Label

Although lisinopril was antihypertensive in all races studied, Black hypertensive patients (usually a low-renin hypertensive population) had a smaller average response to monotherapy than non-Black patients 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). Concomitant administration of lisinopril and hydrochlorothiazide further reduced blood pressure in Black and non-Black patients and any racial differences in blood pressure response were no longer evident.

The first-line antihypertensive medications for African American patients are not explicitly stated in the provided drug labels. However, the labels suggest that:

• Lisinopril may have a smaller average response in Black patients as monotherapy.
• Combination therapy (e.g., lisinopril and hydrochlorothiazide) may be more effective in reducing blood pressure in Black patients.
• Other antihypertensive agents, such as losartan or amlodipine, may be considered, but their effectiveness in Black patients is not directly stated in the provided labels 5, 6, 7. It is recommended to consult 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), for specific advice on goals and management.

From the Research

First-Line Antihypertensive Medications for African American Patients

• The first-line antihypertensive medications for African American patients include diuretics, such as chlorthalidone, and calcium channel blockers 8, 9.
• According to the ALLHAT study, diuretics were associated with greater reductions in blood pressure and a relative risk reduction in stroke compared to ACE inhibitors in African American patients 8.
• The use of ACE inhibitors, such as ramipril, may also be effective in African American patients, particularly those with kidney disease 8.
• Combination therapy with a diuretic and an ACE inhibitor or calcium channel blocker may be necessary for many African American patients to achieve adequate blood pressure control 10, 11.
• The choice of drugs for combination therapy in African American patients may be different than in non-African American patients, with a preference for diuretics and calcium channel blockers 8, 11.

Specific Medication Options

• Diuretics:
  • Chlorthalidone 8
  • Hydrochlorothiazide 12
• Calcium channel blockers:
  • Amlodipine besylate 9
  • Nifedipine coat core (CC) 9
  • Nifedipine gastrointestinal therapeutic system (GITS) 9
• ACE inhibitors:
  • Ramipril 8
  • Lisinopril 8

Treatment Considerations

• African American patients with systolic BP >15 mm Hg or a diastolic BP >10 mm Hg above goal should be treated with first-line combination therapy 8, 11.
• Patients with kidney disease or heart failure may require special consideration and alternative treatment options 10, 11.