What is the recommended initial dose and titration of Angiotensin-Converting Enzyme (ACE) inhibitors for a black patient with hypertension?

ACE Inhibitor Dosing for Black Patients with Hypertension

For black patients with hypertension, ACE inhibitors are not recommended as first-line therapy; instead, the initial treatment should be a low-dose ARB combined with either a dihydropyridine calcium channel blocker (DHP-CCB) or a thiazide-like diuretic. 1

Initial Treatment Algorithm for Black Hypertensive Patients

1. First-line therapy options:

   • Low-dose ARB + DHP-CCB (preferred combination)
   • Low-dose ARB + thiazide/thiazide-like diuretic
   • DHP-CCB + thiazide/thiazide-like diuretic

2. Second-line therapy:

   • Increase to full dose of initial medications

3. Third-line therapy:

   • Add ACE inhibitor or additional diuretic (if not already included)

ACE Inhibitor Dosing When Needed in Black Patients

If an ACE inhibitor is added as part of the treatment regimen (typically as third-line therapy), the following dosing approach should be used:

• Initial dose: 2.5 mg once daily (lower than the standard 5 mg starting dose used in non-black patients) 1, 2
• Titration: Increase gradually based on blood pressure response
• Maximum dose: Up to 40 mg daily, but higher doses are often needed in black patients compared to non-black patients 3
• Monitoring: Check blood pressure after 2-3 hours following the initial dose and again after one hour of stabilization 2

Important Considerations for ACE Inhibitors in Black Patients

• Reduced efficacy: ACE inhibitors generally have lower blood pressure-lowering effects in black patients compared to non-black patients when used as monotherapy 4, 5
• Sodium intake: High dietary sodium intake may significantly reduce ACE inhibitor effectiveness in black patients 3
• Combination therapy: ACE inhibitors are more effective in black patients when combined with diuretics or calcium channel blockers 5
• Dose requirements: Black patients often require higher doses of ACE inhibitors to achieve similar blood pressure reductions as non-black patients 3

Special Precautions

• Angioedema risk: Black patients have a higher risk of ACE inhibitor-induced angioedema
• Renal function: Monitor renal function closely, especially in patients with renal impairment
• Potassium levels: Monitor serum potassium, particularly when combining with potassium-sparing diuretics
• Initial hypotension: If the patient is currently on a diuretic, consider discontinuing it 2-3 days before starting an ACE inhibitor to reduce the risk of first-dose hypotension 2

Renal Impairment Dosing Adjustments

For black patients with renal impairment who require an ACE inhibitor:

• Normal renal function (CrCl >80 mL/min): 5 mg once daily
• Mild impairment (CrCl 30-80 mL/min): 5 mg once daily
• Moderate to severe impairment (CrCl ≤30 mL/min): 2.5 mg once daily 2

Treatment Targets

• Aim to reduce BP by at least 20/10 mmHg
• Target BP <130/80 mmHg (individualize for elderly based on frailty) 1
• Monitor BP control and aim to achieve target within 3 months 1

Remember that while ACE inhibitors can be effective in black patients at appropriate doses and in combination with other agents, they are not the preferred initial therapy for hypertension in this population due to reduced efficacy as monotherapy compared to ARBs, calcium channel blockers, or thiazide diuretics.