What combination of hypertensive medications, including brand names like Norvasc (amlodipine) and Zestril (lisinopril), are effective for black patients in Canada with hypertension?

Effective Combination Antihypertensive Medications for Black Patients in Canada

For black patients with hypertension in Canada, the recommended first-line combination therapy should include a dihydropyridine calcium channel blocker (DHP-CCB) with either a thiazide/thiazide-like diuretic or an angiotensin receptor blocker (ARB). 1

First-Line Combination Therapy Options

Preferred Combinations with Brand Names:

1. DHP-CCB + Thiazide/Thiazide-like Diuretic

   • Amlodipine (Norvasc) + Hydrochlorothiazide (HCTZ)
   • Available as single-pill combination: Exforge HCT (includes valsartan) 2

2. ARB + DHP-CCB

   • Valsartan + Amlodipine (Exforge)
   • Irbesartan + Amlodipine (Aprovasc) 3

Evidence-Based Treatment Algorithm for Black Patients

Step 1: Initial Therapy

• Start with low-dose ARB + DHP-CCB or DHP-CCB + thiazide/thiazide-like diuretic 1
• Example: Amlodipine 5mg + valsartan 160mg has shown excellent efficacy and tolerability 4

Step 2: Dose Optimization

• Increase to full dose if blood pressure remains uncontrolled 1
• Example: Amlodipine 10mg + full-dose ARB

Step 3: Add Third Agent

• Add diuretic (if not already included) or ARB/ACEI (if not already included) 1
• Triple therapy with amlodipine + valsartan + HCTZ has demonstrated superior efficacy compared to dual therapies 2

Step 4: Resistant Hypertension

• Add spironolactone or, if not tolerated, consider amiloride, doxazosin, eplerenone, clonidine, or beta-blocker 1

Key Considerations for Black Patients

Medication Efficacy

• Thiazide diuretics and CCBs are more effective in lowering BP in black patients than RAS inhibitors (ACEIs/ARBs) or beta-blockers 1
• CCBs like amlodipine are as effective as chlorthalidone (thiazide-like diuretic) in reducing BP, CVD, and stroke events in black patients 1

Safety Considerations

• Black patients have a greater risk of angioedema with ACE inhibitors 1
• ARBs are preferred over ACEIs when a RAS blocker is indicated 1

Combination Benefits

• Most black patients require ≥2 antihypertensive medications to achieve adequate BP control 1
• Single-pill combinations improve adherence and are particularly effective in black patients 1, 2
• The combination of amlodipine + valsartan has shown excellent tolerability and efficacy 4

Target Blood Pressure

• Target BP <130/80 mmHg for most patients 1
• Aim to reduce BP by at least 20/10 mmHg 1
• Monitor BP control and aim to achieve target within 3 months 1

Clinical Pearls

• The response to amlodipine tends to be greater with higher initial blood pressure 5
• Black patients may not respond as well to ACE inhibitor monotherapy (like lisinopril) compared to Caucasian patients, but respond similarly to combination therapy 5
• Triple therapy attenuates diuretic-induced hypokalemia 2
• Benefits of triple therapy over dual therapy are observed regardless of age, sex, race, ethnicity, or baseline blood pressure 2

Remember that single-pill combinations can significantly improve adherence, which is crucial for long-term blood pressure control in hypertensive patients.