From the Guidelines
For a 62-year-old Black female with gout, sleep apnea, and family history of type 2 diabetes and chronic kidney disease, a calcium channel blocker (CCB) such as amlodipine is the preferred first-line antihypertensive medication. This recommendation is based on the most recent and highest quality evidence, which suggests that CCBs are particularly effective in Black patients due to their pathophysiology of hypertension, which often involves low renin levels and salt sensitivity 1.
Key Considerations
- CCBs are metabolically neutral, meaning they don't worsen gout or increase diabetes risk, which is important given her history of gout and family history of diabetes.
- They also don't negatively impact kidney function, making them appropriate considering her family history of chronic kidney disease.
- If additional medication is needed, a thiazide diuretic like chlorthalidone could be considered as a second agent, though careful monitoring would be needed due to her gout history as thiazides can raise uric acid levels 1.
- ACE inhibitors and ARBs, while beneficial for kidney protection, are typically less effective as monotherapy in Black patients but could be added later if kidney protection becomes a priority.
Dosage and Titration
- Amlodipine can be started at 5 mg daily and titrated up to 10 mg daily if needed for blood pressure control.
- The goal is to achieve optimal blood pressure control while minimizing potential side effects and considering her comorbid conditions.
Lifestyle Modifications
- In addition to pharmacological therapy, lifestyle modifications such as weight reduction, dietary modification, and increased physical activity are important for managing hypertension, especially in Black patients 1.
- These modifications can help reduce blood pressure and decrease the risk of cardiovascular disease, and should be encouraged alongside medication therapy.
From the FDA Drug Label
Many patients will require more than 1 drug to achieve blood pressure goals. For specific advice on goals and management, see 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) 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). These considerations may guide selection of therapy.
The preferred class of antihypertensive medication for a 62-year-old black female with a history of gout, obstructive sleep apnea (OSA), and a family history of type 2 diabetes mellitus (T2DM) and chronic kidney disease (CKD) cannot be determined from the provided information.
- The FDA label does not provide a direct recommendation for this specific patient population.
- 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 2.
From the Research
Preferred Antihypertensive Medication
The preferred class of antihypertensive medication for a 62-year-old black female with a history of gout, obstructive sleep apnea (OSA), and a family history of type 2 diabetes mellitus (T2DM) and chronic kidney disease (CKD) can be determined based on the following factors:
- The patient's history of gout:
- A study published in the American Journal of Hypertension 3 found that metoprolol, a beta-blocker, increased uric acid and risk of gout in African Americans with chronic kidney disease.
- Another study published in the Journal of Hypertension 4 found that amlodipine, a calcium-channel blocker, reduced the risk of gout by 37% compared to chlorthalidone and by 26% compared to lisinopril.
- The patient's family history of T2DM and CKD:
- A network meta-analysis published in the journal Drugs 5 found that ACE inhibitors had the highest probabilities of protective effects on outcomes of kidney events, cardiovascular events, cardiovascular death, and all-cause death in non-dialysis CKD patients.
- The same study found that ACE inhibitors were superior to ARBs and other antihypertensive drugs in preventing kidney events, cardiovascular outcomes, cardiovascular death, and all-cause mortality in non-dialysis CKD patients.
Recommended Medications
Based on the evidence, the following medications may be considered:
- Amlodipine: a calcium-channel blocker that has been shown to reduce the risk of gout 4.
- ACE inhibitors: such as ramipril, which have been shown to have protective effects on kidney events, cardiovascular events, cardiovascular death, and all-cause death in non-dialysis CKD patients 5.
- ARBs: may also be considered, although they may not have the same level of benefit as ACE inhibitors in preventing kidney events and cardiovascular outcomes 5.
Medications to Avoid
The following medications may be avoided: