What are the most suitable Hypertension (HTN) medications for specific populations and comorbid conditions?

From the Guidelines

The most suitable hypertension medications for specific populations and comorbid conditions should be chosen based on the latest guidelines, with a focus on reducing morbidity, mortality, and improving quality of life. When selecting hypertension medications, it is crucial to consider the specific needs of different populations, such as Black patients, those with diabetes, heart failure, coronary artery disease, chronic kidney disease, and older adults. For Black patients, calcium channel blockers (like amlodipine 5-10mg daily) or thiazide diuretics (such as hydrochlorothiazide 12.5-25mg daily) are typically first-line due to better efficacy 1. In patients with diabetes, ACE inhibitors (like lisinopril 10-40mg daily) or ARBs (such as losartan 50-100mg daily) are preferred as they provide renoprotection 1. For heart failure patients, beta-blockers (carvedilol 3.125-25mg twice daily), ACE inhibitors/ARBs, and aldosterone antagonists (spironolactone 25-50mg daily) are beneficial 1. Patients with coronary artery disease benefit from beta-blockers and ACE inhibitors, while those with chronic kidney disease should receive ACE inhibitors or ARBs to slow disease progression 1. For older adults, calcium channel blockers or low-dose thiazides are often better tolerated 1. In pregnancy, methyldopa (250-500mg three times daily), labetalol (100-400mg twice daily), or nifedipine (30-60mg extended-release daily) are safer options 1. These recommendations are based on physiological differences in how populations respond to medications and how certain drugs provide additional benefits beyond blood pressure control for specific conditions, as outlined in the latest guidelines from the American College of Cardiology/American Heart Association and European Society of Cardiology/European Society of Hypertension 1. Medication choices should always be individualized, considering potential side effects, drug interactions, and patient preferences. The goal of treatment is to achieve a blood pressure target of less than 130/80 mm Hg, with the choice of antihypertensive drug therapy tailored to the individual patient's needs and comorbidities 1. It is also important to note that the combination of two renin-angiotensin system blockers is not recommended, and beta-blockers are considered first-line antihypertensive drugs in patients with a specific indication for their use 1.

From the FDA Drug Label

8 USE IN SPECIFIC POPULATIONS 8.1 Pregnancy 8.2 Lactation 8.4 Pediatric Use 8.5 Geriatric Use 8.6 Renal Impairment 14.3 Aliskiren in Patients with Diabetes Treated with ARB or ACEI (ALTITUDE study)

The most suitable Hypertension (HTN) medications for specific populations and comorbid conditions are not explicitly stated in the provided drug label. However, based on the available information, aliskiren can be used in certain populations, such as:

• Geriatric use: Aliskiren can be used in geriatric patients, but the label does not provide specific guidance on dosage adjustments or special considerations.
• Renal impairment: Aliskiren should be used with caution in patients with renal impairment, as it may increase the risk of hyperkalemia and hypotension.
• Diabetes: The ALTITUDE study suggests that aliskiren can be used in patients with diabetes who are treated with ARB or ACEI, but the label does not provide specific guidance on the use of aliskiren in this population. It is essential to consult the full prescribing information and other relevant resources to determine the most suitable HTN medication for specific populations and comorbid conditions 2.

From the Research

Hypertension Medications for Specific Populations

• For black patients, at least one agent should be a thiazide diuretic or a calcium channel blocker 3
• Patients with heart failure with reduced ejection fraction should be treated initially with a beta blocker and an ACEI or ARB (or an angiotensin receptor-neprilysin inhibitor), followed by add-on therapy with a mineralocorticoid receptor antagonist and a diuretic based on volume status 3
• Treatment for patients with chronic kidney disease and proteinuria should include an ACEI or ARB plus a thiazide diuretic or a calcium channel blocker 3
• Patients with diabetes mellitus should be treated similarly to those without diabetes unless proteinuria is present, in which case combination therapy should include an ACEI or ARB 3

First-Line Treatment for Hypertension

• The first-choice treatment for hypertension in adults is single-agent therapy with the thiazide diuretic chlortalidone or, when this drug is not available, the thiazide diuretic hydrochlorothiazide 4
• If a diuretic cannot be used, it is better to choose an ACE inhibitor: captopril, lisinopril or ramipril 4
• Initial pharmacologic therapy for hypertension is low-dose thiazide diuretics, beta-blockers, and ACE inhibitors 5

Antihypertensive Therapy in Real Clinical Practice

• The prescription of antihypertensive drugs (AHD) and achievement of targets values were assessed in accordance with current clinical guidelines for the management of AH and hypercholesterolemia 6
• The greatest increase in the number of AHD was observed in patients with hypertension in combination with coronary heart disease, heart failure, and atrial fibrillation 6
• Angiotensin Receptor Blockers (ARBs) have long represented a rational, effective, and safe anti-hypertensive pharmacological strategy 7
• Current US and European guidelines recommend ACEi and ARBs as a suitable first choice for hypertension treatment together with calcium channel blockers (CCBs) and thiazide diuretics 7

Combination Therapy

• More than 70% of adults treated for primary hypertension will eventually require at least two antihypertensive agents, either initially as combination therapy or as add-on therapy if monotherapy and lifestyle modifications do not achieve adequate blood pressure control 3
• Four main classes of medications are used in combination therapy for the treatment of hypertension: thiazide diuretics, calcium channel blockers, angiotensin-converting enzyme inhibitors (ACEIs), and angiotensin receptor blockers (ARBs) 3
• ACEIs and ARBs should not be used simultaneously 3