What medications to start a black male patient with hypertension and impaired renal function (creatinine 1.67, Glomerular Filtration Rate (GFR) 54) on?

Initial Antihypertensive Therapy for Black Male Patient with Stage 3 CKD

Start with a calcium channel blocker (CCB) plus an ARB or thiazide-like diuretic as initial dual therapy, given this patient's chronic kidney disease (GFR 54) and race. 1

Immediate Treatment Considerations

This patient has Stage 3 CKD (GFR 54 mL/min/1.73 m²) and is high-risk, requiring immediate drug treatment regardless of blood pressure grade. 1 The presence of CKD automatically classifies him as high-risk and mandates prompt pharmacological intervention. 1

Recommended Initial Regimen

For black patients with CKD, the optimal starting approach is:

• Low-dose ARB (e.g., losartan 50 mg daily) PLUS a dihydropyridine CCB (e.g., amlodipine 5 mg daily) 1

OR

• Dihydropyridine CCB (e.g., amlodipine 5 mg daily) PLUS a thiazide-like diuretic (e.g., chlorthalidone 12.5 mg daily) 1

The 2020 International Society of Hypertension guidelines specifically recommend that black patients start with either low-dose ARB combined with a DHP-CCB, or DHP-CCB combined with a thiazide/thiazide-like diuretic. 1

Why This Approach for Black Patients with CKD

Black patients respond better to CCBs and thiazide diuretics than to ACE inhibitors or ARBs as monotherapy. 1 However, the presence of CKD changes this calculus significantly. 1

• All patients with CKD should eventually be on an ACE inhibitor or ARB for renoprotection, though it need not be the initial agent. 1
• Starting with dual therapy is appropriate because most black patients require ≥2 medications for adequate control, and this patient has CKD making him high-risk. 1
• CCBs are particularly effective in black patients and have demonstrated favorable effects on renal disease progression. 1, 2

Specific Drug Selection

First-Line Combination Options:

Option 1 (Preferred):

• Amlodipine 5 mg daily (CCB) 1
• Losartan 50 mg daily (ARB) 1, 3

Option 2:

• Amlodipine 5 mg daily (CCB) 1
• Chlorthalidone 12.5 mg daily (thiazide-like diuretic) 1

Why ARB Over ACE Inhibitor:

The ISH 2020 guidelines specifically recommend ARBs over ACE inhibitors as the initial RAS blocker in black patients. 1 While both are effective for renoprotection in CKD, ARBs may have slightly better tolerability profiles. 1

Blood Pressure Target

Target BP is <140/90 mmHg for this patient with CKD. 1 The JNC-8 guidelines established this target for all CKD patients regardless of age. 1 Some guidelines suggest a more aggressive target of <130/80 mmHg, particularly in the presence of proteinuria. 1

Titration Strategy

1. Start both medications at low doses simultaneously 1
2. Increase to full doses (e.g., amlodipine 10 mg, losartan 100 mg) if BP not at goal after 2-4 weeks 1
3. Add a thiazide-like diuretic if still not at goal (if not already part of initial regimen) 1
4. Add spironolactone 25 mg daily as fourth-line agent if BP remains uncontrolled 1, 4

Critical Monitoring Parameters

• Recheck BP within 2-4 weeks after starting therapy 4
• Monitor serum creatinine and potassium within 1-2 weeks after starting ARB, as ACE inhibitors and ARBs can cause acute increases in creatinine (acceptable up to 30% increase) and hyperkalemia 5
• Achieve target BP within 3 months 1
• Monitor for orthostatic hypotension, especially when adding multiple agents 4

Important Caveats

Avoid ACE inhibitor + ARB combination - this dual RAS blockade is potentially harmful and not recommended. 1

Consider single-pill combinations to improve adherence, though ensure adequate doses of each component (some combinations contain suboptimal thiazide doses). 1

Thiazide diuretics may be less effective at GFR <30 mL/min - at this patient's GFR of 54, thiazides remain effective, but loop diuretics may be needed if renal function declines further. 1

Beta-blockers are NOT first-line in black patients with hypertension unless there is a specific cardiac indication (e.g., heart failure, post-MI, coronary artery disease). 1

Renal-Specific Considerations

This patient's creatinine of 1.67 with GFR 54 indicates Stage 3 CKD, which is common in hypertensive African Americans and often represents hypertensive nephrosclerosis. 6, 7 The AASK trial specifically studied this population and demonstrated that:

• Aggressive BP control slows CKD progression in hypertensive African Americans 8
• ACE inhibitors (and by extension ARBs) provide renoprotection beyond BP lowering alone 8
• Calcium channel blockers combined with RAS blockade are effective in this population 2