What is the most effective antihypertensive medication for African Americans with hypertension?

From the Guidelines

For African Americans with hypertension, calcium channel blockers (like amlodipine) and thiazide diuretics (like hydrochlorothiazide or chlorthalidone) are generally considered first-line treatments. These medications have shown better efficacy in this population compared to ACE inhibitors or ARBs when used alone, as supported by the 2017 ACC/AHA/AAPA/ABC/ACPM/AGS/APhA/ASH/ASPC/NMA/PCNA guideline for the prevention, detection, evaluation, and management of high blood pressure in adults 1. A typical starting dose for amlodipine is 5mg daily, which can be increased to 10mg if needed, while hydrochlorothiazide typically starts at 12.5-25mg daily.

Key Considerations

• Combination therapy may be necessary to reach blood pressure goals, and in such cases, adding an ACE inhibitor or ARB can be beneficial, especially for those with diabetes or kidney disease, as noted in the guideline 1.
• The enhanced effectiveness of calcium channel blockers and thiazide diuretics in African Americans is related to the pathophysiology of hypertension in this population, which often involves lower renin levels and greater salt sensitivity.
• Blood pressure should be monitored regularly after starting medication, and lifestyle modifications including reduced sodium intake, increased physical activity, and maintaining a healthy weight remain essential components of hypertension management regardless of medication choice.

Supporting Evidence

The guideline recommendations are based on evidence from several studies, including the ALLHAT trial, which demonstrated that ACE inhibitors were less effective in lowering blood pressure than either thiazide-type diuretics or calcium channel blockers in African Americans 1. Additionally, the guideline notes that racial differences in incidence of antihypertensive drug side effects may occur, with African Americans having a higher risk of angioedema and cough attributed to ACE inhibitors 1.

Clinical Implications

In clinical practice, the choice of antihypertensive medication for African Americans should be guided by the individual patient's characteristics, including the presence of comorbid conditions such as diabetes or kidney disease. However, calcium channel blockers and thiazide diuretics are generally considered the preferred initial treatment options due to their demonstrated efficacy and safety in this population 1.

From the FDA Drug Label

Although lisinopril was antihypertensive in all races studied, Black hypertensive patients (usually a low-renin hypertensive population) had a smaller average response to monotherapy than non-Black patients Concomitant administration of lisinopril and hydrochlorothiazide further reduced blood pressure in Black and non-Black patients and any racial differences in blood pressure response were no longer evident. Some antihypertensive drugs have smaller blood pressure effects (as monotherapy) in Black patients, Losartan may be administered with other antihypertensive agents. Some antihypertensive drugs have smaller blood pressure effects (as monotherapy) in black patients,

The best hypertension medication for African Americans is not explicitly stated in the provided drug labels. However, lisinopril in combination with hydrochlorothiazide may be effective in reducing blood pressure in Black patients, as it eliminates racial differences in blood pressure response. Losartan and amlodipine may also be used, but the labels do not provide specific information on their efficacy in African Americans. It is essential to consider individual patient characteristics and medical history when selecting a hypertension medication. 2 3 4

From the Research

Hypertension Medication for African Americans

• The most effective hypertension medication for African Americans is a topic of ongoing research and debate 5, 6, 7, 8, 9.
• According to the Eighth Joint National Committee (JNC-8) guidelines, thiazide diuretics and calcium channel blockers are recommended as first-line agents for African American patients with hypertension 7, 9.
• A study published in the Journal of the American Board of Family Medicine found that among African American patients on monotherapy, 41.3% were on thiazide diuretics, 40.1% were on calcium channel blockers, and 18.6% were on angiotensin-converting enzyme inhibitors (ACE) or angiotensin receptor blockers (ARB) 5.
• Another study published in the Journal of Clinical Hypertension found that thiazide diuretics were the most commonly used antihypertensive medication among African American adults, and that persons taking a thiazide were more likely to have their blood pressure controlled than persons not taking them 8.
• However, a study published in the North American Journal of Medical Sciences found no significant difference in the optimal control of blood pressure and frequency of end-organ damage among African American patients treated with diuretics, calcium channel blockers, or other antihypertensive agents 7.

Comparison of Antihypertensive Medications

• A comparison of antihypertensive medications found that:
  • Thiazide diuretics were associated with better blood pressure control among African American patients 8.
  • Calcium channel blockers were often considered to be effective monotherapy for African Americans, but were less likely to be used among men than women 8.
  • ACE inhibitors and ARBs were removed from the treatment algorithm for Black patients in the JNC-8 guidelines, due to physiologic theories and potential complications with race-based treatment algorithms 9.

Limitations and Future Directions

• The current evidence suggests that an individualized approach to hypertension therapy for all patients may be more important than race-based guidelines 5.
• Further research is needed to determine the most effective hypertension medication for African Americans, and to address the disparities in hypertension control and outcomes among this population 5, 6, 7, 8, 9.