What is the next best antihypertensive medication to add to an African American patient's regimen who is already on maximum dose amlodipine (calcium channel blocker) with uncontrolled hypertension?

Add a Thiazide-Like Diuretic or ARB/ACEI Next

For an African American patient on maximum dose amlodipine with uncontrolled hypertension, add either a thiazide-like diuretic OR an ARB/ACEI as the next antihypertensive agent. 1

Guideline-Based Treatment Algorithm for Black Patients

The 2020 International Society of Hypertension guidelines provide a clear stepwise approach specifically for Black patients with hypertension 1:

Current Status

• Your patient is on Step 2: Full dose DHP-CCB (amlodipine at maximum dose) 1

Next Step (Step 3)

Add either:

• Thiazide or thiazide-like diuretic (preferred option), OR
• ARB/ACEI (alternative option) 1

Practical Considerations

Why Diuretic is Preferred

• The ACC/AHA 2017 guidelines specifically recommend that initial antihypertensive treatment in Black adults should include a thiazide-type diuretic or CCB 1
• Since the patient is already on maximum CCB therapy, adding a thiazide-like diuretic follows the evidence-based treatment algorithm 1
• Thiazide-like diuretics (chlorthalidone, indapamide) are preferred over hydrochlorothiazide for superior cardiovascular outcomes 1

Why ARB/ACEI is Also Acceptable

• ARBs are specifically mentioned in the ISH guidelines for Black patients at this step 1
• ACEIs have smaller blood pressure effects as monotherapy in Black patients, but remain effective when combined with CCBs 1, 2
• Losartan and lisinopril are both FDA-approved for hypertension and can be combined with amlodipine 3, 2
• Research demonstrates that combining amlodipine with ACEIs (lisinopril) or ARBs (losartan, valsartan) produces significant additional blood pressure lowering 4, 5, 6

Specific Drug Recommendations

Option 1: Thiazide-Like Diuretic (Preferred)

• Chlorthalidone 12.5-25 mg once daily, OR
• Indapamide 1.25-2.5 mg once daily 1

Option 2: ARB or ACEI

• Losartan 50-100 mg once daily 3, 4, OR
• Lisinopril 10-40 mg once daily 2, 6

Important Clinical Caveats

Before Adding Medication

• Verify medication adherence - this is a critical step before escalating therapy 1
• Confirm diagnosis with home or ambulatory BP monitoring if not already done (target: home BP ≥135/85 mmHg or 24h ambulatory BP ≥130/80 mmHg confirms uncontrolled hypertension) 1
• Check for secondary hypertension if BP remains severely elevated or resistant 1

Target Blood Pressure

• Aim for BP <130/80 mmHg (or at minimum <140/90 mmHg) 1
• Achieve target within 3 months of treatment adjustment 1

If Still Uncontrolled After Step 3

• Step 4: Add spironolactone (preferred), or if not tolerated/contraindicated, consider amiloride, doxazosin, eplerenone, clonidine, or beta-blocker 1

Single-Pill Combinations

• Consider using single-pill combinations to improve adherence and simplify the regimen 1
• Amlodipine/valsartan and amlodipine/benazepril combinations are available 5