What medications are most effective for treating hypertension in African American patients?

From the Guidelines

For African American patients with hypertension, thiazide diuretics or calcium channel blockers (CCBs) are the most effective first-line treatments, as they are more effective in lowering blood pressure and reducing cardiovascular disease events compared to RAS inhibitors or beta blockers. These medications are preferred due to the high prevalence of low-renin hypertension and salt sensitivity in this population 1. A typical starting dose would be amlodipine 5mg daily or hydrochlorothiazide 12.5-25mg daily.

Key Considerations

• If blood pressure remains uncontrolled with a single medication, combining a CCB with a thiazide diuretic often provides better results than adding an ACE inhibitor or ARB initially 1.
• For patients with comorbidities like diabetes or kidney disease, adding an ACE inhibitor (like lisinopril) or ARB (like losartan) is crucial for organ protection, although they may be less effective for blood pressure control alone in this population 1.
• When prescribing ACE inhibitors or ARBs to African American patients, higher doses may be needed, and combining them with a diuretic significantly improves their effectiveness 1.

Physiological Basis

The differences in treatment response among African American patients with hypertension are attributed to variations in the renin-angiotensin system and increased vascular reactivity commonly seen in this population 1.

Treatment Approach

The goal is to achieve the blood pressure target using a combination of medication classes, with a preference for thiazide diuretics and CCBs as first-line treatments, and adding ACE inhibitors or ARBs as needed for patients with specific comorbidities 1.

From the FDA Drug Label

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). ACE inhibitors, including lisinopril, have an effect on blood pressure that is less in black patients than in non-blacks.

Hypertension treatment in African American patients may require careful consideration of the available antihypertensive drugs.

• Amlodipine and spironolactone may be considered as options, but the labels do not provide direct evidence of their efficacy in African American patients compared to other populations.
• Lisinopril, an ACE inhibitor, has been shown to have a lesser effect on blood pressure in black patients compared to non-black patients 2. It is essential 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 of hypertension in African American patients.

From the Research

Medications for Hypertension in African American Patients

• The choice of medication for hypertension in African American patients may differ from other populations, with certain combinations being more effective 3, 4, 5.
• Diuretics, such as chlorthalidone, have been shown to be effective in reducing blood pressure in African American patients 3.
• Calcium channel blockers and angiotensin-converting enzyme (ACE) inhibitors are also effective, and combination therapy with these agents may be beneficial 4, 5.
• The use of ACE inhibitors, such as ramipril, has been shown to be effective in reducing the incidence of kidney disease in African American patients 3.
• Beta blockers, such as atenolol, may also be effective in certain situations, but may not be as effective as other agents in African American patients 3, 6.

Combination Therapy

• Most African American patients with hypertension will require combination therapy to achieve blood pressure goals 3, 4, 5, 6.
• Combination therapy with a diuretic and an ACE inhibitor or calcium channel blocker may be effective 4, 5.
• The choice of combination therapy should be individualized based on the patient's specific needs and medical history 3, 4, 5.

Lifestyle Modifications

• Lifestyle modifications, such as weight loss, salt restriction, and increased physical activity, are also important in managing hypertension in African American patients 4, 5, 6.
• These modifications can help to reduce blood pressure and improve overall health outcomes 4, 5, 6.

Guidelines and Recommendations

• The Eighth Joint National Committee (JNC-8) guidelines recommend the use of diuretics, calcium channel blockers, and ACE inhibitors as first-line agents for the treatment of hypertension in African American patients 7.
• The International Society of Hypertension in Blacks guidelines also recommend the use of combination therapy and lifestyle modifications to manage hypertension in African American patients 5, 6.