In Black patients with hypertension, when and how should an angiotensin receptor blocker (ARB) such as losartan be used?

ARB Use in Black Patients with Hypertension

Primary Recommendation

In Black patients with hypertension, ARBs (like losartan) should NOT be used as initial monotherapy but are appropriate and effective when combined with either a thiazide diuretic or calcium channel blocker (CCB), and are specifically indicated for those with heart failure, chronic kidney disease, or diabetic nephropathy. 1, 2

Initial Treatment Strategy

First-Line Therapy (Without Compelling Indications)

• Start with a thiazide-type diuretic or CCB as initial monotherapy in Black patients with hypertension who do not have heart failure or CKD 1, 2
• Thiazide diuretics (chlorthalidone 12.5-25 mg/day or hydrochlorothiazide 25-50 mg/day) and CCBs are more effective than ARBs at lowering blood pressure and reducing cardiovascular events in Black patients when used as monotherapy 1
• ARBs show reduced blood pressure response as monotherapy in Black patients compared to diuretics or CCBs 3, 4

Most Patients Require Combination Therapy

• Most Black patients with hypertension require ≥2 antihypertensive medications to achieve BP control 1, 2
• Single-tablet combinations including either a diuretic or CCB are particularly effective in achieving BP control in Black patients 1, 2

When ARBs ARE Appropriate in Black Patients

Compelling Indications (Use ARBs as Part of Regimen)

• Chronic kidney disease (CKD): ARBs are recommended as components of multidrug regimens 1, 2
• Heart failure: ARBs should be added along with beta-blockers 1, 2
• Type 2 diabetes with nephropathy: Losartan specifically indicated for diabetic nephropathy with elevated serum creatinine and proteinuria (urinary albumin to creatinine ratio ≥300 mg/g) 5
• Post-myocardial infarction with coronary heart disease: As part of combination therapy 1

Effective Combination Therapy

• ARB + thiazide diuretic: Produces similar BP lowering in Black patients as in other racial groups 1, 3
• ARB + CCB: Equally effective across races with no racial disparity in BP response 1, 4
• Losartan combined with hydrochlorothiazide achieved 62.7% response rate with reductions of 16.8/10.8 mmHg in Black patients 3

Important Caveats and Pitfalls

Race-Specific Considerations

• Do NOT use ARBs for stroke reduction in Black patients with left ventricular hypertrophy: The LIFE study showed Black patients treated with atenolol had better outcomes than those on losartan (17% vs 11% primary endpoints) 5
• This lack of benefit for stroke reduction in Black patients is specific to the left ventricular hypertrophy indication and does not apply to other uses 5

Monotherapy Limitations

• ARBs as monotherapy are less effective than diuretics or CCBs in reducing cardiovascular events in Black patients 1
• ARBs offer no advantage over diuretics or CCBs in Black hypertensive patients with diabetes but without nephropathy or heart failure 1, 2

Safety Considerations

• ARBs are generally well-tolerated in Black patients with similar adverse event profiles to placebo 3
• Contraindicated in pregnancy: Must transition to methyldopa, nifedipine, or labetalol if pregnancy occurs 2

Practical Algorithm

Step 1: Assess for compelling indications (CKD, heart failure, diabetic nephropathy)

• If present: Include ARB as part of multidrug regimen 1, 2, 5
• If absent: Proceed to Step 2

Step 2: For uncomplicated hypertension in Black patients

• Initial therapy: Thiazide diuretic OR CCB 1, 2
• If BP remains >15/10 mmHg above goal: Start combination therapy immediately 6

Step 3: When adding second agent

• Preferred combinations: Thiazide + ARB OR CCB + ARB 1, 4
• These combinations eliminate racial disparities in BP response 4, 7

Step 4: Avoid ARB monotherapy

• Racial differences in monotherapy response are corrected when diuretics are added 6
• Race should not exclude any antihypertensive class in combination therapy 1, 2