African-American patient

More recently, the value of adding the combination of isosorbide dinitrate 40 mg and hydralazine 75 mg three times daily to therapy including ACE inhibitors, P-blockers, digoxin, and diuretics was evaluated in a prospective, randomized trial26 The study enrolled only African-American patients and demonstrated a significant reduction in mortality, as well as first hospitalization for HF. Quality-of-life scores were also improved over placebo. Combination therapy with hydralazine and isosorbide dinitrate is an appropriate substitute for angiotensin II antagonism... 

The clinical significance of this ethnic difference for psychiatry was found later. A study examining lithium tolerability found more side effects in African American patients with high RBC/plasma ratio even when the lithium levels were in the therapeutic range (Strickland etal., 1995). It is not known whether African Americans require lower doses and will respond with lower plasma levels. We do know that African Americans with mood disorders are less likely to be prescribed lithium either as primary treatment or adjunctive therapy (Valenstein etal., 2006 Kilbourne 8c Pincus, 2006). It is unknown as to whether the lack of tolerability at usual therapeutic doses is a factor. 

Tran, P. T., Lawson, W. B., Andersen, S. et al. (1999). Treatment of the African American patient with novel antipsychotic agents. In J. M. Herrara, W. B. Lawson and J. J. Sramek, eds., Cross-Cultural Psychiatry. Sussex John Wiley Sons. 

A study on racial differences in receipt of analgesics found that nearly three-fourths (74%) of white patients compared with 57% of African American patients received analgesics for lower extremity fractures in emergency departments (Todd et al., 2001). An assessment of racial/ethnic differences in physicians prescriptions of patient-controlled analgesia for postoperative pain found that after adjustment for age, gender, preoperative... 

Response less in African-Americans Patient/Family Education... 

Hydralazine, a hydrazine derivative, dilates arterioles but not veins. It has been available for many years, although it was initially thought not to be particularly effective because tachyphylaxis to its antihypertensive effects developed rapidly. The benefits of combination therapy are now recognized, and hydralazine may be used more effectively, particularly in severe hypertension. The combination of hydralazine with nitrates is effective in heart failure and should be considered in patients with both hypertension and heart failure, especially in African-American patients. 

Kimmel PL, Patel SS, Peterson RA. Depression in African-American patients with kidney disease. J Nati Med Assoc 2002 94(Suppl.) S92-S103. 

Clinical benefits and effects on mortality and hospitalization Whether used alone or in combination, hydralazine and isosorbide dinitrate decrease the preload and afterload, decrease mitral regurgitation, improve cardiac output, increase exercise capacity, modestly increase LVEF and prolong survival in patients with HF (63,64). V-Heart Failure Trial (HeFT) II (64) showed that enalapril had a major benefit on survival when compared with the combination of hydralazine-isosorbide dinitrate with enalapril in patients with predominantly NYHA class ll-lll. The African Americans in Heart Failure Trial (A-HeFT) (65) showed a beneficial effect of adding vasodilator therapy to African-American patients already treated with ACE inhibitors, (3 blockers, and spironolactone. There are no results with the same strategy in other patient groups. 

In a survey of data from several studies in 126 African-American patients and 574 white patients who were randomly selected and for whom neuroleptic drugs were prescribed, the African-American patients, after adjustments for clinical, sociodemographic, and health-system characteristics, were less likely than the white patients to receive second-generation neuroleptic drugs (49% compared with 66%) (579). 

CCT as a Function of Race, Age, and Disease. Average CCT varies with race (Box 34-1), age, and diagnosis. Whites, Chinese, Hispanics, and Filipinos tend to have comparable CCTs. Among the Asian races, Mongolians have the thinnest CCT, whereas the Japanese have thinner corneas than Chinese and Filipinos. African-Americans, patients with glaucoma, and older patients tend to have thinner corneas. Patients with ocular hypertension tend to have thicker corneas. 

Vision better preserved if ALT first (vs. trabeculectomy) in African-American patients (7-year follow-up). 

McMahon FG, Fujioka K, Singh BN, Mendel CM, Rowe E, Rolston K, Johnson F, Mooradian AD. Efficacy and safety of sibutramine in obese white and African American patients with hypertension a 1-year, double-blind. 

Caucasian patients treated with desipramine or irrupramine actually weighed slightly less than the corresponding African American patients. Therefore, one might have expected the Caucasian... 

With respect to the atypical neuroleptic clozapine, the mean dose among African American patients (428.6 mg) compared with that for Caucasian patients (365.0 mg) suggests that African Americans need a higher mean dose of clozapine than do Cau-... 

The results of our study focusing on antidepressant dosing at the time of discharge tend to corroborate previous evidence that African American patients need lower doses of TCAs than do Caucasian patients. Results are more equivocal with respect to our study of African American and Caucasian patients taking SSRIs. However, when weight is taken into consideration, it is found that African Americans might need lower doses of SSRIs compared with Caucasians. 

Findings of our study of atypical neuroleptics and antipsychot-ics show that African American patients may need a higher dose of clozapine than that required by Caucasian patients. Likewise, it appears that African Americans may need a higher dose of olanzapine than Caucasians do and that Hispanics have intermediate requirements. Asian patients appear to require the lowest dose of all, but it must be noted that the study included a relatively small sample of Asians. Finally, Hispanics may need a lower dose of risperidone than that required by African Americans or Caucasians, and the dose difference between the latter two groups may be negligible. 

Culture also plays a major role. For instance, physician bias, placebo effects, compliance factors, and patient beliefs and expectations all can influence the clinical effects of psychotropic agents (Smith et al. 1993). It has been reported that because of psychiatric practitioner bias, severe psychiatric illnesses are often diagnosed in African American patients, who are then prescribed high doses of neuroleptics (Price et al. 1985). It has also been reported that Caucasians tend to be more responsive than non-Caucasians to placebo (Escobar and Tuason 1980). 

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