When to Hold Losartan and Amlodipine Based on GFR
Losartan should generally be continued even when eGFR falls below 30 mL/min/1.73 m² and only considered for discontinuation when eGFR is <15 mL/min/1.73 m² in the setting of uremic symptoms, symptomatic hypotension, or uncontrolled hyperkalemia despite medical management. Amlodipine does not require discontinuation based on eGFR alone.
Losartan (ARB) Management by eGFR
Continue Treatment:
- eGFR ≥30 mL/min/1.73 m²: Continue losartan without dose adjustment 1, 2
- eGFR 15-30 mL/min/1.73 m²: Continue losartan unless specific complications arise 1, 2
The KDIGO 2024 guidelines explicitly state to "continue ACEi or ARB in people with CKD even when the eGFR falls below 30 ml/min per 1.73 m²" 1. This recommendation is reinforced by research showing that discontinuing ARB therapy when eGFR drops below 30 mL/min/1.73 m² is associated with 39% higher mortality risk and 37% higher risk of major adverse cardiovascular events 3.
Consider Dose Reduction or Discontinuation:
Only when eGFR <15 mL/min/1.73 m² AND one of the following occurs 1, 2:
- Symptomatic hypotension unresponsive to management
- Uncontrolled hyperkalemia despite medical treatment (potassium binders, dietary modification, diuretics)
- Uremic symptoms requiring reduction to improve quality of life
Critical Monitoring Parameters:
Within 2-4 weeks of initiation or dose changes, check 1, 2:
- Serum creatinine (discontinue if rises >30% within 4 weeks)
- Serum potassium
- Blood pressure
Important Caveats:
- Pediatric exception: Losartan is not recommended in children with eGFR <30 mL/min/1.73 m² 4
- Volume depletion: Start with 25 mg daily if patient is volume depleted (e.g., on diuretics) 4
- Hepatic impairment: Start with 25 mg daily in mild-to-moderate hepatic dysfunction 4
Amlodipine Management
Amlodipine does not require dose adjustment or discontinuation based on eGFR. Calcium channel blockers are not renally cleared to a clinically significant degree and can be safely continued across all stages of CKD.
Key Distinction:
While losartan provides renoprotection by reducing intraglomerular pressure, amlodipine may actually increase glomerular filtration and intraglomerular pressure 5. However, this does not contraindicate its use—amlodipine remains a reasonable antihypertensive choice in CKD and is specifically recommended as first-line therapy in kidney transplant recipients 2.
Clinical Pitfalls to Avoid:
Do not reflexively discontinue ARBs when eGFR drops below 30: This common practice is associated with worse cardiovascular outcomes 3
Manage hyperkalemia aggressively rather than stopping the ARB: Use potassium binders, dietary modification, and diuretics before discontinuing 1, 2
Do not combine losartan with ACE inhibitors or direct renin inhibitors: Dual RAS blockade increases risks of hyperkalemia, hypotension, and acute kidney injury without additional benefit 1, 2, 4
Monitor for acute kidney injury with NSAIDs: Concomitant NSAID use with losartan significantly increases risk of renal deterioration, especially in elderly or volume-depleted patients 4