Which Angiotensin Receptor Blocker (ARB) and dose should be prescribed for a patient with hypertension or heart failure?

From the Guidelines

For patients with hypertension or heart failure, valsartan 80-320 mg once daily is the recommended Angiotensin Receptor Blocker (ARB) dose, as it has proven mortality benefits and is a preferred option for heart failure, as stated in the 2022 AHA/ACC/HFSA guideline for the management of heart failure 1. When selecting an ARB, it's essential to consider the patient's specific condition, such as heart failure with reduced ejection fraction (HFrEF), and choose a medication with established benefits in that area.

• Valsartan, with a dose range of 80-320 mg once daily, is a suitable option for patients with hypertension or heart failure, as it has demonstrated mortality benefits in clinical trials 1.
• Candesartan, with a dose range of 4-32 mg daily, is another preferred option for heart failure, particularly for patients who cannot tolerate other ARBs or have specific comorbidities 1.
• Losartan, with a dose range of 50-100 mg once daily, is also a commonly recommended ARB for hypertension or heart failure, although it may not have the same level of mortality benefits as valsartan or candesartan 1. It's crucial to start with the lower dose and titrate upward based on blood pressure response or heart failure symptoms, while monitoring kidney function and potassium levels, especially in patients with renal impairment or those taking potassium supplements or potassium-sparing diuretics 1.

From the FDA Drug Label

The usual starting dose of losartan is 50 mg once daily. The dosage can be increased to a maximum dose of 100 mg once daily as needed to control blood pressure [see CLINICAL STUDIES (14.1)]. The usual starting dose is 50 mg of losartan once daily. Hydrochlorothiazide 12.5 mg daily should be added and/or the dose of losartan should be increased to 100 mg once daily followed by an increase in hydrochlorothiazide to 25 mg once daily based on blood pressure response [see CLINICAL STUDIES (14.2)]. Valsartan tablets are indicated for the treatment of hypertension, to lower blood pressure in adults and pediatric patients one year of age and older.

Losartan is a suitable Angiotensin Receptor Blocker (ARB) that can be prescribed for a patient with hypertension or heart failure. The recommended starting dose is 50 mg once daily, which can be increased to a maximum dose of 100 mg once daily as needed to control blood pressure 2. Valsartan is also an option, however the dose is not specified in the provided drug label 3.

From the Research

Angiotensin Receptor Blockers (ARBs) for Hypertension and Heart Failure

• The choice of ARB and dose depends on the individual patient's requirements and risk factors 4.
• For patients with hypertension but at low additional risk, an ARB that provides sustained, powerful 24-h reductions in blood pressure is suitable 4.
• Candesartan cilexetil is an effective agent in reducing the risk of cardiovascular mortality, stroke, heart failure, and other conditions, with a recommended dose of 8-32 mg once daily for adult patients with hypertension 5.
• Telmisartan is a suitable option for patients at very high additional risk, with demonstrated efficacy in patients with heart failure 4.
• The duration of action of ARBs varies, with telmisartan and valsartan showing a longer duration of action compared to losartan 6.

Comparison of ARBs

• Candesartan cilexetil has been shown to provide better antihypertensive efficacy than losartan and is at least as effective as telmisartan and valsartan 5.
• Valsartan has been found to be more effective at lowering blood pressure than losartan, with comparable efficacy to other ARBs 7.
• The choice of ARB should be based on individual patient needs and evidence-based decision making 4.

Dosing Considerations

• The recommended dose of candesartan cilexetil is 8-32 mg once daily for adult patients with hypertension 5.
• Telmisartan has been shown to be effective at a dose of 10-40 mg once daily 6.
• Valsartan has been found to be effective at doses of 160-320 mg once daily 7.
• Losartan has been shown to have a shorter duration of action, with a recommended dose of 25-100 mg once daily 6.