What is the recommended initial dose of losartan when transitioning from lisinopril 40mg?

From the Guidelines

When transitioning from lisinopril 40mg to losartan, the recommended initial dose is 50mg once daily. This recommendation is based on the dose equivalency and the goal of maintaining comparable blood pressure control, as suggested by the guidelines 1. The starting dose of losartan can be found in Table 28 of the guidelines, which lists the starting and goal doses for various ACE inhibitors and ARBs, including losartan, with a starting dose of 25-50mg daily. Given that the patient is already on a high dose of lisinopril (40mg), it's reasonable to start with the higher end of the starting dose range for losartan, which is 50mg. Some key points to consider when making this transition include:

• Monitoring blood pressure closely for 2-4 weeks after initiating losartan to assess response and determine if dose adjustment is needed.
• The maximum losartan dose is 100mg daily if needed for better blood pressure control, as indicated in the guidelines 1.
• Discontinuing lisinopril 24 hours before starting losartan to avoid overlapping ACE inhibitor and ARB therapy, which could increase adverse effects like hyperkalemia or hypotension.
• Losartan's mechanism of action, which blocks angiotensin II receptors rather than inhibiting ACE enzyme activity, often results in fewer side effects like cough while maintaining similar efficacy for hypertension, heart failure, and kidney protection in diabetes.

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

The recommended initial dose of losartan when transitioning from lisinopril 40mg is 50mg once daily.

• This is the usual starting dose for adult hypertension.
• The dosage can be increased to 100mg once daily as needed to control blood pressure 2.

From the Research

Transitioning from Lisinopril to Losartan

When transitioning a patient from lisinopril 40mg to losartan, the recommended initial dose of losartan is an important consideration.

• The CORD IA trial 3 involved switching patients from an angiotensin-converting enzyme inhibitor (ACEI) to the angiotensin II receptor blocker (ARB) losartan, with patients initially switched to losartan 50 mg once daily.
• If the blood pressure was > or = 140/90 mm Hg after 1 month or more, the dose of losartan was increased to 100 mg.
• This study suggests that starting with a dose of 50 mg and titrating upwards as needed may be an effective approach.

Dosing Considerations

• There is no direct evidence in the provided studies to suggest that a specific dose of losartan (50 mg or 100 mg) is more appropriate when transitioning from lisinopril 40mg.
• However, the CORD IA trial 3 provides guidance on the initial dosing and titration of losartan when switching from an ACEI.
• Other studies, such as the comparison of olmesartan with other angiotensin II receptor antagonists 4, do not provide direct guidance on the initial dosing of losartan when transitioning from lisinopril.

Clinical Decision Making

• The decision to start with losartan 50 mg or 100 mg should be based on individual patient factors, such as blood pressure control and potential side effects.
• Clinicians should consider the patient's current blood pressure, medical history, and other medications when making this decision.
• The CORD IA trial 3 and other studies provide general guidance on the use of losartan and other antihypertensive medications, but clinical judgment is necessary to make individualized treatment decisions.